State Health Policymakers Look to Washington and Each Other to Fight the Opioid Epidemic

In the last two weeks, there has been a flurry of federal and state activity focused on the nation’s opioid epidemic that currently kills more Americans than guns or car accidents.

  • In Washington, the President’s Commission on Combating Drug Addiction and the Opioid Crisis released its final report featuring 56 recommendations to stem opioid and substance abuse and improve treatment, followed by a State Medicaid Director Letter from the Centers for Medicare & Medicaid Services (CMS), outlining expanded flexibility for states seeking Section 1115 Waivers to address the problem.
  • At the annual National Academy for State Health Policy (NASHP) conference, it was standing room only at a day-long session entitled State Innovations and Interventions in America’s Opioid Crisis. State health officials from across the country shared their new approaches, which ranged from treatment improvements, innovative use of data, and coalition-building between public safety, businesses, and communities to stem the epidemic that claimed more than 64,000 lives in 2016.
For more details about how states are combatting the opioid crisis, explore NASHP’s State Innovations and Interventions in America’s Opioid Crisis Preconference resource book.

While it’s unclear whether the Trump Administration will adopt all of the commission’s recommendations, which include additional block grant funding and federal incentives for evidence-based programs, the state Medicaid directors’ letter offered guidance for state officials interested in using Section 1115 Waivers to create innovative or experimental programs that meet the goals of Medicaid. In this case, states could use Section 1115 Waivers to expand or create new prevention and treatment initiatives in order to provide a fuller continuum of services to address opioid use disorders within their states.

Section 1115 of the Social Security Act permits CMS to waive certain federal Medicaid requirements so states have more flexibility to innovate and test new models of care, including providing services and expanding Medicaid in ways not typically permitted under current Medicaid rules. States must show that their initiatives still align with the purposes of the Medicaid program, and their waiver applications can be far-reaching or narrowly tailored, and usually require discussion and negotiation with federal partners.

The recent Medicaid letter reiterates the ability of CMS to waive the restrictive “Institutions for Mental Disease” or IMD exclusion, which would enable state Medicaid programs to receive federal financial participation (FFP) support for those facilities that treat opioid use disorders. The guidance notes that IMD costs do not include room and board unless those settings qualify as inpatient facilities.

Additionally, while states may submit an implementation plan after they apply for the waiver, IMD costs will only be paid prospectively once the plan has been approved. Moreover, interested states will need to demonstrate their ability to make improvements on a number of additional goals and milestones, and, as with other 1115 Waivers, the cost of the waiver initiative must be budget-neutral, and incur no costs beyond what the federal government would otherwise have paid.

States may access technical support and resources from the Innovation Accelerator Program to develop their 1115 Waivers. The administration recently approved its first substance use disorder-focused waiver application from West Virginia, which provides additional insight for states looking to go in this direction.

West Virginia’s 1115 Waiver enables the state to expand its substance use disorder (SUD) treatment to include methadone treatment services, peer recovery support services, withdrawal management services, and short-term residential services to all Medicaid enrollees.

“In implementing the SUD demonstration, West Virginia is delivering SUD services through comprehensive managed care plans for managed care enrollees and introducing new policy, provider and managed care requirements to improve quality of the care delivered to West Virginia Medicaid beneficiaries and to ensure that SUD treatment services are delivered consistent with national treatment guidelines established in the American Society of Addiction Medicine Criteria,” CMS officials wrote in their letter announcing the waiver.

“In addition, West Virginia is taking steps to improve the quality and access to care for West Virginia Medicaid beneficiaries with SUD, such as introducing new care coordination features and collecting and reporting quality and performance measures,” they noted. While obtaining financial support for services in IMD may help support a full continuum of services for SUDs, states are also moving forward with innovative community-based approaches, using other funding and policy levers. Examples from the NASHP preconference include:

  • The Drug Free Moms and Babies Program in West Virginia, spearheaded by that state’s Office of Maternal and Child Health. The program is decreasing the presence of illicit substances at delivery through screening and comprehensive care, including long-term follow-up.
  • Connecticut’s multi-pronged approach incorporates increased use of medication-assisted treatment in corrections settings, a statewide access line with transportation, and targeted supports in emergency departments to initiate treatment, including recovery coaches.
  • Ohio’s Episodes of Care payment model measures share data on opioid prescribing in connection with dental extraction, a common pathway for opioid access.

Federal focus on the opioid crisis is expected to produce tangible supports for state policymakers who are on the frontlines of the opioid epidemic. In the meantime, policymakers attending the NASHP conference concurred that they will continue to serve as the leaders, innovators, and problem-solvers in their battles against this devastating epidemic.