Biden EO Expands Access to Medicaid Funds to Violence Intervention Programs

WASHINGTON — He may be in his final months in office, but President Joe Biden remains committed to advancing his administration’s efforts to combat gun violence.

During a ceremony in the East Room of the White House last week, the president signed an executive order creating a task force to improve school shooter response plans, while also mandating steps to restrict new technologies that make guns easier to fire and obtain.

Significantly, the EO was accompanied by several action items, a number of which were aimed to invest in and support community-based violence intervention strategies and services.

Perhaps the most significant of all these items was Biden’s directing the Centers for Medicare and Medicaid Services to take an “active role” with states to expand access to Medicaid reimbursement for these violence intervention programs.

More than any one action, however, Fatimah Loren Dreier, executive director of the Health Alliance for Violence Intervention, said what was most thrilling for her about the Sept. 26 signing ceremony was that it reinforced the idea that “violence is a public health crisis.”

“This administration understands violence behaves the way we see diseases like COVID behave,” she continued. “It spreads in our population through exposure and the way that we stop it, ultimately, is through interventions.”

Dreier should know. Though she holds a business degree from Yale, her work background has mainly been in behavioral health.

The Health Alliance for Violence Intervention, the coalition she runs, is now in its 15th year, through its model — hospital-based violence intervention — is one that’s been around and gaining ground since the mid-1980s.

“When it comes to gun violence, there are certain things that we know,” Dreier said. “The first is that the lion’s share of non-fatal shootings in the United States occur in communities of color, communities where there’s been a lot of economic divestment.

“The other thing we know is that these patterns of violence are cyclical,” she said.

“What practitioners of hospital-based violence intervention do is look beyond that immediate encounter in the hospital with someone who has been shot, who has been a victim of gun violence, and say, ‘This is an opportunity to break the cycle of violence this person has been caught up in,’” Dreier continued.

“We have an opportunity in the hospital to provide intensive case management and leverage community members who are leaders and have credibility with those who have been affected by violence,” she said. “Oftentimes, these individuals have been affected by gun violence themselves, and they provide support to the hospitalized individual, post-discharge, through a range of wraparound services.”

Dreier said that support might last weeks, sometimes months, but the goal at the end is to get the gunshot victim on a different path, “one that’ll afford them better job security and, certainly, a chance to live their lives much more safely.”

“Right now, there are many hospitals in the United States that don’t have these kinds of intervention programs, and the doctors in them treat the same gunshot wound victim time and again, each time allowing them to leave and walk right back into a situation of elevated risk,” she said. “My organization is working to stand up these kinds of programs all across the country.”

Early on, in addition to its grassroots, community-based work, the Health Alliance advocated for violence prevention professionals to be recognized under the national uniform claim code, a standardized code set used to manage health care transactions.

That goal was achieved in 2015, when the National Uniform Claim Committee approved the Violence Prevention Professional recognition.

“That was step one,” Dreier said. “But after that, you need to have a reimbursement structure in place to make the whole thing work — so beginning in 2015, we began making the case that there needed to be a reimbursement benefit in Medicaid for violence prevention.”

Advocates like Dreier and her fellow members in the Health Alliance maintain that reliable federal funding will help local nonprofits reach more of those who are most at risk of being victims of gun violence or committing such violence themselves. 

In 2021, with gun control legislation stalled in Congress, Biden opened the door to Medicaid dollars being used for violence prevention.

But because Medicaid, which provides health care for low-income and disabled residents, is a state-federal program, states must also approve spending the money on violence prevention.

So far, Dreier said, eight states — California, Colorado, Connecticut, Illinois, Maryland, New York, North Carolina and Oregon — have done just that.

The obvious question then was, how do you get the other 42 states and the District of Columbia on board?

Dreier responded by saying she’s seen “a significant explosion of interest” in several states, “in no small part due the executive order President Biden signed in 2021, opening the door to this discussion.”

“That marked the first time any sitting president had issued an executive action related to Medicaid’s relationship to violence prevention, and following his initial guidance, we saw a number of states adopt these benefits,” she said.

“Since then, we’ve been in conversation with over a dozen states, and I think what really has to occur at this point is an education process,” Dreier said. “The reality is not every state has the same kind of violence problems. Violence is highly concentrated across the country. So you have to get in front of people and explain how and why this will work for them and make those connections.

“And I happen to think this latest executive order is a huge step in that direction,” she said.

As part of the president’s latest call to action, the Centers for Medicare and Medicaid Services will play a larger role in communicating with states, clarifying how the reimbursements will work and explaining, in real terms, how states will benefit from these violence intervention services.

“At the same time, I think this executive order puts states on notice that these kinds of violence interventions should be more of a norm … and that health dollars can actually be used to foster greater safety across the country,” Dreier said.

Asked how the impending election might affect all of this, Dreier said she’s optimistic that the momentum for adoption of Medicaid reimbursement for violence prevention will only continue to grow.

“This is already part of our existing infrastructure,” she said. “At this point, it’s really about advocacy. It’s really about having compelling conversations. So what I think the Biden administration is saying is, with the time we have left, we can be talking to states. And they can start these conversations right away.

“CMS, to its credit, has already done a lot of work in this area already, but this is upping the ante, and I believe these conversations will have a cascading effect,” Dreier continued. “If CMS really spends the next few months reaching out to states and having these conversations, we could see significant movement in that time.

“That’s exciting and it means that this meaningful work can continue,” she said. “Because as states begin to see what other states are achieving, and when the public sees that violence intervention in hospitals is making communities safer, then the demand for these services is only going to grow and people in these other states will start building their own roadmaps to make this happen.”

Through it all, Dreier said, Health Alliance for Violence Intervention will be available to provide assistance.

“We are a membership-based organization. We support hospitals and health systems with the implementation of these models of violence prevention, and we have played an emerging role supporting states in the implementation of this policy,” she said.

“In essence, we offer advice and the benefit of experience to help states and health care administrators begin to build the scaffolding of what a reimbursement structure might look like,” she continued. “At the same time, of course, we really want to elevate and amplify the voices of those who have been working on the ground locally, and who can talk about the need for and benefit of violence prevention in their communities.

“All of these things are really important when you’re on that last mile, so to speak, between the adoption of a policy and actually making sure it’s real,” Dreier said.

Dan can be reached at [email protected] and @DanMcCue