Last month, President Trump signed into law the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the “SUPPORT Act”). Most stakeholders agree that the law is an important step forward, offering a range of policies to prevent new addictions and to expand access to treatment, including medication-assisted treatment. The law also seeks to promote harm-reduction strategies, such as greater distribution of Naloxone, to reduce deaths. And it authorizes pilot and demonstration projects for states to experiment with ways to expand health provider capacity. However, the law is also notable for what it does not include, most prominently, a major, sustained infusion of new funding to expand community-based care for substance use disorders.
Compared with commercial insurance, Medicaid often has taken the lead on addressing the opioid epidemic. For example, Pennsylvania eliminated prior authorization in Medicaid for medication-assisted treatment, the gold-standard for opioid use disorder. The state then leveraged that experience to reach agreement with six major insurance carriers to adopt the same policy in the individual and small-group markets.
But there are still gaps in Medicaid coverage of substance use disorder treatment. Fifteen states do not yet cover all three forms of medication-assisted treatment. Moreover, states have historically been precluded under federal law from using federal Medicaid funds to provide care to beneficiaries between ages 21 and 64 residing in Institutions for Mental Disease (IMDs), which are hospitals or residential facilities that care for people with mental illnesses or substance use disorders.
The SUPPORT Act takes some important steps to address these issues. It includes:
- Mandatory coverage of medication-assisted treatment. For fiscal years (FYs) 2020–25, all state Medicaid programs must cover medication-assisted treatment, including related counseling and behavioral health services.
- State option to provide IMD services. The law partially eliminates the IMD payment exclusion from FYs 2019–23. Specifically, states can cover, with Medicaid funds, IMD services to people with at least one substance use disorder for up to 30 days over a 12-month period (federal funding is not extended for treatment of mental illness). The law provides states with this option only if they agree to offer the full continuum of care that someone with a substance use disorder might require, including outpatient services and support making the transition back into the community. This is an important but not failsafe guarantee against overuse of institutional care and helps mitigate the risks of discharging people from residential treatment. Also notable, states must ensure that the IMDs offer two or more forms of medication-assisted treatment. Given that fewer than half of substance use disorder facilities currently offer any form of medication-assisted treatment, this provision is expected to increase access to this evidence-based treatment method.
- Additional enhanced funding for substance use disorder “health homes,” which provide heightened care coordination and care management for Medicaid enrollees with substance use disorders. The SUPPORT Act authorizes an additional two quarters (for a total of 10) of 90 percent Medicaid funding for these care coordination services for new substance use disorder health homes established after the beginning of FY 2018.
- Demonstration project on increasing capacity. In response to concerns about provider capacity, the SUPPORT Act includes a 54-month Medicaid demonstration project for a limited number of states. Up to 10 states can receive planning grants to develop a strategy for increasing substance use disorder treatment capacity, particularly with respect to medication-assisted treatment. Then, five of those states will be selected to implement their strategy, which could include recruiting, training, technical assistance, and higher reimbursement rates. For the duration of the demonstration (three years), Medicaid will match 80 percent of the cost of treatment or recovery services that exceed FY 2018 spending levels.
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Impact of Federal Medicaid Policy on State Delivery Reform
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These changes are likely to lead to improvements in opioid use disorder prevention and treatment, but the loss of life and devastation inflicted by the epidemic requires greater — and permanent — investments. Only five states will have the opportunity to secure additional Medicaid funding to increase substance use disorder capacity, and the reprieve from the IMD exclusion ends after 2023. At an even more fundamental level, the bill adds only $2.1 billion to Medicaid for FYs 2019–28, or less than one-tenth of 1 percent (0.04%) of total Medicaid funding over this period.
More funding for care provided through Medicaid would likely be required as it is the single largest source of coverage for people with opioid use disorders, serving nearly four of 10 such individuals. Indeed, Medicaid spending on opioid use disorders treatment outstrips grant funding from the Substance Abuse and Mental Health Services Administration and other federal agencies, in some states by a factor of 10 or more. To adequately address the need, states likely would need Medicaid to cover all appropriate treatment options, and to have a sufficient number of providers to serve beneficiaries.
Given that the epidemic takes more than 115 lives each day, more resources and effort likely will be needed in the months and years ahead to reverse the epidemic. In particular, more resources will be needed for Medicaid, which remains the most important source of coverage for people with an opioid use disorder.