Among the myriad health issues that remain unresolved by policymakers in Washington is how to stanch the unrelenting toll of our nation’s opioid epidemic.
Drug overdoses are now the leading cause of death for Americans under 50. In 2016, the overdose rate increased by 28 percent over the previous year, claiming 42,000 lives—or 174 each day. And in the wake of the opioid and addiction crisis, the United States has now recorded the second straight year of declining life expectancy in more than a half century.
In October, President Trump drew valuable attention to the problem by declaring a public health emergency, although it did not come with financial support for the people and communities on the front lines.
In this sea of bad news, there is one bright spot in the policy world we must be sure to protect: the unique and central role Medicaid plays in providing substance abuse prevention and treatment, particularly in states that have expanded Medicaid coverage.
The Effect of the Medicaid Expansion
The Affordable Care Act (ACA) allowed states to expand Medicaid programs at a fraction of the cost and required that they include coverage for mental health and substance-use disorder services, thereby enabling Medicaid expansion states to care for many more people who required such services. The ACA also strengthened mental health parity by requiring insurers to cover mental and behavioral health services at the same level as other services. Together, these provisions significantly broadened Medicaid coverage and the capacity of states to address the opioid epidemic.
Medicaid expansion has particularly benefited the states hardest hit by the opioid epidemic. According to the Substance Abuse and Mental Health Services Administration, as of 2016, Medicaid expansion states were able to extend coverage for substance-use disorders to 1.2 million Americans. And the Kaiser Family Foundation notes that Medicaid provides treatment to more than three in 10 people with an opioid addiction.
The most effective treatment for opioid addiction, according to the American Society of Addiction Medicine and the Centers for Disease Control and Prevention (CDC), is medication-assisted treatment (MAT), which combines medication with counseling and other therapies. All state Medicaid programs cover at least one of the three MAT medications. Nationally in 2016, Medicaid paid for more than 20 percent of buprenorphine prescriptions, a MAT medication that has proven highly effective in treating opioid addiction.
Some states have promoted their effective use of MAT in the context of their Medicaid expansions. Moreover, Medicaid now pays for as much as 50 percent of MAT in those states, according to Richard Frank, PhD, a health economics professor at Harvard Medical School and former Assistant Secretary for Planning and Evaluation at the U.S. Department of Health and Human Services, and Sherry Glied, dean of the Wagner School of Public Service at NYU, citing reports of the statistic in a column published by The Hill. Without expansion, these states would have a much harder time maintaining access to evidence-based treatment.
Medicaid expansion also has eased the burden of uncompensated care on hospitals and other healthcare providers. The share of uninsured hospitalizations for substance use or mental health disorders fell from 22 percent to 14 percent after the ACA’s insurance provisions went into effect. In states that expanded Medicaid, the uninsured proportion of hospitalizations related to behavioral health decreased from 20 percent in 2013 to 5 percent in 2015 according to the U.S. Department of Health and Human Services.
Threats Posed by ACA Repeal
Unfortunately, legislative proposals to alter Medicaid could reverse coverage gains and jeopardize these critical services when and where they are most needed. As Frank and Glied note in the Hill column, if the ACA were fully repealed, about 2.8 million Americans with a substance use disorder—222,000 of whom have an opioid use disorder—would lose some or all of their health insurance and their access to mental health treatment. The nonpartisan Congressional Budget Office has projected that proposals to block grant Medicaid could result in the loss of more than $1 trillion between 2017 and 2026, severely undermining states’ ability to provide comprehensive care, including substance abuse services, and greatly increasing the challenge of combatting the opioid epidemic. Senators Rob Portman (R-Ohio) and Shelley Capito (R-W.Va.), among others, have raised concerns that this approach would erode access to substance-abuse services, and are working to address the issue.
In the face of these threats, several states have taken steps to improve access to prevention, treatment, and recovery services. Areas of focus have included:
- Reducing inappropriate prescribing through increased use of prescription drug monitoring programs and limits on prescriptions
- Expanding access to naloxone through first responders and standing orders at pharmacies
- Ensuring a path to treatment and recovery by increasing the number of MAT providers and requiring public and private insurance coverage of MAT
The Centers for Medicare & Medicaid Services (CMS) also released new guidance in November encouraging states to apply for 1115 waivers that would loosen Medicaid restrictions on payment for care in residential treatment facilities, paving the way for states to pay for the full continuum of care for people with substance use disorders.
Clearly, the healthcare industry has a leading role to play in areas such as education, prevention, and treatment. Marketing by opioid manufacturers, misinformation, and lack of provider education has fueled inappropriate prescribing. According to CDC, sales of prescription opioids in the United States nearly quadrupled from 1999 to 2014, without Americans reporting an overall change in pain levels. CDC reports 214 million total opioid prescriptions were dispensed in 2016. Physicians, pharmacists, and health plans must collaborate to ensure not only appropriate prescribing but also that non-opioid, evidence-based therapies are available and new ones are researched thoroughly.
UCare of Minneapolis, for example, is working with community providers to expand access to treatment across the region. The health plan also is piloting an emergency department (ED)/inpatient diversion program at a local behavioral health center. The program implements a holistic approach to treatment services that includes health assessments, physician visits, care plan development and coordination, peer recovery support, and discharge/transfer planning. By offering an enhanced system of care at a fraction of ED costs, while improving health outcomes for members, the program could produce $197,000 of savings in 2018.
Another example is UPMC Insurance Services Division in Pittsburgh, which has created a variety of innovative programs focused on prevention and treatment. UPMC purchases naloxone kits for distribution to local first responders to help prevent overdoses. At the provider level, UPMC offers extensive education on substance-use screening and treatment and has developed a provider-insurer partnership to systematize interventions, enhance the scope of interventions, and support community-based primary care practices and addiction-treatment providers to increase access to MAT. The intensive care management program also deploys community health workers and care managers to work individually with members to support engagement in treatment and recovery.
A National Imperative
Access to prevention and treatment services is critical to curbing the opioid epidemic. Medicaid funding has opened the door to services for millions of Americans in need. Continuing support for Medicaid funding and maintaining Medicaid expansion are central to curbing the opioid crisis. In the face of Medicaid’s uncertain future, states and health plans are doing more with less to maintain and increase access to coverage. It’s time for Washington to do the same: fully realize the impact of this crisis, put politics aside, and put people first to save lives.