The current opioid epidemic is driving a heightened focus on substance use disorder (SUD) prevention and treatment for pregnant and parenting women, who have unique needs and face unique challenges. However, gaps in care often remain, particularly during the postpartum period. This NASHP webinar, supported by the Health Resources and Services Administration, will highlight a state that is coordinating across agencies and systems to meet the needs of pregnant and parenting women affected by SUD. Speakers from Colorado will describe the coverage, financing, and care delivery strategies that their state agencies and safety net providers leverage to facilitate recovery among pregnant and parenting women with SUD, including opportunities for cross-system collaboration.
Substance use disorder (SUD), including opioid use disorder (OUD), is prevalent among pregnant and parenting women, and these women have unique and often un-met treatment needs. Despite significant efforts, states report that access to treatment continues to lag for this population. In 2014, half of pregnant women with OUD who were enrolled in publicly-funded treatment programs received medication-assisted treatment (MAT) – considered the standard of care for people with OUD. New mothers are also at increased risk of relapse and overdose during the postpartum period.
Recognizing the needs of this population, Congress recently passed the SUPPORT for Patients and Communities Act, which orders a Government Accountability Office study into the coverage gaps that persist for pregnant and postpartum women with SUD who were eligible for Medicaid during pregnancy. And last week, the federal Center for Medicare & Medicaid Innovation announced the Maternal Opioid Misuse Model, which will offer cooperative agreements to up to 12 states to transform their delivery systems for pregnant and postpartum women with OUD and reduce fragmentation in delivery of care.
As SUD impacts mothers, it also affects their children. Between 2000 and 2012, rates of neonatal abstinence syndrome (NAS), caused by opioid exposure during pregnancy, rose five-fold, accounting for $462 million in Medicaid hospital costs in 2014. Exposure to other substances, such as alcohol, can also affect child development and parental substance use is linked to increased risk of child welfare involvement and childhood trauma.
A new National Academy for State Health Policy (NASHP) report, State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder, supported by the Health Resources and Services Administration Office of Women’s Health, identifies promising strategies from Colorado, Pennsylvania, and Texas to support pregnant and parenting women with SUD. These states:
- Support access and coverage through early identification of substance misuse by expanding postpartum coverage for SUD treatment, and by facilitating transitions between care settings. In Texas, a state that has not expanded Medicaid, women may become ineligible for Medicaid coverage 60 days after giving birth. As a result, they face challenges continuing SUD treatment beyond 60 days postpartum. To address this issue, Texas expanded state-funded SUD treatment slots for postpartum women. Under this initiative, when a woman’s Medicaid coverage ends after giving birth, she can seamlessly transition to a treatment slot funded by state general revenue without being on a waiting list, and experience no change or disruption in her providers or services.
- Implement innovative care delivery models that consider the unique needs of women and families, such as integrating reproductive health care and SUD treatment, family-centered care models, and supports for social determinants of health. For example, Pennsylvania offers a Centers of Excellence (COE) program, funded by Medicaid and state general revenue, which provides coordinated and team-based care to individuals with OUD. Six COEs focus on meeting the unique needs of pregnant and postpartum women. These COEs coordinate services including SUD treatment, obstetric and postpartum care, and services that address social determinants of health, such as housing and transportation.
- Promote cross-system financing and collaboration to develop alignment across policies and programs and to leverage multiple federal and state funding streams. For example, Colorado’s Special Connections program offers comprehensive and coordinated SUD treatment services for Medicaid enrollees who are pregnant and the services continue up to 12 months postpartum. The program is administered through a partnership between the state’s Department of Health Care Policy and Financing and Office of Behavioral Health. The program weaves together funding from Medicaid (authorized under the Medicaid state plan and a 1915(b) waiver), the federal Substance Abuse Prevention and Treatment Block Grant, and state general funds.
To learn more:
- Read NASHP’s new issue brief, State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder.
- Listen to a recording from an Oct. 24, 2018 webinar that explores how Colorado supports pregnant and parenting women with SUD.
- Read NASHP’s issue brief State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis, and listen to a NASHP webinar on the topic.
- Read presentations from NASHP’s preconference Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.
The opioid epidemic has heightened states’ efforts to prevent and treat of substance use disorder (SUD) in pregnant and parenting women. The National Academy for State Health Policy (NASHP), with support from the Health Resources and Services Administration, interviewed Colorado, Pennsylvania, and Texas officials about the unique interagency approaches they are using to promote recovery for this population. This new report explores:
- State coverage, care delivery, and financing strategies to support pregnant and parenting women with SUD;
- Available state and federal funding sources for these initiatives; and
- Key considerations for states working to promote recovery.
- Download webinar slides and listen to the webinar that explored how Colorado supports pregnant and parenting women with SUD. The speakers were:
- Amy Cooper, Women’s Services Coordinator, Office of Behavioral Health, Colorado Department of Human Services;
- Susanna Snyder, Maternal Child Health Policy Specialist, Health Programs Office, Colorado Department of Health Care Policy and Financing; and
- Dr. Kaylin Klie, Physician, Denver Health; Assistant Professor, University of Colorado Department of Family Medicine
- Read NASHP’s issue brief State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis, and listen to a NASHP webinar on the topic.
- Read presentations from NASHP’s preconference Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.
Last week, Congress sent the SUPPORT for Patients and Communities Act, a wide-ranging bill that seeks to address the country’s opioid crisis across a number of policy areas, to the President for his signature. The act contains numerous provisions that affect how state Medicaid agencies structure and administer services and supports for individuals with opioid and other substance use disorders (SUD).
Medication-assisted treatment (MAT) emerges as a central strategy, and the act gives states some flexibility to expand SUD service delivery using Institutes for Mental Disease (IMDs). A number of provisions also address the impact of SUD on pregnant women, infants, children, and youth. The table below highlights some of the act’s key provisions affecting state Medicaid programs.
|Requires states to cover children in foster care up to age 26 and to suspend eligibility for juvenile justice-involved youth (Sec. 1001, 1002)||By calendar year 2023, states must provide former foster care youth with Medicaid coverage up to age 26, regardless of what state they lived in when they aged out of the foster care system. Currently, Medicaid must cover youth up to age 26 within the state the youth aged out of foster care, and states have the option to cover youth who age out of another state’s foster care system. For youth engaged in the criminal justice system, the act requires states to suspend, rather than terminate, Medicaid coverage while these youth are incarcerated, and to restore their Medicaid coverage upon their release, without completing a new application, unless they no longer meet eligibility requirements.|
|Creates a demonstration program to expand SUD treatment
|The act creates a new demonstration program to improve capacity for SUD treatment services, with a particular focus on MAT, neonatal abstinence disorder, pregnant and post-partum women, and adolescents. Ten states will receive planning grants, and of those states, five will be selected to receive enhanced federal match for SUD treatment and recovery services.|
|Additional requirements for Medicaid drug utilization review
|By October, 2019, states will be required to have safety edits and automated review processes in place to avoid prescription abuse, monitor and report on antipsychotic medication prescribing to children, and identify fraud and abuse by Medicaid enrollees, providers, and pharmacies.|
|Extends SUD health home enhanced match to 10 quarters
|For health home state plan amendments approved on or after Oct. 1, 2018, the act extends enhanced Federal Medical Assistance Percentages (FMAP) funding to states from eight quarters to ten.|
|Requires MAT to be included in state plans
|From Oct. 1, 2020 to Sept. 30, 2025, states will be required to include MAT services in their state plans. States may certify that implementing the provision is not feasible due to a shortage of qualified providers or facilities to provide MAT.|
|Changes in Institutions for Mental Disease coverage
(Sections 1012, 1013, 5052)
|Clarifies payment for treatment at residential pediatric recovery centers
|Permits states to pay for inpatient or outpatient services, including counseling for parents, at residential pediatric recovery centers that treat infants with neonatal abstinence syndrome.|
|Strengthens prescription drug monitoring programs
|Starting October 2021 , states must require Medicaid providers to check patients’ prescription drug history before prescribing controlled substances. The act allows for enhanced FMAP to states for expenditures to design, develop, or implement a prescription drug monitoring program that meet the act’s requirements.|
|Changes Medicaid managed care medical loss ratio
|Permits states to receive an enhanced share of remittances from Medicaid managed care plans that do not meet the minimum medical loss ratio of 85 percent.|
|Mandates reporting on adult behavioral health measures
|Beginning with the state report for 2024, states will be required to report on all behavioral health measures included in the adult core measure set.|
|Extends mental health parity to Children’s Health Insurance Programs (CHIP)||Requires all state CHIP programs to include coverage of mental health services, including behavioral health treatment. The provision explicitly notes that the requirement for these comprehensive services applies to both children and pregnant women regardless of the type of coverage (including separate CHIP programs) that a state has selected to operate.|
In 2016, only 3.8 million of the 21 million Americans with substance use disorder (SUD) received treatment. As the opioid crisis persists, states have been working to identify new SUD treatment approaches, but the Medicaid Institutions for Mental Diseases (IMD) exclusion has historically put certain residential health care facilities out of reach for many Medicaid beneficiaries who need SUD treatment.
In July 2015, the Centers for Medicare & Medicaid Services allowed states to develop demonstration projects that provide a full continuum of care to patients with SUD, including the chance to waive the IMD exclusion. Massachusetts submitted a SUD waiver request and won approval in November 2016. As an early adopter, Massachusetts offers critical lessons about how to structure and implement expanded SUD treatment.
The National Academy for State Health Policy (NASHP), in partnership with the Association of State and Territorial Health Officials, has convened the Cross-Agency Leaders Roundtable —a group of 11 state leaders working to identify innovative, cross-agency state policies to improve SUD prevention, intervention, treatment, and recovery. NASHP sat down with roundtable member Adam Stoler, manager of Addiction Treatment Services at MassHealth (Massachusetts’ Medicaid program), to learn how his agency is using its 1115 SUD expansion authority, which includes an IMD exclusion waiver, to address treatment gaps.
How do IMDs fit into the continuum of SUD treatment in Massachusetts and why was obtaining an IMD exclusion waiver important?
Massachusetts is working to create a continuum of SUD treatment, aligned with the American Society for Addiction Medicine (ASAM) criteria, ranging from outpatient services to medically managed intensive inpatient services. We recognized that lower-intensity residential services, called residential rehabilitation services (RRS) in Massachusetts, are an important part of this continuum. RRS most closely correspond to ASAM Criteria 3.1 and include providing patients with residential counseling and support to help them transition back to their families and communities.
Prior to the waiver, MassHealth could not reimburse for these services because the majority of RRS facilities qualify as IMDs, creating a gap in the SUD treatment coverage continuum. RRS were available to people with SUD, but could only be supported by state dollars from the Department of Public Health (DPH), separate from the Medicaid benefit. Because MassHealth did not cover RRS, members often transitioned from more intensive inpatient services directly to outpatient services. This may not have been appropriate for all patients receiving treatment for SUD, particularly those with unstable housing or employment who benefit from having a longer-term, lower-intensity residential service to support their transition back to the community.
The waiver allows MassHealth to cover RRS for the first time. We are working with our accountable care organizations (ACOs), managed care organizations (MCOs), and our behavioral health managed care provider to develop relationships between RRS providers and the larger health care delivery system, which will be critical as MCOs and ACOs begin coverage of RRS services. Our behavioral health managed care provider began coverage of the RRS benefit on March 1, 2018, and the MCOs and ACOs will phase in coverage by Jan. 1, 2019.
How has implementation been for the behavioral health managed care provider that recently launched its RRS benefit?
MassHealth continues to work with plans and RRS providers to find the best ways to implement coverage. RRS providers are currently in the process of integrating into the larger health care system, including developing contracts and relationships with ACOs and MCOs. MassHealth is working with DPH to provide technical support to ACOs, MCOs and RRS providers during this transition on topics such as billing, contracting, relationship-building, and using ASAM criteria to identify the most appropriate level of care for members seeking SUD treatment.
Can you talk more about how Massachusetts is integrating SUD treatment, including RRS, into its broader health care delivery system?
We really wanted to develop solutions to increase access to SUD treatment from a systems-level perspective in order to ensure they were aligned with the priorities and structure of our ACO delivery system and other MassHealth reforms. For example, our MCOs and ACOs are required to establish networks of behavioral health providers to ensure Medicaid members have access to coordinated, comprehensive care. We see the addition of RRS within the Medicaid benefit as another tool in ACOs’ and MCOs’ toolboxes to improve health outcomes for MassHealth members.
We are also currently planning for an expansion of RRS that will add between 450 to 500 beds to the state’s 2,500 current beds. These additional beds will be targeted toward more complex patients with co-occurring mental health and SUD diagnoses. Facilities will have smaller patient-to-staff ratios and fewer beds. This enhanced RRS model will also require facilities to embed mental health services and develop partnerships with outpatient medication assisted treatment providers.
Acknowledging many state Medicaid programs are asked to do more with the same or fewer resources, what should they consider when implementing new Medicaid services, such as RRS?
States should start by identifying the value for RRS (or similar lower-intensity residential services) using data to better understand unmet need for these services and opportunities to drive cost savings in other parts of the health system. In Massachusetts, we found that patients with unmanaged or untreated SUD diagnoses often presented in acute settings where their addiction was not always identified and addressed. We also found that these same individuals had disproportionately high annualized costs of care, as compared to other MassHealth members, largely driven by expenditures in acute settings. By creating a continuum of care, including RRS, we can now reduce avoidable utilization in acute settings and support appropriate placements in community settings, which are often more cost-effective and better equipped to support members’ long-term treatment and recovery.
Do you have any lessons learned to share with other states?
Comprehensively addressing the needs of people living with SUD is a top-level priority of the Baker-Polito Administration. Strong, aligned leadership is incredibly important to help drive coordinated state priorities and ensure the appropriate state agencies and stakeholders participate in developing and implementing solutions. We have also found that it is critical to engage a number of different agencies and multi-sector partners when developing policy changes. As part of this work, we have engaged with the Department of Public, the Department of Mental Health, accountable care organizations, health plans, residential treatment services providers, other treatment and recovery providers, and consumers. Through the SUD and IMD exclusion waiver, Massachusetts has had the opportunity to work across agencies to develop innovative, cost-effective solutions to improve treatment and recovery for people with SUD.
NASHP will continue to report insights and recommendations from the members of the Cross-Agency Leaders Roundtable in the months ahead.
With elections just three weeks away, governors’ races in 36 states – with 17 open seats – are down to the wire and important health policy issues, such as Medicaid expansion, stabilizing insurance markets, public options, and prescription drug price controls, are at play in most of them. The National Academy for State Health Policy (NASHP) scanned candidates’ websites and press coverage to provide this snapshot of key health care election issues. While limited in scope and focusing only on major party candidates, this scan provides a glimpse of state campaign health issues that could be harbingers of policy action in 2019.
Addressing the opioid epidemic: No surprise to state health policy watchers, addressing the opioid epidemic remains a bipartisan priority for gubernatorial candidates. Strategies differ, but there is general support for more treatment and prevention. In Iowa, Democrat Fred Hubbell wants more support for local law enforcement and has called for the attorney general to hold pharmaceutical manufacturers accountable. In Oregon, Republican Knute Buehler seeks to cut opioid overdose deaths by 50 percent by investing in medication assisted treatment (MAT), peer counseling, and evidence-based strategies to address the crisis while incumbent Democrat Kate Brown cites her creation of a task force that is tackling these issues and her leadership to increase the availability of naloxone. In several states that have not expanded Medicaid, Democratic candidates are supporting expansion as a means to improve addiction treatment coverage.
Medicaid expansion: Seventeen states have not expanded Medicaid and that issue is front and center in many of these races. Candidates’ stances on the issue follow party lines, with Republican candidates opposing expansion and Democrats supporting it. A number of these states have open seats and highly competitive races. Whether pollsters have it right or not, these state campaigns provide insight into the current debate about Medicaid expansion.
In states with both highly competitive races and open seats, arguments for and against expansion follow similar themes. In Georgia, Republican Brian Kemp argues that the state can provide affordable health care without expanding Medicaid while Democrat Stacey Abrams has made expansion a top priority, noting its importance for coverage, mental health treatment, jobs, and support for rural hospitals. In Kansas, a recent plan to close a rural hospital is cited as one of the reasons to support expansion by Democrat Laura Kelly while Republican Kris Kobach opposes expansion. Oklahoma’s Democrat Drew Edmondson expresses strong support for expansion and he too cites the issue of rural hospitals’ financial challenges while Republican Kevin Stitt does not mention expansion on his website but seeks an audit of Medicaid spending. In Florida, Republican Ron DeSantis does not mention Medicaid on his website, but has stated opposition to expansion, while Democrat Andrew Gillum supports expansion. Democrats in South Dakota and Tennessee also support expansion and cite the plight of rural hospitals as a key factor.
In Idaho, Nebraska, and Utah, Medicaid expansion is on the ballot. In Maine, a successful citizen initiative in 2017 was stymied by outgoing Republican Gov. Paul LePage’s resistance, because the state legislature had not appropriated funds that met his conditions. After numerous court battles, LePage submitted a state plan amendment to expand Medicaid to the federal government, but urged them to deny it. In the state’s current gubernatorial race, Republican Shawn Moody mirrors LePage’s opposition while Democrat Janet Mills has made expansion a top campaign priority. In Idaho, Republican Brad Little says he will enforce expansion if that state’s ballot initiative passes, but he raises concerns about “uncertainty at the federal level.” In Nebraska, Republican incumbent Pete Ricketts strongly opposes expansion but concedes the issue is up to voters.
Medicaid work requirements: Support for work requirements generally follows party lines, but in Alabama Democrat Walt Maddox supports work requirements as part of his endorsement of Medicaid expansion. In Ohio, Republican Mike DeWine supports a “reasonable work requirement” for individuals newly covered by Medicaid expansion who are healthy and able to work.
Improving affordability of private coverage: Candidates have proposed a wide array of approaches to make health insurance coverage in the individual and small group markets more affordable.
In about one-third of the states, candidates are talking about a public option, the opportunity to buy-in to Medicaid, or other initiatives. In Alaska, Democrat Mark Begich wants to combine coverage for individuals on Medicaid, Medicare, TriHealth, and Indian Health Services into a single health care option. In Connecticut, Democrat Ned Lamont proposes strengthening the Access Health CT exchange by instituting a Medicaid buy-in option to lower costs by adding younger participants to the pool. In Illinois, Democrat J.B. Pritzker is proposing a public option/Medicaid buy-in — Illinois Cares — to allow every resident to buy low-cost health insurance. Pritzker wants to work with legislators and the health care community to design this public option as another choice on the health insurance marketplace. Minnesota’s Tim Walz, a Democrat, wants to provide a strong public health care option and suggests that MinnesotaCare, the state’s Basic Health Program, can already serve that role. In New Mexico, Democratic candidate Michelle Lujan Grisham supports “cost-effective, innovative approaches to providing affordable, high-quality health care to all New Mexicans,” including a Medicaid buy-in. Maine’s Democratic candidate Janet Mills proposes the Small Business Access Plan, a buy-in to public purchasers for small businesses and self-employed individuals.
Republican candidates, however, generally warn against a “government takeover” of health care and express concern about the high costs to taxpayers of such proposals.
A few Democrats express support for Medicare for All proposals and some identify incremental steps a state could take toward that goal. In Arizona, Democrat David Garcia supports a Medicaid buy-in as a strategy while Colorado Democrat Jared Polis seeks to “pioneer a western single-payer system” by partnering with other western states to develop a regional, multistate consortium to provide a common payer system to reduce prices, increase coverage, and improve care quality.
Premium rating rules: In Colorado, Republican Walker Stapleton said he would convene a task force to evaluate the state’s Affordable Care Act (ACA) rating regions, geographic boundaries, and departmental overlap. He opposes a single rating region supported by Democratic candidate Jared Polis, who is advocating a statewide geographic rating system and reconfiguration of rating zones with rural rate protections.
Reinsurance: In Georgia, both candidates support creating a reinsurance program to stabilize rates in the individual insurance market. Reinsurance is also supported by Democratic candidates in Colorado and Connecticut. Wisconsin Gov. Scott Walker lauds his state’s reinsurance program, Health Care Stability Plan, and notes the state is investing $200 million in market-based solutions to lower costs, which he predicts will reduce rates by 3.5 percent in 2019.
Market-based strategies: Many candidates support market-based solutions, including Colorado Republican Walker Stapleton, who would address rising health care costs for families by creating more insurance choices for consumers, such as association health plans (AHPs), short-term plans, and catastrophic coverage options. This approach is similar to strategies offered by Georgia’s Republican candidate Brian Kemp who would set “specific, achievable goals to lower the uninsured population by expanding choices” and indicates he would embrace AHPs if elected. Minnesota Republican Jeff Johnson believes MNsure has been a “complete disaster” and that new approaches are needed. He notes the “skyrocketing” cost of health insurance and lack of access to care and has proposed to request waivers to “abandon the provisions of Obamacare” because they limit choice and increase costs. He supports an interstate compact to buy and sell health insurance across state lines. Oklahoma’s Kevin Stitt similarly supports buying coverage across state lines.
A few candidates are focusing on retooling primary care. Florida Republican Ron DeSantis said he would back proposals to install direct primary care models, in which patients pay a monthly rate directly to doctors to cut out insurers. Kansas Republican Kris Kobach supports allowing patients to pay their doctors $50 a month for unlimited primary care visits.
Several candidates offer different approaches. In New Mexico, Republican Steve Pearce would encourage employers to provide health insurance by providing a tax credit for employees who work less than 20 hours per week. In New York, Republican Marc Molinaro suggests addressing high taxes on private health insurers to increase health care quality and affordability. In Rhode Island, Gov. Gina Raimondo recently issued an executive order directing the state to codify all ACA protections into state law. Her Republican opponent, Allan Fung, wants to keep the state-based exchange and control of insurance regulation in-state, and does not want to change the existing protections “whether it’s pre-existing conditions” or “taking away coverage” or changes in Medicaid eligibility. Maryland Gov. Larry Hogan opposes any changes to the ACA that would “jeopardize Marylanders’ access to quality health care” and supports stabilizing the insurance market and keeping premiums down. In contrast, South Carolina Gov. Henry McMaster states that “Obamacare was an unprecedented encroachment on state sovereignty” and wants to ensure greater access and affordability through removal of anti-free market mandates and regulations to allow for investment, expansion, and ingenuity to lower health care costs. Maine’s Democratic candidate Janet Mills would protect against rollbacks of ACA protections and also supports “well-regulated” AHPs.
Reducing prescription drug costs: Addressing rising pharmaceutical costs is another issue that has bipartisan support. A number of candidates from both parties indicated support to lower costs on their websites while others present specific proposals.
In Ohio, Republican Mike DeWine advocates for greater transparency of drug prices by bringing more attention on pharmacy “middle men.” His Democratic opponent, Richard Cordray, has also supported more transparency around pharmacy benefit manager (PBM) activities. In Colorado, Democrat Jared Polis seeks to improve support for the state’s all-payer claims database (APCD) and to use data to identify health care savings. He also advocates for increased transparency by requiring drug companies to publicly disclose pricing and would crack down on price gouging by forcing drug companies to justify price increases. Additionally, he proposes to set up a framework to import prescription drugs from Canada. Other Democratic candidates also support importation, including Drew Edmonson of Oklahoma, Tony Evers of Wisconsin, as well as Ben Jealous of Maryland, who supports a Prescription Drug Affordability Plan that requires drug companies to give notice when increasing prices and drug spending caps for Medicaid. Connecticut Democrat Ned Lamont wants to “take strong and multipronged action to reduce drug prices” and supports pricing transparency for manufacturers, including requirements that drug companies include their wholesale prices in advertisements. He also wants to limit coupon use in private insurance and cap out-of-pocket pharmaceutical costs. In contrast, his Republican opponent, Brad Stefanowski, opposes government regulation of prescription drug costs.
Two candidates propose expanding the state’s public purchasing role to lower costs. Nevada Democrat Steve Sisolak proposes creating Silver State Scripts — a consortium of private and public health plans that will negotiate for lower drugs prices, while New Mexico Democrat Michelle Lujan Grisham seeks to pool state resources to reduce drug prices.
In Maine, Republican Shawn Moody proposes to lower prescription drug costs by providing greater access to generic drug alternatives. Democrat Janet Mills has a multifaceted plan to lower drug prices that includes investigating pooling public purchasers, increasing transparency and following the work in other states on importation and establishing payment caps to “step in quickly if solutions pioneered elsewhere take hold”. In Wisconsin, Gov. Scott Walker wants to make permanent a waiver for SeniorCare, a program to make prescription drugs more affordable for seniors, while Democrat Tony Evers proposes a rate review board and banning PBM gag clauses. In Oregon, Republican Knute Buehler has made drug pricing a major campaign issue. He wants to prosecute leaders of price-gouging pharmaceutical companies and would like to adopt a single formulary for all state taxpayer-funded drug purchasing. Incumbent Kate Brown cites her work in the past to support price transparency.
Social determinants of health: A number of candidates have targeted social determinants of health, including Arkansas Democrat Jared Henderson who proposes reducing teenage pregnancy and childhood poverty as ways to address long-term health care spending without reducing Medicaid enrollment. In Ohio, Republican Mike DeWine has a plan for wellness programs that would require Medicaid managed care plans to provide education and promote healthy benchmarks geared towards upstream prevention efforts. Colorado Democrat Jared Polis suggests moving toward global budgeting for hospitals, which would provide them with a set amount of revenue that could incentivize efficiency, innovation, and a focus on social determinants of health and preventive care. Oregon Republican Knute Buehler wants to coordinate investments, set financial expectations, and determine specific metrics in social determinants of health, such as workforce training, employment, community engagement, and housing. Democrat Karl Dean of Tennessee supports preventive health care and promoting healthy lifestyles, and as governor would focus on preventing childhood obesity because of its link to both chronic health problems later in life as well as social and emotional issues.
Delivery system and payment reforms: States have been actively engaged in a variety of reforms designed to improve how care is delivered and paid for –moving from a volume- to a value-based system – and a number of candidates have embraced these efforts. In Colorado, both candidates refer to the lessons learned from the state’s State Innovation Model (SIM) initiative. Democrat Jared Polis wants to use lessons from SIM to increase access to integrated physical and behavioral health care and supports moving Colorado Medicaid to a bundled payment system. He also proposes global budgeting for hospitals and using health information technology to measure hospital care quality and tie payments to community health improvement. Republican Walker Stapleton wants to build on the success of the state’s SIM work and continue expanding the state’s Regional Accountability Entities to make sure reimbursement systems promote the best patient outcomes. Ohio Democrat Richard Cordray plans to reform the Medicaid payment system to incentivize primary and preventive care in physical and behavioral health, and would invest in high-quality, value-based programs. Oregon Republican Knute Buehler wants to prepare for a third generation of Coordinated Care Organizations (CCOs) by aligning early learning hubs, regional solutions, and related social and health services. He also proposes to reorganize Medicaid mental health services payment and delivery to fully integrate mental and physical health through CCOs (with counties continuing to serve as providers) and tie CCO funding to outcomes. Tennessee Democrat Karl Dean would continue the state’s work to promote health care value over volume, which has included phased implementation of episodes of care for TennCare enrollees.
This snapshot suggests governors’ races are fueling spirited discussions about health policy and promises a lively 2019 as policymakers continue to address how to provide affordable, high-quality health care and improve population health. New governors’ ideas will be considered by state legislatures, whose political make-up will also likely change, as 80 percent of all state lawmakers are up for election in November. As voters make their choices, NASHP will continue to track and support policymakers who advance solutions to the current challenges of health care access, cost, and quality, and help identify new opportunities for state innovation.
Karen Palombo is the substance use disorder (SUD) team lead in the Texas Health and Human Services Commission’s mental health and substance use division who helps shape state intervention and treatment policies. Before joining state government, she worked in hospital, mental health, and SUD treatment settings for nine years as a licensed chemical dependency counselor. Her first-hand knowledge of SUD treatment challenges in a state with an expansive mix of rural and urban gives her a unique perspective into how a state policymaker can use data, relationships, and grassroots connections to design and promote effective programs.
How did you come to work in SUD treatment in direct care, and then at a state policy level?
During my undergraduate and graduate years, I worked at a short-term residential treatment center for kids removed from their parents. About 80 percent were over age 12 and they talked a lot about seeing their parents drunk and high all the time. They were often prescribed depression and anxiety medications, but what they were really dealing with was trauma. They talked about how when they became parents they would do things differently.
My next job was in child protective services, where I worked with grown-up versions of those same traumatized kids, who still didn’t have the skills to do things differently. They had limited support, a mistrust of government resources, inappropriate social skills, and none or few coping skills. I wanted to work on a policy level to address that.
How did you come to focus on women and children?
I thought if I could keep women and children together during recovery, it would have the most impact. When women and kids don’t stay together, we know kids are safe, but are they secure? Unfortunately, children going through the child welfare system learn not to trust adults because if they tell them about their parents’ relapse and abuse, their family is separated and they are removed. My goal is for health care providers to have the community resources they need available so they know who to call and how to respond when a pregnant woman with SUD walks in the door to make sure her whole family is treated.
Like many rural states, Texas has inconsistent state data on opioid overdose deaths. As a policymaker, how do you make the case for more targeted resources to improve opioid prevention and treatment when data is unreliable?
In some areas, we have very good data, for example, we’re one of only two states that track if alcohol and other substances were involved — even if it was not the direct reason for a child’s removal. When we don’t have data, we rely on relationships with the people on the ground who know the things we need to know. I make tours around the state all the time and have the luxury of sitting on lots of committees where I’m always making the case for data collection. If I’m talking to a hospital, I know to talk about poison control, emergency department data, and hospital costs. It makes us better data collectors and sharers, but it’s done on a regional basis and relies on relationships.
I also know that when I call our Medicaid office and say, ‘I’m trying to find out how long newborns with neonatal abstinence syndrome stay in NICUs at the hospitals where I have given a community presentation,’ my contact knows what code to use and she can tell me from her data indicators what is happening on a statewide basis vs. on a regional basis. When individual staff persons see why they collect the data they do — when they see it in a report — it starts to matter.
Is regional information critical in order to fine-tune program design in such a large state?
When you work in a state the size of Texas, with its diverse rural and urban populations, knowing what’s happening on a regional level is critical. The types of [illegal] drugs used vary between regions. In some areas, opioids never really arrived and cocaine never left. From a public health perspective, we need programs that work no matter what drug is used. When I’m talking to officials in Odessa, they don’t care about a statewide picture, they only care about what will work in Odessa.
Your state legislature meets every two years, how do you get the resources you need to redesign or launch programs for a rapid response to this epidemic?
As part of legislative recommendations, Behavioral Health Services division moved from the Department of State Health Services to the Health and Human Services Commission, which has led to better collaboration and communication to address behavioral health alongside primary health. We have been able to reconfigure our programs, and now have a foothold so our workgroups now touch all of these government programs that affect women. For instance, Texas Medicaid now reimburses for SBIRT [Screening, Brief Intervention, and Referral to Treatment] and postpartum depression screenings. We were able to assist in writing language about the Medicaid benefit, which screenings would be reimbursable, and suggested at one meeting that it would be important at well-child visits to be able to screen for postpartum depression. This is now a benefit in Texas. We probably would not have been involved in this process if not for the state agency re-organization.
How are you breaking down traditional siloes that impede a collaborative response to this crisis?
I have attended monthly workgroup meetings for four years waiting for someone to turn to me and say, ‘don’t you do that?’ If we’re not there to share what we do and learn how to collaborate, nothing happens. Our team members work with child welfare, public health, maternal child health, community health workers, train-the-trainer programs in local communities, homelessness, housing, and recovery programs, education departments, and workforce development. Serving on those committees makes us better data collectors and sharers. Data is everything, you never know what the scope of a problem is until you identify the data you need.
Can you give me an example of how has data collection has resulted in better state policy?
At our workgroups, we started hearing anecdotal information about women with SUD miscarrying in jails. [Pregnant women are at high risk of miscarriage if they go into withdrawal and do not receive medication-assisted treatment (MAT), such as methadone.] The Texas legislature instructed the Texas Commission on Jail Standards to collect data on miscarriages starting in 2016. When data collection began, we started to get more calls from jail nursing staff asking how to get methadone to pregnant women. The data collection led to awareness and to development of new policies to address the problem. Most jails that have nearby methadone clinics are developing standard protocol for when [incarcerated] pregnant women report opioid use disorder.
We’re also collecting data for the MOM – Maternal Opiate Mortality study. We know opioid overdose is the leading cause of death for women after childbirth in Texas. We’re looking at what happens that made women relapse, we’re interviewing these women and their families, and identifying how the state can make sure women who leave Medicaid after childbirth continue to receive MAT. In 2020, we’ll use the findings to develop guidelines for providers to screen more high-risk women and work to reduce maternal deaths.
What would you recommend to other states that are working to develop more effective SUD programs?
What I’ve learned is you never stop going back into communities and asking them what they want and need. When you work at a state level, you often stop doing community outreach, asking questions, or attending forums. If people in the community don’t agree with what you’re trying to do on a state level, it’s not going to work.
The biggest issue for us is getting treatment to rural areas. Communities with more people have more money and more access to health care. Rural communities will tell you they know that people don’t care about them. That’s hard to hear when you’re sitting in a room listening to them, but as a state official, you really need to know what’s going on if you’re going to develop effective policies.
The opioid epidemic is having a devastating impact on children and families and placing a significant strain on states as they work to develop effective programs and find new funding to respond to this crisis.
To address the crisis and promote healthy child development, states are implementing innovative whole-family approaches to prevention and treatment (see below). On the federal level, new funding is available and recently the federal Center for Medicare and Medicaid Innovation announced its Integrated Care for Kids model, which states can use to improve care and outcomes while reducing costs through early identification, integrated care coordination, and case management for physical and behavioral health care and non-clinical local services.
Children can experience many negative consequences as a result of their parents’ opioid use disorder (OUD). Prenatal opioid exposure can cause neonatal abstinence syndrome in infants, which is usually treated by costly hospitalizations and may increase the risk of developmental disabilities. Children affected by parental substance misuse are at increased risk of adverse childhood experiences and trauma, which can have significant short- and long-term physical, mental, and behavioral consequences.
A new National Academy for State Health Policy (NASHP) issue brief, written in partnership with the Alliance for Early Success, identifies the following promising state strategies developed by Kentucky, New Hampshire, and Virginia to support children and families:
- Facilitate access to and coverage of services by improving identification of at-risk infants and children, enabling rapid access to treatment, expanding coverage of services, and enhancing provider capacity. For example, New Hampshire’s Project First Step embeds licensed alcohol and drug counselors (LADCs) within its Division of Children, Youth, and Families (DCYF) district offices. The LADCs train child welfare and juvenile justice staff about substance misuse — including screening and facilitating access to treatment — to enable DCYF staff to better meet the needs of children and families affected by OUD.
- Implement family-focused care delivery models, such as providing family-centered treatment approaches for the family unit, offering care at home and in the community, coordinating care, and providing trauma-informed care. Virginia’s Medallion 4.0 Medicaid managed care program contract requires Medicaid managed care organizations to provide specialized care coordinators for substance-exposed newborns and align a mother’s and infant’s care plan. Additionally, Virginia’s Medicaid 4.0 contracts promote delivery of trauma-informed care, particularly for children impacted by the foster care system.
- Align and maximize resources across systems by sharing data and leveraging diverse funding sources. Kentucky’s Sobriety Treatment and Recovery Team (START) program is a family-centered, service delivery model within the state’s child welfare system that pairs families affected by substance use disorder (SUD) with a child protective services (CPS) worker and a family mentor who has lived experience with SUD. The CPS workers and family mentors coordinate care, offer rapid access to treatment, and provide comprehensive wrap-around services. The program weaves together funding from a Title IV-E waiver demonstration, Medicaid, the Temporary Assistance for Needy Families block grant, and state general funds. The state has also established a data-sharing agreement to advance the program between its Department for Community Based Services and its Department for Behavioral Health, Developmental, and Intellectual Disabilities.
An additional report and webinar exploring state strategies to support pregnant and parenting women affected by substance use disorders, including opioid use disorder, will be published in the weeks ahead.
The opioid epidemic continues to have devastating consequences for children and families across the country, with growing social and financial implications for states. The National Academy for State Health Policy (NASHP), in partnership with the Alliance for Early Success, interviewed Kentucky, New Hampshire, and Virginia officials representing state Medicaid, child welfare, and behavioral health programs to explore how their child-serving agencies were responding to the opioid epidemic. This new report explores:
- State strategies to support young children and families affected by the epidemic;
- Available state and federal funding sources for these initiatives; and
- Key considerations for states working to improve services and outcomes for this vulnerable population.
- Listen to a webinar that featured two New Hampshire officials detailing their state’s strategies to support families affected by the opioid epidemic. The speakers are:
- Geraldo Pilarski, Bureau of Community, Family, and Program Support Administrator, New Hampshire Division for Children, Youth and Families, and
- Erica Ungarelli, Bureau for Children’s Behavioral Health Director, New Hampshire Division for Behavioral Health
Download webinar slides. View the webinar:
- Explore resources from #NASHPCONF18’s session: Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.
Below is a full list of the Conference speaker presentations.
- Sandra Robinson
- Daniel Cohen
- Kevin Cranston
- Kristina Larson
- Jacqueline Clymore
- Heather Hauck
- Joseph Kerwin
- Pete Liggett
- David Neff
- Michael Wofford
- Karen Robinson
Thursday Morning Plenary: Understanding the Health Care Cost Conundrum
Session 3: May the (Work) Force Be with You
Session 4: Cha-Ching! Lowering Rx Costs
- Greg Poulsen
- David Seltz
- Erin Taylor