CIGH Blog

By Danielle Cohen

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and has a startling reach. According to the NIH Cancer Institute, “nearly all sexually active people are infected HPV within months to a few years of becoming sexually active” (1). While many infected individuals may notice no symptoms, a sizeable portion of those infected will end up with cancer later in life. According to the CDC, nearly 36,000 new cancer cases in the US are caused annually by HPV (2). With the introduction of the HPV vaccine in 2006, many of these cases of cancer could now be considered preventable. Indeed, to reduce the significant burden of HPV and its associated cancers on the US healthcare system, we must vaccinate all eligible people. Given that the Federal Advisory Committee on Immunization Practices recommends people get vaccinated at age 11 or 12, the most effective way to ensure mass vaccination is by implementing mandates through the education system.

Mandatory school vaccination laws exist across the United States for diseases such measles, mumps, rubella, and diphtheria. It has been previously shown that implementing vaccination mandates through schools reduces morbidity of targeted diseases; vaccination mandates are attributed to half of the drop in measles in the 1960s (3). Despite the proven success of vaccine mandates for disease prevention, as of April 2020, only two states and Washington D.C. require the HPV vaccine for school attendance (4). Here in Illinois, students of the appropriate age (11-12) and their families are provided with information on HPV and its links to cancer. However, the state has failed thus far to mandate vaccination.

While some may argue that a mandate would cause excess backlash on moral or religious grounds, consider two key points. First, a recent robust study demonstrated that new HPV legislation has not been associated with changes in adolescent sexual activity (5). Second, as with other vaccine mandates, provisions could be included allowing individual families to opt out on moral or religious grounds when appropriate.

While it is evident that school-imposed vaccine mandates are effective, one must now consider why the HPV vaccine specifically is of such grave importance. HPV is unique in its prevalence among newly sexually active people in tandem with its risk of cancer later in life. Sexually active adolescents may be exposed to a virus at age 15 that comes back to haunt them in form of cancer at age 50. Not only is HPV responsible for “virtually all” cervical cancers, the virus can also cause cancer in other commonly infected body parts; 70% of oropharyngeal cancers and over 90% of anal cancers in the US are reportedly caused by HPV (1). By encouraging the vaccination of all eligible adolescents, the Illinois Board of Education could significantly reduce the burden of these cancers on the health system.

An additional benefit of mandating the HPV vaccine through schools would be closing the gap between male and female vaccination rates. Upon its release in 2006, the vaccine was widely discussed as a preventative measure against cervical cancer for girls. However, the vaccine is also recommended for boys, who are susceptible to oropharyngeal, anal, and penile cancers caused by HPV (1). Despite this recommendation, as of 2018 just 27% of males have received one or more doses of the HPV vaccine, compared with 53.6% of females (6). Mandating the vaccine could help close this gap.

We are fortunate to live in a time where the most common sexually transmitted infection, and one with potentially lethal consequences, has a vaccine. In an ideal world, all families would ensure their children were vaccinated without pressure from outside sources. However, in the US less than 40% of adults aged 18-26 have had one or more doses of the HPV vaccine in their lifetime (6). By mandating vaccination for students, the Illinois Board of Education could significantly reduce the rate of HPV and as a result, the virus’s related cancers. For the health of our community, it is imperative that the Board of Education mandate HPV vaccines.

References 

1. https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-and-cancer#cancers-caused
2. How Many Cancers Are Linked with HPV Each Year? https://www. cdc.gov/cancer/hpv/statistics/cases.htm
3. The Effects of Mandatory Vaccination Laws on Childhood Health and Adult Educational Attainment https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1987898#:~:text=The%20results%20demonstrate%20that%20school,of%20its%20vaccine%20in%201963.
4. HPV Vaccine: State Legislation & Regulation https://www.ncsl.org/research/health/hpv-vaccine-state-legislation-and-statutes.aspx
5. Legislation to Increase Uptake of HPV Vaccination and Adolescent Sexual Behaviors https://pediatrics.aappublications.org/content/142/3/e20180458.full
6. Human Papillomavirus Vaccination Among Adults Aged 18-26, 2013-2018 https://www.cdc.gov/nchs/products/databriefs/db354.htm#:~:text=Among%20adults%20aged%2018%E2%88%9226%2C%20the%20percentage%20who%20ever%20received,2013%20to%2021.5%25%20in%202018.

By Dharrnesha Inbah Rajah

This Policy brief has been published by the Chicago Policy Review. Click here to read full publication. 

By Suzanna Buck

Non-communicable diseases (NCDs)—predominately diabetes, heart and lung disease, and cancer—have long been the major causes of death in the United States (US) and the European Union (EU). But rates of NCDs are skyrocketing everywhere, as obesity, sedentary lifestyle, smoking, and drinking rapidly spread globally. These ailments cause 71% of all deaths worldwide and up to 85% of deaths in low- and middle-income countries.[1][2]

Even when they don’t kill, NCDs decrease the quality of life. Meanwhile, health organizations, particularly in developing economies, are largely set up to combat infectious diseases, so are often ill-prepared to care for patients with cancer, diabetes or other NCDs.

Inadequate health infrastructure notwithstanding, only ramping up preventive care and, ultimately, policy change will stop the onslaught of NCDs. Clean air, nutritious food, physical activity, time and space to be smoke free—these are some of the means to stem the tsunami of lifestyle diseases.[3] Progress toward such health fundamentals requires reducing pollution and creating sustainable food systems.[4] Worryingly, headway toward these basic goals is stymied on the one hand by climate change risks, and on the other, by the same corporate disregard for health that led to the climate crisis.[5]

Climate change is exacerbating the global burden of NCDs.[6] At the same time, global corporate power slows down work to combat climate change and pollution and to reduce smoking rates and consumption of sugar, alcohol, and trans-fats. [7] Mass campaigns of science-denialism by major US oil companies has led to a failure to recognize climate change as a leading global health threat.  Meanwhile, heatwaves are leading to excess mortalities, as are more intense and frequent natural disasters such as hurricanes, floods, and wildfires.[8] Heat and soil degradation are reducing air quality and decreasing the nutritional value of our food.  As droughts “of the century” become commonplace, so do famine, conflict, and displacement, causing not only direct physical health effects but also mental health crises.

As if their effects on NCDs weren’t enough, warmer winters increase the ranges of disease vectors, allowing zoonotic diseases to claim new territories. Environmental degradation can cause viruses to jump species, as may have happened with COVID-19 and Ebola.  

We have arrived at this dire state of affairs by subsidizing low-nutrition food, industrial agriculture, and fossil fuels.[9] Today’s global health crises are not the result of the alien logic of viruses and bacteria but of choices made, or not made, by humans and our institutions. Corporate interests, in pursuit of profits, have globalized cheap, low-nutrition foods, pushed cigarette smoking and alcohol consumption, and made de-regulation a requirement for free trade.[10]

Consider the case of cigarettes. As consumer advocates and, belatedly, health establishments, pushed back against tobacco growers and cigarette manufacturers, these interests instead sowed doubt about the scientific method itself while flooding Washington with political lobby money. When lobbying and obfuscation could no longer hide the mounting health toll of lung cancer, these companies turned the focus of their businesses elsewhere, concentrating on hooking new and larger consumer bases in less regulated developing economies.[11]

Tobacco companies wrote the playbook that fossil fuel companies quickly followed and executed more successfully. Soda companies finance their own research to undercut any argument in favor of sugar taxes.[12] Commodity farmers were already getting huge subsidies, and industrial agriculture is made up of vertically integrated monopolies, so they just lobby to maintain the status quo. The opioid crisis is yet another egregious example of the death toll that is tolerated in the pursuit of profits.

To change the trajectory, and to combat climate change, we must prioritize health. While economic development may be the surest way to reduce poverty, unfettered profit seeking is not the way toward sustainable growth. Effective regulation to protect human and ecological health has been slowed down by global corporate lobbying efforts. Unless we find a means to change the power structures that have gotten us here, we will not avert the deepening health crises of NCDs and climate change.[13]

References

[1] Bigna, Jean Joel et al. The rising burden of non-communicable diseases in sub-Saharan Africa. The Lancet Global Health, Volume 7, Issue 10, e1295 - e1296

[2] Branca Francesco, Lartey Anna, Oenema Stineke, Aguayo Victor, Stordalen Gunhild A, Richardson Ruth et al. Transforming the food system to fight non-communicable diseases BMJ 2019; 364 :l296

[3] Beaglehole et al., Priority actions for the non-communicable disease crisis, The Lancet, Volume 377, Issue 9775, 2011, Pages 1438-1447, ISSN 0140-6736, https://doi.org/10.1016/S0140-6736(11)60393-0.

[4] Branca Francesco, Lartey Anna, Oenema Stineke, Aguayo Victor, Stordalen Gunhild A, Richardson Ruth et al. Transforming the food system to fight non-communicable diseases BMJ 2019; 364 :l296

[5] Corvalán, C., Reyes, M., Garmendia, M.L. and Uauy, R. (2013), Food labeling legislation favoring public health in Chile. Obes Rev, 14: 79-87. https://doi.org/10.1111/obr.12099

[6] Amy Savage, Lachlan McIver & Lisa Schubert (2020) Review: the nexus of climate change, food and nutrition security and diet-related non-communicable diseases in Pacific Island Countries and Territories, Climate and Development, 12:2, 120-133, DOI: 10.1080/17565529.2019.1605284

[7] Kadandale S, Marten R, Smith R. The palm oil industry and noncommunicable diseases. Bull World Health Organ. 2019;97(2):118-128. doi:10.2471/BLT.18.220434

[8] Michael E. St. Louis, Jeremy J. Hess, Climate Change: Impacts on and Implications for Global Health, American Journal of Preventive Medicine, Volume 35, Issue 5, 2008, Pages 527-538, ISSN 0749-3797, https://doi.org/10.1016/j.amepre.2008.08.023.

[9] Penelope Milsom, Richard Smith, Phillip Baker, Helen Walls, Corporate power and the international trade regime preventing progressive policy action on non-communicable diseases: a realist review, Health Policy and Planning, 2020;, czaa148, https://doi.org/10.1093/heapol/czaa148

[10] Sacks, G., Swinburn, B., Kraak, V., Downs, S., Walker, C., Barquera, S., Friel, S., Hawkes, C., Kelly, B., Kumanyika, S., L'Abbé, M., Lee, A., Lobstein, T., Ma, J., Macmullan, J., Mohan, S., Monteiro, C., Neal, B., Rayner, M., Sanders, D., Snowdon, W., Vandevijvere, S. and (2013), Monitoring private‐sector policies and practices. Obes Rev, 14: 38-48. https://doi.org/10.1111/obr.12074

[11] Francey Neil, Chapman Simon. “Operation Berkshire”: the international tobacco companies' conspiracy BMJ 2000; 321 :371

[12] Tselengidis A, Östergren P-O. Lobbying against sugar taxation in the European Union: Analysing the lobbying arguments and tactics of stakeholders in the food and drink industries. Scandinavian Journal of Public Health. 2019;47(5):565-575. doi:10.1177/1403494818787102

[13] Yang, J.S., Mamudu, H.M. & John, R. Incorporating a structural approach to reducing the burden of non-communicable diseases. Global Health 14, 66 (2018). https://doi.org/10.1186/s12992-018-0380-7

By Virginia Stattman

The past four years of the Trump administration were characterized by frustrating, and at times dangerous, steps against social progress. Yet there was one potential beacon held aloft by Trump and his senior advisors that the Biden Administration should move toward: expanded benefits for working parents. The United States (US) needs to implement mandatory paid maternity/paternity leave policies. Doing so will strengthen gender parity, improve child health outcomes, and build a stronger workforce.

Parents of all genders, be they biological or adoptive, should by law have access to paid parental leave. However, given its potential impact on female workforce retention and the low probability of more sweeping policy reform, I will focus on maternity leave. The United States lags behind other developed nations for parental leave policies. According to the Organisation for Economic Co-operation and Development (OECD), the US is one of 38 countries that does not have a legally-required paid maternal leave policy in place.[1] In comparison, the United Kingdom is a leader among nations in offering up to 52 weeks off for eligible employees, with 39 weeks of statutory maternity pay at roughly 90% of average weekly earnings.[2] The UK also requires a minimum period of paid maternity leave, a measure that may have the added benefit of normalizing taking time off to raise young children.

In the US, the most recent national family leave reform was the 1993 Family and Medical Leave Act (FMLA), which requires public agencies and private employers with 50 or more employees to provide unpaid Parental leave to all eligible employees.[3] This policy is limited and outdated, covers only approximately 60% of the workforce, and fails to address critical economic implications of raising a new child without a salary. For many Americans, taking off 12 weeks without an income is impossible. More critically, we should not be asking Americans to balance post-natal care and the needs of their immediate family with unnecessary financial stress.

These stressors continue to have an impact on women as they progress through their careers. The COVID-19 pandemic has highlighted the challenges women face raising children but the pattern of women leaving the workforce to deal with family obligations began well before. According to one study, from 1990 to 2010, there is a 29% drop in female labor participation rate relative to other OECD countries, due to the lack of family policies including parental leave in the US.[4], [5] Additionally, researchers with Rutgers Center for Women and Work found that, of women sampled, those “with a paid leave are 93% more likely to be working at postpartum months 9‐12 than are those who did not take any leave.”[6]

Paid maternal leave is also associated with better health outcomes for infants and children. According to a study led by Jody Heymann, “An increase of 10 full-time-equivalent weeks of paid maternal leave was associated with a 10% lower neonatal and infant mortality rate and a 9% lower rate of mortality in children younger than 5 years of age.”[7] Researchers also found paid maternal leave was associated with higher and longer rates of breastfeeding and immunization adherence. These are critical considerations for healthy child development that can all be facilitated by better maternal health policies.

Given the health benefits for children and greater gender parity in the workforce possible from maternity leave policies, the US should implement mandatory, 12-week, paid maternity leave for all workers.

References

[1] Length of maternity leave, parental leave and paid father-specific leave. Organisation for Economic Co-operation and Development. https://www.oecd.org/gender/data/length-of-maternity-leave-parental-leave-and-paid-father-specific-leave.htm. Accessed February 11, 2021.

[2] Statutory Maternity Pay and Leave: employer guide. Gov.UK. https://www.gov.uk/employers-maternity-pay-leave#:~:text=Eligible%20employees%20can%20take%20up,the%20baby%20is%20born%20early. Accessed February 11, 2021.

[3] Paid Family and Sick Leave in the U.S. Kaiser Family Foundation. https://www.kff.org/womens-health-policy/fact-sheet/paid-family-leave-and-sick-days-in-the-u-s/. Published December 14, 2020. Accessed February 11, 2021.

[4] Blau, Francine D. Blau and Kahn, Lawrence M. Female Labor Supply: Why Is the United States Falling Behind? American Economic Review: Papers & Proceedings 2013, 103(3): 251–256. http://dx.doi.org/10.1257/aer.103.3.251

[5] Blau, Francine D. Blau and Kahn, Lawrence M. Female Labor Supply: Why Is the United States Falling Behind? American Economic Review: Papers & Proceedings 2013, 103(3): 251–256. http://dx.doi.org/10.1257/aer.103.3.251

[6] Houser, Linda. Pay Matters: The Positive Economic Impacts of Paid Family Leave for Families, Businesses and the Public. A Report of the Center for Women and Work. January 2012.

[7] Heymann J, Raub A, Earle A. Creating and using new data sources to analyze the relationship between social policy and global health: the case of maternal leave. Public Health Rep. 2011;126 Suppl 3(Suppl 3):127-134. doi:10.1177/00333549111260S317.

By Chinasa Imo

The research documented by Brian J. Honermann[1] on past epidemics highlighted the consequences of infectious disease outbreaks on mental health. Even though the COVID-19 pandemic is a physical health crisis, it has also contributed greatly as a major mental health crisis for women[2]. Good mental health is critical to the functioning of all aspects of society. Therefore, a focus on the mental wellbeing of every member of society should be integrated into the COVID-19 pandemic response and recovery phase[3]. 

Although the pandemic severely and negatively impacted the mental health and wellbeing of the society at large; women constitute the demographics that have been highly impacted by the mental health burden. Along with frontline workers and first responders (who are also mostly women), children, and older people[4]. This is due in part to the fact that besides being able to quickly slide into the increased caregiving role, women who contract the virus or are taking care of someone with the virus were mentally distressed by the immediate health effects and the consequences of physical isolation. Adding to these stressors is the fact that most women who need to access a wide range of reproductive healthcare services during the lockdown were unable to do so, as funds and attention were repurposed directly for the Covid-19 emergency response[5]

Women are bearing the brunt of increased stress at home, taking care of everyone under their care, with little or no consideration of the impact these may have on their mental health. Women in low-income settings are even at greater risk of having their mental health needs overlooked entirely[6].

A survey of the stress levels of the outbreak in the Indian population during this COVID-19 pandemic indicates that 66% of women reported being stressed compared to 34% of men[7]. In the current pandemic situation, pregnant women and new mothers are especially likely to be anxious due to difficulties associated with accessing health care services, finding social support, and the fears of being infected[8]. 

In some family arrangements, there has been an increased burden on women to take on additional duties of caregiving such as homeschooling children and taking care of older relatives[9]. Also, as with the increased prevalence of childhood abuse, the situation with restrictions on movement, and lockdown stress, increased the incidence of violence towards women by their partners/family members [10]. 

Some of the impacts of Covid-19, especially on women include:

Economic Impact: Compounded economic impacts are felt especially by women and girls, who generally earn less, save less, and hold insecure jobs, or live close to poverty. The COVID-19 pandemic has caused many women to live with the fear of losing their means of livelihood. 

Frontline response: Globally, women makeup 70 percent of the healthcare workforce and are more likely to be front-line health workers, especially nurses, midwives, and community health workers[11]. They also comprise most health facility service staff, playing a crucial role in fighting the outbreak and saving lives. However, they are under exceptional stress. They are burdened with extreme workloads, make difficult decisions during every work shift, risk becoming infected and spreading the infection to their family members and communities, face stigmatization, and witness the deaths of many patients[12]. 

Exposure to Domestic Violence: As the COVID-19 pandemic deepens economic and social stresses, coupled with Public health measures such as social isolations, restriction of movements: gender-based violence is increasing at an alarming rate. Many women are being forced to ‘lockdown’ at home with their abusers while services to support such victims and survivors are either disrupted or has been made inaccessible. It has been estimated that globally 31 million additional cases of gender-based violence can be expected to occur if the outbreak continues[13].

Inability to access basic healthcare when needed: While early reports by George Bwire[14] Reveals a higher mobility and mortality rate among men with COVID-19, the health of women is more generally and adversely impacted by the reallocation of resources and a shift of government priorities from other regular healthcare services[15]. Most women seeking routine primary care including sexual and reproductive health services are unable to access care easily[16].

Increase stress from home care work: With children out-of-school, heightened care needs of older persons, and overwhelming health services, women have had to escalate efforts to take care of their families’ immediate needs and to maintain the home front, at the expense of their physical and mental health.

What has been done?

During the past few months, efforts to support women with mental health vulnerability have been initiated. Innovative ways of providing mental health services have been implemented, and initiatives to strengthen psychosocial support have sprung up[17] these are reactionary measures set up to address the already escalating problems. Yet, the sheer size of the problem, along with other socio-economic burdens of the pandemic and low investment in mental health interventions, mean that most mental health needs remain unaddressed. 

Recommendations 

• All Social Service Agencies should develop and include mental health response strategies that incorporate a concrete framework on how to protect women’s mental wellbeing during a pandemic in their health emergency response plan. 
• They should design and include communication and awareness strategies on how to manage mental health challenges during health emergencies, including where women can seek help.
• The government at all levels needs to make provisions for emergency mental health and psychosocial support for women for this ongoing pandemic, as well as during the recovery phase post-pandemic by investing in mental health interventions that are comprehensive, innovative, available, and accessible.
• The global Covid-19 response team should Adopt a comprehensive mental health intervention approach to the COVID-19 emergency response. As a matter of urgency, mental health response strategy should be standardized as a policy framework/mechanism for all global health emergencies.  

References 

 [1] Brian J. Honermann, (Feb 2015). An “Epidemic Within an Outbreak”: The Mental Health Consequences of Infectious Disease Epidemics. O’Neill Institute for National and Global Health Law, Georgetown University Law Center

[2] WHO (Oct 2019). Mental Health. Accessed via https://www.who.int/news-room/facts-in-pictures/detail/mental-health)

[3] Person, Bobbie et al. “Fear and stigma: the epidemic within the SARS outbreak.” Emerging infectious diseases vol. 10,2 (2004): 358-63. doi:10.3201/eid1002.030750

[4] UNFPA. (2020). Accessed via https://www.unfpa.org/press/new-unfpa-projections-predict-calamitous-impact-womens-health-covid-19-pandemiccontinues

[5] UN-Women Policy Brief. (April 2020). The Impact Of Covid-19 On Women. Accessed via policy_brief_on_covid_impact_on_women_9_april_2020.pdf (un.org)

[6] Ibid

[7] WHO (2019). Gender equity in the health workforce: Analysis of 104 Countries: https://apps.who.int/iris/bitstream/handle/10665/311314/ WHO-HIS-HWF-Gender-WP1-2019.1-eng.pdf?ua=1

[8] Ibid

[9] Ibid

[10] “Domestic Violence Spikes During Coronavirus as Families Trapped at Home” accessed 2nd April 2020 https://10daily.com.au/news/australia/a200326zyjkh/ domestic-violence-spikes-during-coronavirus-as-families-trapped-at-home-20200327, 

[11] UN-Women Policy Brief. (April 2020). The Impact Of Covid-19 On Women. Accessed via policy_brief_on_covid_impact_on_women_9_april_2020.pdf (un.org)

[12] UN (May 2020). Covid-19 and the Need for Action on Mental Health: Policy Brief. Accessed via un_policy_brief-covid_and_mental_health_final.pdf on April 10, 2021

[13] CARE. (May 2020). Gender Based Violence and Covid-19: The Complexities of Responding to the Shadow Pandemic; A Policy Brief. Accessed via GBV_and_COVID_Policy_Brief_FINAL.pdf (reliefweb.int) on April 10, 2021.

[14] Bwire G. M. (2020). Coronavirus: Why Men are More Vulnerable to Covid-19 Than Women?. SN comprehensive clinical medicine, 1–3. Advance online publication. https://doi.org/10.1007/s42399-020-00341-w

[15] Deb Gordon, (Mar 2021). Women not Getting the Healthcare they Need During Covid-19, New Survey Shows. Forbes News

[16] Ibid

[17] Shidhaye R, et al, (Nov 2020). An Integrated Approach to Improve Maternal Mental Health and Well-Being During the COVID-19 Crisis. Front Psychiatry. 24; 11:598746. doi: 10.3389/fpsyt.2020.598746. PMID: 33329148; PMCID: PMC7732456.

To: Illinois Department of Healthcare and Family Services (HFS)

From: Siyuan (Sabrina) Gao, Policy Analyst

Problem Statement:

Illinois faces a continuity of care crisis, especially in rural and underserved areas. Rising demand is not matched by a system capable of ensuring patients receive ongoing, coordinated, and connected services across time and settings. In 2023, over 25% of adults reported anxiety or depression symptoms, up from 11% in 2019.i Illinois has only 13.8 behavioral health professionals per 10,000 residents, well below the national average, and nearly 40% of residents live in designated shortage areas.ii Gaps in provider availability, fragmented handoffs between services, and insufficient infrastructure for follow-up care all contribute to disjointed and often interrupted treatment journeys.

Policy Solutions:

1. Renewing Illinois’ 1115 Behavioral Health Transformation Waiver to Ensure Continuity of Care: The Illinois Department of HFS should institutionalize and expand its Section 1115 Behavioral Health Transformation Waiver as a long-term strategy to improve continuity of care for Medicaid enrollees with behavioral health needsiii and ensure that patients receive consistent follow-up or care coordination. The waiver facilitates improvement of continuity of care for Medicaid enrollees with behavioral health needs by reimbursing for services such as care coordination, co-located case management, and CHWsupported transitions, which are often not funded under traditional Medicaid models. Gaps lead to higher readmission rates, worse medication adherence, and less opportunities for preventive care. iv While the current waiver enables pilot programs, such as mobile crisis outreach, transitional housing support, and CHW-led reentry planning, it remains timelimited. These interventions directly reduce the fragmentation patients experience when moving between systems. Although federal law limits each waiver approval to five years, HFS can pursue successive renewals as a long-term strategy or a Medicaid State Plan Amendment. Doing so would secure ongoing federal matching funds, standardize provider reimbursement for transitional services, and embed cross-sector collaboration into Illinois’ behavioral health delivery model. As a Medicaid authority, HFS is uniquely positioned to operationalize this reform statewide and mandate participation through managed care contracts. By reimbursing services that prioritize seamless care transitions, the waiver reduces reliance on acute care and improves patient stabilization in the community. v

2. Expanding Illinois’ Behavioral Health Workforce Through a Continuity-Focused Residency and Scholarship Program: Over 40% of surveyed workers reported symptoms of burnout, and 37% were considering leaving their jobs within a year.vi The Illinois House Mental Health & Addiction Committee has also acknowledged these systemic issues, calling for enhanced training and continuity-building strategies. vii To address these persistent behavioral health workforce shortages and enhance continuity of care, the Illinois Department of HFS should establish a behavioral health residency and service scholarship program. HFS is uniquely positioned to lead this effort because it oversees both Medicaid services and workforce development investments. Many providers are trained in settings that are disconnected from the broader continuum of care, such as working only in hospitals and lack practical experience coordinating care across setting,viii which are key components of continuity in behavioral health treatment. This program would support trainees, such as social workers, licensed professional counselors, and psychologists, who rotate through multiple behavioral health service settings including crisis stabilization units, inpatient facilities, and primary care-integrated behavioral health sites. In exchange for tuition support and stipends, participants would commit to working in high-need, community-based organizations that serve Medicaid enrollees, especially in rural or underserved areas.ix This strategy not only brings more providers to areas with the greatest need but also helps build lasting providerpatient relationships over time.

III. Evaluation on Efficiency, Equity, and Feasibility

Efficiency:

Efficiency strongly favors Policy 1. This initiative has already demonstrated success in strengthening care continuity and improving efficiency by shifting patients away from fragmented treatment toward coordinated, community-based services that support sustained care across time. Rather than duplicating or replacing existing care, Policy 1 complements the broader Medicaid system by filling gaps between services, ensuring smoother transitions, and reducing unnecessary institutional use.x In contrast, Policy 2 requires substantial upfront investment and has a slower return on efficiency. Recruiting and retaining behavioral health professionals is costly and time-consuming, and workforce expansion alone does not guarantee improvements in care quality or service utilization, particularly without addressing structural inefficiencies within the delivery system.

Equity:

Policy 2 performs slightly better by directly addressing geographic and socioeconomic disparities in access to behavioral health care. It targets rural and underserved areas where workforce shortages are most acute, offering scholarships, loan forgiveness, and housing subsidies to reduce barriers to entry for aspiring professionals. This aligns with findings which highlighted widespread dissatisfaction with pay, high debt burdens, and high turnover among providers.xi However, Policy 1 also achieves a meaningful degree of equity by making proven services more broadly available through Medicaid and improving access among low-income beneficiaries.xii

Feasibility:

Feasibility clearly favors Policy 1. The infrastructure, legal authority, and data supporting the 1115 waiver are already in place, and the program has demonstrated success in its pilot phase, lowering the political and administrative barriers to implementation. The proposed five-year extension builds on established collaborations between providers, payers, and state agencies, making it a practical and scalable policy option.xiii In contrast, Policy 2 faces more complex implementation challenges under which efforts to incentivize workforce participation require interagency coordination, legislative appropriations, and long-term commitment to funding education and training programs. Moreover, systemic issues such as high debt-to-income ratios and licensing hurdles may continue to deter new entrants despite incentives.xiv IV.

Recommendation:

Based on the evaluation, I recommend that HFS move forward with Policy 1: Extending the 1115 Waiver to Expand Community-Based Services. This policy provides a practical, cost-effective solution that improves long-term access to behavioral health care. It supports low-income populations, strengthens community infrastructure, and aligns with HFS’s ongoing strategic priorities to transform behavioral health delivery under Medicaid. It directly addresses the fragmentation in Illinois’ behavioral health system by supporting crisis hubs, mobile response teams, and coordinated outpatient services. While Policy 2 targets long-term workforce shortages, it requires higher upfront investment and faces significant implementation barriers. Compared to other options, Policy 1 is more feasible to implement, builds on established infrastructure, and demonstrates clear efficiency gains through lower costs and improved care coordination.

Appendix

Policy Outcomes Matrix Criterion

References

i Cook County Health RFQ H23-0022. (2024a, October). https://illinoisbhwc.org/wpcontent/uploads/2024/10/Cook-County-Behavioral-Health-Workforce-Full-Report-Cook-County-BHWorkforce-Assessment-October-2024-FINAL.pdf

ii Addressing Illinois’ behavioral health workforce shortage. BHECON. (n.d.). https://www.bhecon.org/wp-content/uploads/2019/06/IL-Workforce-Fact-Sheet.pdf

iii Pritzke, J. (2023, June 23). Illinois Behavioral Health Transformation 1115 Demonstration. https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/il-behave-healthtransform-pa-06232023.pdf

iv Pritzke, 2023 v Pritzke, 2023

vi Cook County Health RFQ H23-0022, 2024a vii Behavioral Health Workforce Shortage. House Mental Health & Addiction Committee Senate Behavioral Health Committee. (2024, January 25). https://www.ilga.gov/house/committees/103Documents/HMEH/Book%20-%20Behavioral%20Health% 20Workforce%20Shortage%201-25-24.pdf

viii Grazier, K. L., Smiley, M. L., & Bondalapati, K. S. (2016, July 4). Overcoming barriers to integrating behavioral health and Primary Care Services. Journal of primary care & community health. https://pmc.ncbi.nlm.nih.gov/articles/PMC5932707/?utm_source

ix Obstacles to behavioral health services for Medicaid. Carenet Health. (2024, December 12). https://carenethealthcare.com/obstacles-to-behavioral-health-services-increasingly-difficult-formedicaid-populations/

x Pritzke, 2023

xi Cook County Health RFQ H23-0022, 2024a

xii The State of Illinois Newsroom. (2024, July 29). Gov. Pritzker announces federal approval of 1115 waiver, expanded Medicaid coverage. The State of Illinois Newsroom. https://gov-pritzkernewsroom.prezly.com/gov-pritzker-announces-federal-approval-of-1115-waiver-expanded-medicaidcoverage?utm_source

xiii Pritzke, 2023 xiv Mental Health Matters: Addressing Behavioral Health Workforce Shortages. The Council of State Governments. (2024, October 10). https://csg.org/2024/10/10/mental-health-matters-addressingbehavioral-health-workforce-shortages/?utm_source