States May Soon Have to Provide Medication-Assisted Treatment to Inmates, Here’s How to Fund It

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.

Does MAT in jails curb costly recidivism and drug use?

Without MAT, 77 percent of inmates with OUD relapse within three months of their release, even if they receive counseling in jail.According to a SAMSHA report, MAT has been found to “reduce criminal activity, arrests, as well as probation revocations and re-incarcerations.”

• A Sacramento County Jail MAT program with 174 inmates found only 31% were arrested for new offenses.

• A study of 370 individuals who completed a MAT program in Middlesex County, MA, found only 19% were rearrested.

• A MAT study of 200 in Louisville, KY, jails found 47% remained arrest-free.

Source: Jail-Based MAT: Promising Practices, Guidelines and Resources, National Commission on Correctional Health Care and the National Sheriffs’ Association

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.