To tackle the opioid epidemic, which has been the leading cause of unnatural deaths since 2013, Virginia recently developed an integrated physical and behavioral health continuum of care, which spans multiple treatment settings and includes case management and peer recovery support. The initiative, combined with increased access to naloxone and other efforts, has helped reduce fatal overdoses by 3.3 percent between 2017 and 2018.
In March 2016, with support from Virginia Gov. Terry McAuliffe, the Virginia General Assembly passed appropriations mandating transformation of the SUD Medicaid benefit entitled the Addiction and Recovery Treatment Services program or ARTS, which was implemented on April 1, 2017. Early results from Virginia’s ARTS program indicate success in increasing access to care for Medicaid-eligible pregnant women with SUD and opioid use disorder (OUD).
Data obtained from pre-ARTS implementation (covering April 2016-March 2017) compared to post-ARTS implementation (April 2017-March 2018) indicate that the percent of Medicaid-enrolled pregnant women with SUD who received treatment increased from 2 percent to 21 percent, while the rate of pregnant women with OUD who received treatment increased from 4 percent to 31 percent. In addition to increasing treatment rates, the number and types of treatment providers and treatment programs available to pregnant women with SUD and OUD also increased significantly in the post-ARTS implementation period.
Ashley Harrell, senior program advisor with Virginia’s Department of Medical Assistance Services (DMAS), recently shared the goals and highlights of the program with the Maternal and Child Health Policy Innovation Program (MCH PIP) Policy Academy, hosted by the National Academy for State Health Policy (NASHP). The academy, made up of eight cross-sector state teams, focuses on the mental health needs of pregnant and parenting women, particularly those with or at risk of substance use disorder (SUD). The ARTS program has six major goals:
- Expand the short-term SUD inpatient detox benefit to all Medicaid/FAMIS enrollees (FAMIS is Virginia’s health insurance program for uninsured children);
- Expand short-term SUD residential treatment to all Medicaid enrollees;
- Increase reimbursement for existing Medicaid/FAMIS SUD treatment services;
- Add peer support services for individuals with SUD and/or mental health conditions;
- Require SUD care coordinators for DMAS-contracted managed care plans; and
- Organize provider education, training, and recruitment activities.
The Virginia state Medicaid agency has made additional policy changes to improve access to care for pregnant enrollees with SUD. Some of these changes include:
- Allowing and encouraging same-day billing of medical and behavioral health services;
- Requiring access to medication-assisted treatment (MAT) along the addiction care continuum; and
- Removal of prior authorization requirements for up to 24 mg/day of Suboxone film for in-network buprenorphine-waivered practitioners.
Additionally, the Virginia Medicaid MEDALLION 4.0 has an embedded High-Risk Maternity Program that includes comprehensive care management and family planning services to women with SUD. MEDALLION 4.0 is a statewide, fully capitated, risk-based, mandatory managed care program for Medicaid and Family Access to Medical Insurance Security (FAMIS) members that operates under the authority of a §1915(b) waiver. MEDALLION 4.0 covers pregnant women, infants and children and provides acute and primary health care services, prescription drug coverage, and behavioral health services for their members.
Harrell’s presentation spurred much discussion among academy participants, who quickly shared their concerns about access to care, integration of services, health equity, and the long-term health outcomes of women, children, and families affected by SUD.
Over the next two years, NASHP academy participants will continue to learn from each other and from subject matter policy experts as they strive to develop, support, and advance state-level policy innovations for pregnant and parenting women with or at risk for SUD and/or mental health conditions. Understanding state innovations is key to identifying new strategies to leverage change. As one policy academy participant observed during the meeting, “No one [state] has all the answers, but we have a lot of resources in each other.”
For more information on the academy, read NASHP’s blog, New Eight-State Policy Academy Advances Access to Care for Pregnant/Parenting Women with SUD. For more information about the Virginia ARTS program, visit the Virginia DMAS ARTS website or email questions about the ARTS program to firstname.lastname@example.org.
Medicaid expansion, which took effect as the opioid epidemic ballooned, provided insurance coverage to people at highest risk of opioid use disorder (OUD) – lower-income, younger adults. Because Medicaid covers the overdose-reversal drug naloxone, the expansion gave Harvard Medical School professor Richard Frank an opportunity to compare how Medicaid expansion impacted naloxone prescribing in expansion and non-expansion states.
In a recent study published in the journal Addiction, Frank found that expansion states dramatically increased their Medicaid-covered naloxone prescriptions. In 2016, states that did not expand Medicaid averaged 83.1 Medicaid-covered prescriptions per 100,000 enrollees, while expansion states averaged nearly four-times that amount – 215.6 per 100,000 enrollees. On average, naloxone (Narcan) saves one life for every 14 prescriptions written, which means expansion states saved an additional 22.7 lives per year per state.
Frank’s study suggests Medicaid expansion has been highly effective because it made naloxone available and affordable to the consumers, family members, and friends who are most likely to be on-site when an overdose occurs.
Frank, who specializes in the economics of health, took time recently to answer questions about how his findings could enhance states’ policy responses to the opioid epidemic.
Why is naloxone and harm reduction critical for states working to improve OUD treatment?
Given that addiction is an illness, your goal should be to prevent death and disability and get people into treatment. If a person with diabetes doesn’t eat properly, you don’t stop giving them insulin, you keep treating them.
Why was providing insurance coverage and free access to naloxone so successful?
Previously, when if you didn’t have insurance coverage, the way most people who overdosed (OD’d) got naloxone was through first responders who carried it and administered it – if they got there in time. But two things happened, recently, user-friendly versions of naloxone became available, and that opened up the opportunity for lay people to be able to administer it to family and friends. Suddenly, a new opportunity to have naloxone johnny-on-the spot when someone OD’d became available. Second, what Medicaid did was to make naloxone available by giving purchasing power and access to consumers, families, and friends who were most likely to be on-site when there was an overdose. This is especially important as the epidemic morphed from one mostly that involved prescription medications to one where deaths were driven by heroin cut with fentanyl, and fentanyl alone, because fentanyl takes effect much more quickly, so having naloxone accessible is much more important today than it was six or seven years ago. [Fentanyl’s reach has recently spread from New England to the Midwest and Appalachia and is now appearing in California and Oregon.]
Does this study suggest that funding naloxone through Medicaid expansion is more effective than through federal funding vehicles? [The federal government has allocated $1 billion under the 21st Century Cures Act and $11 million from the Substance Abuse and Mental Health Services Administration to 12 states.]
The federal government has set up grant programs that are generous and important, but grant program funding goes away as soon as public attention to an issue disappears. The nice thing about Medicaid is that it’s a mandatory program with long-term insurance coverage. As a result, Medicaid continuously puts purchasing power into the hands of people who are most at risk from opioids. It’s not impacted by the ebb and flow of political salience, it just ebbs and flows with the demand of people caught up in the opioid epidemic.
How does naloxone deployment improve access to treatment?
Having an overdose reversed by naloxone is extraordinarily unpleasant, so many people who are treated with naloxone are taken to a hospital emergency department (ED). What’s interesting about naloxone is it detoxes you, it blocks the opioid receptors in your system and creates an opportunity to start treatment with evidence-based, medication-assisted treatment (MAT) like buprenorphine [which can be prescribed or dispensed in physician offices, significantly increasing treatment access.] There is an increasing number of EDs starting to do that warm hand-offs to treatment facilities and provide MAT when they get overdoses. If you can get someone who ODs to go to the ED, the chance of getting them started on treatment goes up. These are important opportunities to link harm reduction to treatment.
There’s another consideration, we need to remember that there are people who are not addicted who experiment with heroin who will unknowingly use heroin cut with fentanyl. They’re going to suddenly OD, so they need to be revived and how you treat them is different when they’re not addicted. You have to take the opportunity to address the problem in an appropriate matter, in some cases MAT is needed and in other cases you need to educate people about this dangerous recreational drug use.
What other steps can states can take to improve OUD treatment?
It’s hugely important that states do more to ensure that people have the opportunity to get evidence-based, MAT treatment for addiction. Right now, there are many states where providers can get accredited to treat addiction, and yet refuse to offer MAT to individuals or refuse to take people who are currently being treated with MAT, (e.g., following release from a hospital.) There are also providers/facilities who won’t do a warm hand-off to community-based treatment centers that support MAT. You are less likely to get people better if you don’t do those things. This is a failure of state regulatory and national accreditation agencies that oversee residential treatment centers. The fact that states license them and pay huge amounts of money to these programs is troubling. I think states and accreditation agencies can do more to hold these programs accountable than they have traditionally done in order to promote the use of evidence-based treatments.
Given the results of this study, what would you tell state legislators today who were considering expanding Medicaid in their states?
I would quote former Ohio Gov. John Kasich, who said Medicaid expansion was one of the most important tools to fight the opioid epidemic in his state. He argued that among other things that Ohio hospitals’ budgets were overwhelmed by overdoses among people who had no insurance. After Medicaid expansion increased access to naloxone, Ohio hospitals saw uncompensated care among people with opioid use disorder decline from 20 percent to 5 percent overnight, which put millions of dollars back into hospitals’ bottom line.
State policymakers on the frontlines of the opioid epidemic understand that treating justice-involved individuals with opioid use disorder (OUD) offers a critical opportunity to expand access to treatment. While there is strong evidence that medication-assisted treatment (MAT) promotes recovery, saves lives, and reduces re-incarceration, states must surmount significant policy and financial challenges to provide MAT in correctional settings.
A recent federal court decision indicates that states may need to take a close look at how to overcome barriers to expand access to FDA-approved MAT — methadone, buprenorphine, and naltrexone — in jails. In that decision – which could have nationwide implications – the court ruled that preventing access to MAT is a violation of the Americans with Disabilities Act and the 8th Amendment.
A growing number of state legislatures and governors, through executive orders, have mandated MAT in their correctional facilities. Last month, Maryland passed legislation that requires facilities to assess inmates’ substance use status, treat those with OUD with MAT, and provide follow-up treatment and care coordination after release.
Erek L. Barron, a member of Maryland’s General Assembly and a cosponsor of the new law, suggests the treatment could eventually pay for itself in avoided costs from reduced incarceration rates. “States need to understand that there is a high return on investment in MAT,” he told NASHP. “Addressing this high-risk population will enhance states’ response to the opioid crisis and crimes by reducing overdoses and recidivism rates. The key is understanding that substance abuse is a health care problem, not a crime problem.”
Initially, Maryland’s new treatment requirement will be phased into correctional facilities. The program begins in four counties and will cover the entire state and the Baltimore Pre-trial Complex within two years. The screening and treatment program is funded by the state’s initial allocation of $2 million. A report on the initiative’s impact on recidivism, treatment uptake, and crime will be submitted annually to the state’s General Assembly so lawmakers can assess MAT’s impact and its return on investment.
Barron and bill supporters faced challenges from the state’s various political subdivisions that ran local jails and the state prison system, so they took a “health-focused” approach when negotiating with correctional officials. “My primary partners were the county and local health officers,” he explained, “There was also media attention that helped educate the public about this gap in our response to the opioid crisis. I also learned that states are getting substantial amounts of federal funding from the State Opioid Response Grants that can be directed towards MAT in correction facilities.”
But funding MAT implementation in county and state facilities and after inmates are released remains a challenge for many states, particularly in states that did not expand Medicaid, according to states working with the National Academy for State Health Policy (NASHP) and reports from the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Commission on Correctional Health Care, and the National Sheriffs’ Association.
To start or sustain MAT during incarceration and after, states may want to consider the following strategies:
- Tap state block grants and the federal grant funds recently allocated to states for OUD and substance abuse disorder (SUD) treatment by the SUPPORT for Patients and Communities Act and other federal programs.
- Encourage criminal justice agencies to participate in group purchasing organizations in order to negotiate more affordable rates for MAT medications on their formulary. (Read Cross-Agency Strategies to Curb Health Care Costs: Leveraging State Purchasing Power for more information.)
- Medicaid agencies that do not provide coverage for all three medications approved for MAT may consider including them on their formularies.
- States can consider the use of Medicaid options and funding vehicles – such as 1115 waivers – to cover reentry support services, peer services, outreach services, and wraparound case management services for people with opioid use disorders.
- Review Medicaid suspension/termination rules. These rules may present barriers for individuals to re-activate their Medicaid coverage and obtain MAT following release from jail. Read NASHP’s report, Opportunities for Enrolling Justice-Involved Individuals in Medicaid.
- Despite the passage of the Mental Health Parity and Addiction Equity Act of 2008, the essential health benefits of many health plans do not cover OUD/SUD treatments the same way that other chronic diseases are covered. Oversight of private insurance plans can help to ensure coverage of MAT so that individuals reentering the community from jail or prison can access medication in a timely manner.
- To obtain lower-cost drugs, agencies can also participate in the federal 340B Drug Discount Program, which allows certain entities that serve large numbers of uninsured patients to obtain drugs from pharmaceutical suppliers at the same discounted rates that Medicaid pays (about 25 to 50 percent less).
In the months ahead, NASHP will be publishing additional reports detailing effective strategies that states are employing to address the opioid epidemic.
States are realigning policies, funding, staffing, and data across agencies to better meet the needs of people living with or at risk of developing substance use disorder (SUD). In 2018, NASHP and the Association of State and Territorial Health Officials (ASTHO) convened a group of Medicaid and public health leaders to discuss state strategies for working across agencies to address SUD. Their new report highlights recommendations for structuring and advancing cross-agency approaches to SUD prevention and treatment.
Read or download: Cross-Agency Approaches to Substance Use Disorder Prevention and Treatment – National Recommendations
Watch the NASHP-ASTHO webinar Cross-Agency Approaches to Substance Use Disorder Prevention and Treatment, recorded March 20, 2019, which explores this topic.
Governors’ state of the state and inaugural addresses provide critical insights into their policy proposals that impact the health of their residents. Last week, the National Academy for State Health Policy (NASHP) highlighted the health care issues governors raised in their 2019 addresses. This week, NASHP examines the social and economic issues raised – such as poverty, violence, housing, education, and addiction — that heavily impact the health and well-being of Americans.
By early February, 2019, 48 governors, including 20 newly elected, had outlined policy priorities in their speeches.* Of the health-related social and economic factors identified in their speeches, governors most commonly mentioned plans to address education, jobs, and infrastructure, followed by opioids and the environment. Other topics included violence prevention, child welfare, justice, equity, and cannabis. Ten governors discussed plans to develop new government structures to coordinate services efficiently.
Given that health is shaped by myriad conditions in which people live, work, and age, it is not surprising that many topics interrelate and cross sectors. For example, governors who mentioned plans to address workforce training and job readiness touched on both education and employment as key issues.
Of the 40 governors who addressed education, many highlighted early education, student health and mental health, student debt relief, and increased resources for schools:
- New Mexico Gov. Michelle Lujan Grisham: “I reject the false choice of today’s children or tomorrow’s budget. We must dramatically increase our Pre-K and educational investments today and provide sustainable revenue for the long term. I have also proposed an expansion of the Working Families Tax Credit, which we know creates a ladder out of poverty, providing child care programs so parents can continue to get meaningful support even as they do the hard work to transform themselves and their family’s fortunes for the better.”
- Ohio Gov. Mike Dewine: “Our plans to intervene early in the lives of at-risk kids, to address their physical and emotional needs, and to give them better, higher-quality educational opportunities — all will be undertaken in the faith and hope and confidence that these children will flourish and grow and that their lives will be forever changed by the things that we do. Education is the key to equality and to opportunity.”
Of the 37 governors who addressed jobs, many focused on workforce readiness, public employee and teacher wages, and minimum wage:
- Nebraska Gov. Pete Ricketts: “The first pillar is making sure we’re connecting Nebraskans to great paying jobs and that they’ve got the skills to be able to take those jobs. … As previously announced, I am recommending the creation of the Nebraska Talent Scholarships program to help our community colleges, state colleges, and the university system attract even more students in targeted programs from engineering to health care with over 2,100 new scholarships. Additionally, I am recommending the expansion of the Developing Youth Talent Initiative to connect more middle school students to opportunities in manufacturing and IT with an additional $1.25 million annually. This program has already impacted 7,000 students, and this expansion will help reach even more.”
- New Hampshire Gov. Chris Sununu: “I will be proposing the state’s single largest ever investment into workforce training — a $24 million one-time investment — to grow our state’s nursing and health care workforce and double the number of those graduates in New Hampshire schools.”
Twenty-two governors mentioned plans to address the opioid epidemic. This analysis specifically focuses on the preventive aspects of their plans, including efforts to address mental health:
- Vermont Gov. Phil Scott: “In my first budget address, I talked about the most undeserving victims of our opioid crisis: the children born to addiction. That day — two years ago — I vowed we would not fail them. This budget continues to support our investments in prevention, treatment, recovery, and enforcement. And with an increased investment of $2 million to the Family Services Division, we can give these children more of the support, hope and opportunity they deserve.”
- South Carolina Gov. Henry McMaster: “Last year, I declared a statewide public health emergency, mobilizing the full power of the state’s emergency infrastructure in response to the growth of opioid addiction and abuse. And I signed what must be the most comprehensive set of laws in the country addressing this crisis across the spectrum of law enforcement, education, and health care…. For instance, our doctors are now required to educate minors and their families on the dangers of opioids before prescribing them; the Department of Health and Environmental Control is issuing tamper-proof prescription pads; the anti-overdose drug Narcan is more readily available; and initial prescriptions are now limited to seven days. I also established the Opioid Emergency Response Team, which in June released a plan consisting of recommendations on physical and public education, prevention and response, treatment and recovery, and law enforcement approaches.
Twenty-eight governors mentioned infrastructure issues, from high-speed internet to active transportation, to bridge and road repairs. Georgia Gov. Brian Kemp promised to bring high-speed internet to rural areas and Kansas Gov. Laura Kelly promised, “In the coming days, we will build an interconnected, strategic plan for rural economic development that leverages our communities’ unique assets. That means developing infrastructure.”
Twenty-five governors mentioned environment goals, including clean water, clean and renewable energy, climate change, and environmental protection:
- Maine Gov. Janet Mills: “The Gulf of Maine is warming faster than almost any other saltwater body in the world, driving our lobsters up the coast. Our coastal waters are growing acidic, temperatures are fluctuating, and sea levels are rising, endangering our shellfish industry. Our forests are less suitable for spruce and fir and more suitable for ticks. Climate change is threatening our jobs, damaging our health and attacking our historic relationship to the land and sea.”
- Florida Gov. Ron DeSantis: “Our economic potential will be jeopardized if we do not solve the problems afflicting our environment and water resources. …We will fight toxic blue-green algae, we will fight discharges from Lake Okeechobee, we will fight red tide, we will fight for our fishermen, we will fight for our beaches, we will fight to restore our Everglades and we will never ever quit, we won’t be cowed and we won’t let the foot draggers stand in our way.”
Sixteen governors called for increased access to affordable housing and/or reductions in homelessness:
- Nevada Gov. Steve Sisolak: “I will be supporting the recommendation to create a new program which will offer $10 million of state tax credits per year for the creation and preservation of affordable housing.”
- Oregon Gov. Kate Brown: “[W]e can speed up construction of 200 units of permanent housing for the chronically homeless. We also need to help Oregonians who have homes but are struggling with the high cost of rent. When problems arise, they need technical assistance to stay in their homes and not end up on the streets. We can help landlords and tenants navigate this tight housing market.”
Eighteen governors identified a need to prevent gun violence and improve school safety:
- Delaware Gov. John Carney: “[W]e provided schools with new resources to make them safer, and passed responsible gun safety legislation. This included the Beau Biden Gun Violence Prevention Act.”
- Mississippi Gov. Phil Bryant: “A problem exists in our schools today that threatens children of all ages. It has become commonly known as the active shooter… I will ask you to pass a comprehensive plan to keep our school children safe. …If you will pass and fund the Mississippi Safe School Act, our parents, teachers and administrators will be allowed to care for our children in a safe and protected environment.”
Thirteen governors mentioned the need for equity in educational, employment, and other opportunities:
- Texas Gov. Greg Abbott: “We must ensure destiny is not determined by zip code. Students from the most challenging circumstances can perform at the highest levels. But we have to give them the opportunity to succeed.”
- Washington Gov. Jay Inslee: “We’re the state that’s going to tear down the systemic barriers to work and education faced by people of color, people with disabilities, veterans and women. …We’re the state that embraces our differences and diversity… We’re the state making sure our government looks like the people it serves.”
Other topics that impact health include efforts to improve the justice system, enhance child welfare, and structure state government more efficiently:
- Indiana Gov. Eric Holcomb: “We’ll continue to be transparent and accountable on pressing issues like child welfare…. A year ago we had just started a top-to-bottom review of the Department of Child Services (DCS). Now, we are moving full speed ahead on addressing all those 20 recommendations that not only protect children but recognize the difficult work of those who protect them. It’s still early, but the investments we’ve made to increase caseworker salaries and improve the workforce culture are making a difference. The ratio of supervisors to case managers has improved, so there is more time for supportive supervision and coaching. Turnover among frontline staff is down and retention is up, which means more stability between caseworkers and the families they work with. And, fewer children are reentering the DCS system after their cases close.”
- North Dakota Gov. Doug Burgum: “We’re creating a unified IT Shared Service organization. Already, we have aligned the backend systems of 31 state agencies, saving more than half a million dollars… We created the Office of Recovery Reinvented to promote these [behavioral health] efforts with help from behavioral health professionals and community and tribal leaders.”
- Pennsylvania Gov. Tom Wolf: “Our differences haven’t stopped us from putting a down payment on criminal justice reform with the Clean Slate bill… I want us to be ambitious in imagining the Pennsylvania we can build together… Where we reform a criminal justice system that treats African Americans and the poor unjustly.”
Governors’ plans to address these social and economic issues have clear implications for their residents’ health. NASHP will continue to track these proposals and other, related state initiatives in the coming year.
* For some states, information from both a governor’s inaugural address and a state of the state address was included in this review. For others, information from only one speech is incorporated due to one of the following reasons: the inaugural address has occurred but the state of the state speech has not yet occurred, the inaugural address served as the governor’s primary policy speech and no state of the state address is planned, or the governor did not have an inauguration and delivered only a state of the state address. As of Feb. 5, 2019, Louisiana and North Carolina governors had not made speeches.
Produced in partnership with the de Beaumont Foundation and the Robert Wood Johnson Foundation.
Last week, the Centers for Medicare & Medicaid Services (CMS) released two highly anticipated initiatives — the Maternal Opioid Misuse (MOM) Model and the Integrated Care for Kids (InCK) Model — which will provide multi-year funding to states to improve integrated care for maternal and child health populations enrolled in Medicaid and the Children’s Health Insurance Program (CHIP).
NASHP has been tracking these important initiatives since they were first announced by the CMS Center for Medicare and Medicaid Innovation (Innovation Center) last year and has compiled and promoted exemplary integrated care delivery models, strategies, and innovations for pregnant and postpartum women and children that states can consider as they develop their applications for these initiatives.
The MOM Model is designed to:
- Improve quality of care and reduce costs for pregnant and postpartum women with opioid use disorder (OUD) and their infants;
- Expand access, service-delivery capacity, and infrastructure based on state-specific needs; and
- Create sustainable coverage and payment strategies that support ongoing coordination and integration of care.
The CMS Innovation Center will award a maximum of $64.5 million through up to 12 cooperative agreements with state Medicaid agencies and their care delivery model partners for a five-year period. Applications for the MOM Model are due to CMS by 3 p.m. (EST), May 6, 2019. A CMS webinar about the MOM Model Notice of Funding Opportunity was held Feb. 21, 2019. The recording, slides, and transcript from the webinar are available here.
The InCK Model is designed to reduce expenditures and improve the quality of care for children under 21 years of age covered by Medicaid and CHIP through prevention, early identification, and treatment of behavioral and physical health needs. States and local organizations will work to conduct early identification and treatment of children with health-related needs across settings to:
- Increase behavioral health access;
- Respond to the opioid epidemic; and
- Improve child health outcomes.
The CMS Innovation Center will award a maximum of $128 million through eight cooperative agreements with state and local participants for a seven-year period (awarding up to $16 million per recipient). Applications to implement the InCK Model are due to CMS by 3 p.m. (EST), June 10, 2019. A CMS webinar about the InCK Model NOFO is scheduled for 2:30 to 4 p.m. (EST) Tuesday, Feb. 19, 2019.
Among the many issues confronting new state governors and their administrations, the opioid crisis may be one of the most urgent and complex, and may leave the most devastating legacy. Opioids kill 130 Americans every day. For state policy makers, the ripple effect of the crisis reaches beyond health care systems to impact public safety and corrections, child protective services, and other state agencies and functions.
As part of National Academy for State Health Policy’s (NASHP) work under a National Organizations of State and Local Officials cooperative agreement with the Health Resources and Services Administration, NASHP officials met with policy makers from a dozen states to talk about their challenges and most promising policy strategies to tackle the opioid crisis.
The group discussed and evaluated a range of policy approaches involving Medicaid, behavioral and public health departments, and governors’ offices. State leaders are on the front lines of the opioid crisis, and while the challenges and complexity of this work can be staggering, states generally share a few common goals: prevent addiction, stop people from dying, and get people into treatment.
With those common goals in mind, NASHP identified a few key strategies from the field that are showing results:
- Track opioid prescribing: While the majority of states now have prescription drug monitoring programs (PDMPs), Florida was one of the first states to establish a PDMP. Since establishing its program in 2009 (and continuously refining it over the last decade), Florida has achieved a 69.3 percent decrease in the number of individuals having “multiple prescriber episodes” – doctor-shopping for multiple opioid prescriptions. Florida also recently implemented one of the country’s strictest limits on opioid prescribing. Legislation passed in 2018 restricts opioid prescriptions to no more than a three-day supply, with certain exceptions, such as for palliative care.
- Invest in harm reduction: In Massachusetts, the Department of Health launched an Overdose Education and Naloxone Distribution (OEND) program. The program has trained more than 64,000 people to administer naloxone, invested in training for first responders, provided naloxone doses to community health centers, and participated in a bulk-purchasing program allowing communities to purchase naloxone at a significant discount. The program reports that close to 11,922 overdose reversals had occurred through the use of OEND naloxone kits.
- Build capacity for medication-assisted treatment (MAT). MAT– an approach that includes both medication, counseling, and other supports — is an effective and evidence-based treatment for opioid addiction. However, states have struggled to build sufficient capacity for MAT to address the enormous need created by the opioid crisis. Virginia is addressing this challenge and is starting to see results: the state implemented its Addiction, Recovery, and Treatment Services program through an 1115 waiver. The state is investing in a comprehensive continuum of care that supports primary care practices and a range of other community providers to deliver office-based MAT. Since implementing these wide-ranging delivery system reforms in 2017, the state has seen treatment rates for individuals with opioid disorders increase by more than 70 percent.
- Engage corrections: The first two weeks after release from a corrections facility can be one of the most lethal periods of time for individuals with opioid use disorder (OUD). States can take a number of steps to target and assist this high-risk population:
- Rhode Island offers MAT to inmates statewide. The program, which also includes linkages to continued treatment following release, has shown promising results. A recent study in the Journal of the American Medical Association reported a 60 percent reduction in post-incarceration, opioid-related deaths after the program was implemented.
- Although individuals are not permitted to receive Medicaid benefits while incarcerated, the Medicaid enrollment process can get started before their release. NASHP’s State Strategies to Enroll Justice-Involved Individuals in Health Coverage provides examples and resources for states to maximize Medicaid enrollment and link people to services as they leave corrections settings.
- Ensure access in rural areas: Access to addiction treatment in hard-hit, rural areas is especially challenging. Overcoming transportation barriers, attracting and supporting specialists, and combatting the stigma associated with accessing (and delivering) services, such as methadone treatment in smaller, more rural communities can be difficult. States are seeing success using the Project Echo model to help providers develop the capacity to deliver treatment. This model links clinical specialists with practitioners in rural areas, facilitating long-distance learning and peer-to-peer mentoring. New Mexico has used the Project Echo model for substance use disorder (SUD) since 2005, and ranks fourth in the country in the number of providers able to deliver MAT services, in spite of its ranking as one of the most rural states in the country.
- Expand Medicaid: States that have not expanded Medicaid may be missing an important policy lever to support access to SUD treatment. Recent research found that states that expanded Medicaid saw a significant increase in prescriptions used to treat opioid disorders. Prescriptions for opioids themselves experienced only a modest increase compared to other medications in those .
These strategies represent just a few of the many state innovations happening across the country as health policy makers confront the opioid epidemic. NASHP is continuing to work closely with states to support their opioid epidemic responses and will share other lessons learned in the months ahead.
There has been significant federal investment made in recent years to address the opioid crisis in every state. This chart summarizes the key federal funding that has flowed to each state’s government agencies and other stakeholders to address the opioid crisis. Data featured in these charts represent grants from multiple federal agencies provided through specific initiatives aimed at supporting state efforts to prevent and treat addiction by addressing behavioral and mental health workforce shortages, promoting evidence-based research, making justice system innovations, and more.
The funding summary chart below shows the total federal grant amounts each state received in FY 2018. To see a more detailed breakdown of the targeted federal initiatives in recent years, click the tabs along the top of the chart. Individual agency funding charts feature grants awarded since FY 2017.
In the recent election, Republican and Democratic gubernatorial candidates offered strategies to address the opioid epidemic and meet the needs of children and families affected by substance use disorder (SUD). Incoming and incumbent executives will have new federal resources – including the new Maternal Opioid Misuse (MOM) and Integrated Care for Kids (InCK) models and the SUPPORT for Patients and Communities Act – to bolster their state efforts.
The MOM and InCK models, recently announced by the Center for Medicare & Medicaid Innovation (CMMI), are designed to help selected states better coordinate and integrate treatment and support to improve outcomes and reduce costs.
- Under the MOM model, state Medicaid agencies and care-delivery partners will work to improve care for pregnant and postpartum women with opioid use disorder (OUD). CMMI will award up to $64.5 million over five years, with the funds divided in varying amounts among up to 12 MOM cooperative agreements.
- Under the InCK model, state Medicaid agencies and community partners will collaborate to bolster prevention, early identification, and treatment for children covered by Medicaid. CMMI will award up to eight InCK cooperative agreements, with up to $16 million available to each awardee over a seven-year period.
More information about applying for these initiatives is expected in early 2019.
The recent SUPPORT for Patients and Communities Act includes a number of provisions that also support children and families affected by SUD, including several provisions that could provide new funding to states and new ways for states to use existing federal funds. A previously-published NASHP blog described some of the law’s provisions affecting state Medicaid agencies, while this blog focuses on other key provisions targeting children and families.
Several of the act’s provisions address the impact of childhood trauma. There are multiple connections between SUD and trauma — childhood trauma is a risk factor for SUD and growing up with a parent who has an SUD is itself considered a traumatic experience. Recognizing the significant and long-lasting impacts of childhood trauma, the SUPPORT Act:
- Creates an interagency task force to develop best practices for identifying and supporting children and families who have experienced or are at risk of experiencing trauma. The task force is also responsible for crafting a coordinated federal response to families impacted by SUD and other forms of trauma. These best practices and coordinated federal approach will help states as they promote evidence-based approaches to care. (Section 7132)
- Permits the US Centers for Disease Control and Prevention to collect data about adverse childhood experiences through existing public health surveys, in cooperation with states, with $2 million in annual funding. States can use the findings to track trends, allocate resources, and refine programs that address adverse childhood experiences. (Section 7131)
- Authorizes $50 million per year for grants to state, local, and tribal educational agencies to increase student access to trauma support services by linking educational agencies with mental health systems. The US Secretary of Education would administer the grants in coordination with the Assistant Secretary for Mental Health and Substance Use. (Section 7134)
Other parts of the law are designed to strengthen care delivery systems for children and families affected by SUD. These provisions:
- Authorize $20 million in grants to state governments and other entities to develop and evaluate family-focused SUD residential treatment programs, which permit children to reside with parents in the treatment facility. Due to the recently-enacted Family First Prevention Services Act, evidence-based SUD treatment services for certain parents will soon be eligible for funding from current state allocations of Title IV-E child welfare dollars (learn more in this NASHP blog.) The grants will help additional programs qualify Title IV-E funding. An additional provision requires the US Department of Health and Human Services (HHS) to issue guidance on how states can promote family-focused residential treatment programs and leverage both Medicaid and Title IV-E funds to support them. (Sections 8083 and 8081)
- Appropriate $15 million for HHS to conduct a randomized evaluation of a “recovery coach” program that provides integrated treatment and supportive services to parents who have temporarily lost custody of their children due to SUD. If the evaluation shows positive results, the program could potentially be funded using a state’s existing Title IV-E dollars under the Family First Prevention Services Act. (Section 8082)
- Authorize HHS to provide grants to any state agency to improve implementation of plans of safe care for substance-exposed infants. Existing law requires states to create plans of safe care for all substance-exposed infants. If HHS chooses to award these grants, funds could be used for a number of purposes, including to improve access to treatment, train health professionals and child welfare staff, and strengthen cross-agency collaboration. This provision also requires HHS to provide written guidance and technical assistance outlining how to implement plans of safe care. (Section 7065)
To learn more about how states are supporting children and families with SUD:
- View NASHP’s issue hubs that highlight important information and resources about the InCK and MOM models.
- Read the NASHP issue brief and view the webinar addressing State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder.
- Read NASHP’s issue brief State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis, and listen to NASHP’s webinar on the topic.
- View presentations from NASHP’s preconference Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.
NASHP is also in the process of creating a new policy academy that will support states working to improve access to care for Medicaid-eligible pregnant and parenting women with SUD and/or mental health conditions. The call for applications will be released in December 2018.