Medicaid makes sense as an effective, efficient and ultimately life-saving resource for patients living with opioid-use disorder (OUD), yet in many states the program represents deadly missed opportunities.
The AMA is working at the federal and state levels to advocate changes to promote recovery among what research indicates is a population of roughly 2 million adults with OUD. Opioid overdose deaths grew by 10 percent last year, according to the Centers for Disease Control and Prevention.
“We know what works,” said Patrice A. Harris, MD, chair of the AMA Opioid Task Force. “The research shows that medication-assisted treatment [MAT] helps people stay in recovery longer and saves lives.”
The new, provisional figures from the CDC “yet again underscore that this epidemic will not be reversed until we deal with access issues and stigma associated with opioid misuse,” Dr. Harris added.
The AMA has urged all health insurance companies and other payers to remove administrative and other barriers to high-quality, evidence-based treatment for patients with pain and those with opioid use disorder.
Improving Medicaid OUD treatment is essential to turning the tide. Medicaid expansion under the Affordable Care Act, which requires at least some OUD provisions, and has helped add many thousands of OUD patients to gain coverage for their treatment.
Adequately serving Medicaid OUD patients requires a multipronged approach, but the common thread among solutions from the AMA and the states leading the way is to increase access to high quality, evidence-based care.
Proven MAT therapies like buprenorphine, methadone and extended-release naltrexone, with appropriate cognitive behavioral and mental health support should be included in all public and private insurance plans—without prior authorization or other administrative barriers to treatment. State-by-state levels of MAT coverage and statewide access to trained doctors varies greatly.
Another fundamental requirement is much greater access to inpatient OUD care, which federal policy has blocked through Medicaid’s so-called 16-bed IMD limit. The provision—for the anachronistically named “Institutions for Mental Disease”—bans payment at facilities with more 16 psychiatric beds.
“Given that only about 10 percent of the nearly 2 million patients with a substance-use disorder can access treatment, it is essential that treatment capacity be increased as expeditiously as possible,” AMA Executive Vice President and CEO James L. Madara, MD, wrote in a Feb. 16 letter to leaders of a Senate committee investigating the opioid epidemic. “Removing the 16-bed IMD exclusion is an important first step to increasing physicians’ ability to care for patients with an opioid use disorder.”
Among other essential policy changes, the AMA has called for Washington to remove its ban on Medicaid coverage for incarcerated individuals. Inmates with OUD are at high risk for fatal overdose upon release.
National problem, patchwork coverage
Geography remains a big factor as to whether an OUD patient can access treatment. Their ability to get treatment may be dependent on their state’s policies on MAT payment or if their state sought an IMD waiver.
An analysis from the Kaiser Family Foundation found that as of March, 10 states had secured Section 1115 Medicaid IMD waivers—named after a provision allowing demonstration projects and other limited initiatives—and another 10 had pending applications.
Among the states with approved waivers are California, Massachusetts, New Jersey and Maryland. State waiver requests also have been approved or are pending for community-based benefits, such as assistance with housing and or finding employment.
Virginia was one pioneer, both in obtaining a waiver and in the scope of its commitment, which includes inpatient OUD care and increased payment for MAT. The state’s program “contributes to a comprehensive statewide strategy to combat opioid use disorders by expanding the OUD benefits package to cover the full continuum of care,” noted the AMA’s letter.
Despite the progress that has been made, most states have not applied for waivers. The AMA letter called on Congress to “support and expand innovative Medicaid waivers to improve treatment.”
The AMA’s activities, which include pushing for major improvements to Medicaid concerning OUD treatment, are not limited to government advocacy. In 2014, it created the AMA Opioid Task Force, which remains active in providing physicians with hundreds of resources and promoting effective solutions such as physician registration and use of state prescription drug monitoring programs.
