State Exchange Leaders Express Concern about Potential Rule Changes
Today, 13 state-based marketplace directors submitted a joint letter to the US Department of Health and Human Services responding to its request for comment on possible changes to state insurance rules that could eliminate automatic re-enrollment and change cost-sharing reduction policies by 2021. The directors expressed concern that potential changes curtailing those policies would, “create market instability, harm consumers, and intrude on states’ rights to manage their insurance markets.” Read their letter.
The State of States’ Health Policies: What Governors Highlighted in their 2019 Addresses
State of the state and inaugural speeches give governors the opportunity to highlight their recent policy successes and outline key plans and priorities for the coming year. These speeches are strong indicators of governors’ policy goals and often include proposals and funding recommendations for their legislatures.
As a result of 2018 gubernatorial races in 36 states, there are 20 new governors and seven governorships (IL, KS, ME, MI, NV, NM, and WI) shifted from Republican to Democratic control. There are currently 27 Republican and 23 Democratic governors. As of mid-February, 48 governors had outlined policy priorities through their inaugural and/or state of the state speeches or budget addresses.*
View a chart comparing the health topics each governor addressed.
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Key Health Themes
Forty-five governors addressed health care in their speeches this year, and while many themes were similar to years past, a notable exception was the issue of health care costs and affordability, which emerged as a much more significant concern for governors this year. Twenty-four governors spoke of the need for affordable health coverage and others also addressed Medicaid costs and pharmaceutical pricing.
Behavioral Health Issues
Health issues related to mental health and substance use disorders (SUD) were the most commonly cited by governors. Thirty-seven mentioned these issues — the same number of governors who commented on behavioral health in 2018. Governors frequently highlighted strategies they had implemented or that they planned to implement to increase access to behavioral health services or restructure care systems. For example, New Hampshire’s governor commented on recent initiatives to establish mobile crisis teams and community wrap-around services and plans to continue to improve the quality of the state’s mental health system with an upcoming 10-year mental health plan.
Gov. Michelle Lujan Grisham plans to rebuild New Mexico’s behavioral health system and develop strategies to reduce cost, increase patient access, and focus on improved patient care, better health outcomes, and stronger relationships between patients and providers. In North Dakota, the governor is proposing to invest more than $19 million across a continuum of care services to address the state’s behavioral health issues. In Texas, the governor declared that mental health reform would be an emergency item for the 2019 legislative session.
Fourteen governors (AZ, CO, GA, IN, IA, KY, NH, RI, SC, TX, UT, WA, WI, and WY) referenced plans to increase access to mental health services in schools, with some citing the need to provide these additional services to help prevent school shootings. Iowa’s governor also emphasized behavioral health services for children, citing the recent creation of a children’s mental health board that focused on developing a cohesive children’s mental health system. She noted plans to build on the board’s recommendations, and requested that legislators provide additional funding for home- and community-based mental health services for children.
Twenty-six governors specifically mentioned current and future strategies to address the opioid epidemic — a slight decrease from 30 mentions in 2018 — but this demonstrates that the issue remains a top priority for many states. Ten governors also spoke about the issue of behavioral health within the context of better addressing the needs of justice-involved individuals as they transition back into communities and/or providing mental health and SUD treatment services rather than incarceration when appropriate.
Medicaid Program Reforms and Costs and Medicaid Expansion
In total, 23 governors mentioned Medicaid and/or Medicaid expansion in their speeches, which is similar to last year when 19 governors addressed these topics. Ten governors provided general remarks about their states’ Medicaid programs, highlighting recent program improvements, the growth of overall program costs, or plans to implement reforms to ensure the program’s sustainability. New York’s governor expressed concerns about upcoming Medicaid Disproportionate Share Hospital (DSH) cuts, and that previous proposals by federal policymakers to cut Medicaid funding have created uncertainty.
Fourteen governors specifically mentioned Medicaid expansion in their speeches. Some governors commented positively on expansion or the potential for it, with Maine’s newly-elected governor announcing plans to begin implementing the 2017 voter-approved expansion measure, which had been stalled by the former governor. Nebraska’s governor announced he would move forward with filing a state plan in accordance with the expansion ballot measure that state voters approved in 2018. Utah’s governor noted that while Medicaid expansion is needed, the 2018 voter-approved expansion should be implemented in a fiscally sustainable way, with “common sense adjustments.” Montana’s governor outlined in detail the positive economic effects and increased coverage rates that have resulted from implementing expansion and its importance in helping to sustain small businesses and rural hospitals. He indicated that he would not support adding measures to the state’s expansion model that could potentially reduce enrollment and be costly to administer, and recommended that legislators make expansion permanent. In contrast, New Hampshire’s governor urged the legislature to support the upcoming implementation of federally-approved work requirements for the expansion population, responding to some calls to repeal them.
Addressing Increasing Health Care Costs
In addition to mentioning Medicaid-related health care costs, 24 governors also addressed increasing health care costs more broadly, often mentioning that health care coverage needs to be more affordable for individuals and families. This is a notable increase from 2018, when only 11 governors mentioned the impact of rising health care costs. Colorado’s new governor is taking the bold approach of establishing a specific office to focus on reducing patient costs, improving price transparency, lowering prescription drug costs, and improving the affordability of health insurance. Montana’s governor highlighted the state’s reference-based pricing model for state employee health plans, which has made medical costs more consistent and comparable across facilities and in just two years has resulted in a $13 million reduction in state health plan costs. He also encouraged passage of legislation designed to address surprise medical bills.
Governors in Colorado, Montana, and Rhode Island have signaled plans to establish reinsurance programs in their states to address rising premium costs. Gov. Mark Gordon commented that there is an opportunity to “craft a Wyoming solution for health care” and develop state-led solutions to reduce costs.
Prescription Drug Costs
The rising costs of prescription drugs emerged as a new theme in this year’s speeches, earning mentions from seven governors. This is notable, given last year the issue was not addressed by any governor. Colorado’s governor advocated having residents pay a “fair price” for prescription drugs, and promised to work with the legislature to develop a wholesale importation program. Nevada’s governor plans to create the Patient Protection Commission that will identify options for protecting state residents from exorbitant prescription drug prices. The most comprehensive proposal was came from California’s governor who signed an executive order to establish the nation’s largest single-purchaser system for prescription drugs to leverage the state’s purchasing power as a way to lower drug costs.
Health Care Coverage
Eleven governors commented on potential changes that may occur to the Affordable Care Act (ACA) and health coverage in general. Many indicated they would take action to safeguard ACA coverage gains and insurance protection provisions. Nevada’s governor expressed support for defending the ACA and blocking any efforts to scale back protections for preexisting conditions, and Gov. Andrew Cuomo said New York should codify the ACA and incorporate preexisting condition protections into state law. Governors in Oregon and Rhode Island similarly pledged to protect coverage of preexisting conditions, and Wisconsin’s governor issued an executive order creating a Healthy Communities Initiative to promote affordable and accessible health care and another to ensure preexisting conditions were covered.
In his speech, Washington Gov. Jay Inslee promised to “fight for a public health option to ensure health care for all,” in reference to his recent proposal to offer a public plan through the state’s marketplace to make an affordable coverage option available across all regions of the state.
In California, Gov. Gavin Newsom proposes to provide Medi-Cal coverage to undocumented young adults up to age 26, and also seeks federal changes to allow states to implement even more comprehensive coverage reforms and move toward a single-payer model. He is also planning to increase the amount of subsidies available for marketplace coverage and would allow higher-income families to access ACA subsidies. To help cover the costs of this expanded financial assistance, Newsom’s budget proposes to implement a state-level individual mandate. Other states are also considering individual mandates — although not mentioned in recent state of the state speeches, the governor of Rhode Island’s budget proposal recommends implementing such a measure, and Nevada’s governor has indicated earlier that his proposed Patient Protection Commission would examine the issue.
Health Care Workforce
Fourteen governors addressed health care workforce issues, primarily identifying strategies to address provider shortages. This is similar to 2018, when twelve governors mentioned health care workforce issues. This year, governors in Missouri and South Carolina commented about current and planned investments in telehealth to increase access to providers in rural areas. Governors in Mississippi, Nebraska and Oklahoma expressed plans to either create or expand existing scholarship programs to help increase the number of physicians in rural areas. New Hampshire’s governor proposed a $24 million investment to increase the state’s nursing and health care workforce. Other governors in Iowa and Washington highlighted strategies to enhance the capacity of the behavioral health workforce.
Miscellaneous Health Issues
Most governors mentioned other health-related topics in their speeches, either as recent accomplishments or as future plans. These included support for seniors, disabled individuals, and/or children in foster care; women’s health issues; and efforts to address broader social and/or environmental issues that directly affect health. Delaware, New York, and Vermont governors expressed concerns about the use of tobacco products by youth. Other governors drew direct connections between homelessness and health, with Hawaii’s governor highlighting that a hospital in his state had become the first in the nation to place medically fragile, homeless patients into housing to promote recovery. Governors in Maine and New Mexico commented on plans to revive their states’ children’s cabinets to support the health and safety of vulnerable children. Rhode Island’s governor characterized gun violence as “one of the most disturbing and preventable public health crises of this generation” and New Mexico’s governor is requesting that the state’s Department of Health study gun violence to help inform gun violence prevention reforms. Other governors (CA, HI, ME, MI, NM, NY, UT, VT, WA, and WI) commented on environmental issues affecting health, with a few noting the connection between climate change and health, and others committing to improve air or water quality to reduce the negative health effects of pollution. California’s governor also established a state surgeon general position to help address health disparities (see this NASHP blog for more information).
Culture of Health
Eight governors mentioned the importance of building healthy communities, commenting that promoting population health helped create healthy economies. In a future analysis of the governors’ speeches, the National Academy for State Health Policy (NASHP) will provide a more detailed look at how states are specifically addressing and/or tackling some of the social determinants of health — defined as the social and economic factors that directly affect health.
NASHP will track these proposals as they move toward implementation by state legislatures. Clearly, health policy is in play in the states and NASHP will continue to report on state initiatives on a range of health issues in the coming year.
*For some states, information from both a governor’s inaugural address and a state of the state or budget address is included in this review. For other states, information from only one speech is incorporated, due to one of the following reasons: the inaugural address has occurred but the state of the state speech has not yet occurred; the inaugural address served as the governor’s primary policy speech and no state of the state address is planned; or the governor did not have an inauguration and only had a state of the state address. As of mid-February, 2019, Louisiana and North Carolina governors had not made speeches.
Q&A: How Connecticut Matched Its Medicaid and Homelessness Data to Improve Health through Housing
Brian Roccapriore (L) and Steve DiLella
States working to improve the health of people experiencing homelessness can match their Medicaid data with Homeless Management Information Systems (HMIS) data to track which populations are using housing services and which have the greatest unmet need. HMIS are databases that housing service providers and Continua of Care (CoCs) community and state agencies use to collect and aggregate demographic and service-use information for individuals and families experiencing and at risk of homelessness. Recently, the National Academy for State Health Policy’s Health and Housing Institute interviewed Connecticut Coalition to End Homelessness’ Director of HMIS and Strategic Analysis Brian Roccapriore and Connecticut Department of Housing’s Director of Individual and Family Support Programs Steve DiLella for their insights into the successes and challenges of HMIS-Medicaid data sharing in their state.
What is the history of Connecticut’s HMIS-Medicaid data sharing?
There is a long history in Connecticut of providing permanent supportive housing to homeless populations. Ten years ago, the Corporation for Supportive Housing helped with data matching for the most vulnerable people in the state. The first match between HMIS and state Medicaid data was for a re-entry program for the criminal justice population. They used that data-matching model to identify housing needs and ultimately to decrease costs for high-cost Medicaid users. This cost savings resulted from a substantial reduction in the utilization of health care and shelter systems. The Connecticut Coalition to End Homelessness received a federal Social Innovation Fund grant to house the 160,000 highest-cost Medicaid beneficiaries who use housing services. Once this grant was in place, the state experienced a decrease in high-cost medical services use, such as emergency departments, ambulances, behavioral health care, and hospitals, but also an increase in outpatient and medication usage. The state is currently trying to address some of this increase through a proposed Medicaid 1915(i) plan option.
Connecticut previously had 13 homeless CoCs, which used three different HMIS software systems and six to seven iterations of this software. About four years ago, the CoCs merged their systems into one platform that allows for a single release of information. This process proved challenging for the state, and officials faced a variety of issues. The most important part of addressing these setbacks was getting collective buy-in from providers to move to an open system. There was a great deal of conversation with the state attorney general’s office and the state’s hospital coalition over a year about what the release of information should look like — specifically, how restrictive it should be in terms of what to share and with whom. [The state’s current release of information authorization form can be viewed here.] The current release of information form now allows the state, with a client’s consent, to match data for housing and health opportunities.
Who approves data-matching requests, and who does the actual match?
In Connecticut, HMIS and Medicaid provided their data to a third party, New York University (NYU). NYU completed the actual matching process, and then the matched names went back to the state’s HMIS.
HMIS is guided by a steering committee with representatives from Coordinated Access Networks – referral systems that link people to housing services from all regions of the state. Whenever there is a request to obtain data from the HMIS, the committee must approve it.
Did you have to go through a process of defining appropriate data to be included in the data-use agreements?
There was a discovery period to see what was in each specific data warehouse and what was needed to match it. In Connecticut, each warehouse is unique in how it collects data and the data might not match well. We needed to be sure the data was similar enough to match and that it was collected in a uniform way. We had to look at data dictionaries to find common elements and had to define the requests to specify what specific data was needed, such as enrollment and length-of-stay data for emergency shelters, or transitional shelters, and Medicaid claims data.
How important are agency leadership and buy-in?
It’s important. Connecticut has a broad interagency council to increase supportive housing and we had buy-in from the Department of Social Services. This data sharing became a natural fit with the support of our leadership.
Did you seek input from the US Department of Housing and Urban Development (HUD)?
HUD officials recently said that some HMIS releases are too restrictive in the amount of information they can share.
We received HUD technical assistance on the initial release of information. The trend nationally is toward a more open-sharing model. People often default to “we cannot share information” in fear of violating the Health Insurance Portability and Accountability Act (HIPAA), when the true concern should be ensuring informed consent. In fact, the HIPAA Privacy Rule supports the secure sharing of information for a range of purposes, including improving patient and public health and health care quality.
What roadblocks did you encounter?
Most roadblocks we faced were from individual providers, who are protective of the people they serve. It was also hard to find time in the schedules of officials from the attorney general’s office and the Connecticut hospital association to discuss the work. It is important to start this process as early as possible.
Any additional advice you would like to share with states?
Start early, as this process moves slowly. Washington State has a warehouse of data that could be useful to look at. Allegheny County in Pennsylvania also has an impressive data warehouse. It’s important to ensure that there is someone to drive the process.
Strategic use of data can help states maximize and streamline their efforts to improve the health of state residents by addressing social and living conditions. Connecticut’s data-sharing work is an important example to other states similarly seeking to leverage data to improve health through housing.
This work is supported through NASHP’s Cooperative Agreement with the Health Resources and Services Administration (HRSA), grant #UD3OA22891.
Annual Federal Insurance Rule Includes Proposals to Address Prescription Drug Cost
The Trump Administration’s effort to address drug prices surfaced unexpectedly in the Department of Health and Human Services (HHS)’s recently issued proposed annual rule that regulates state health insurance markets, including coverage sold through the Affordable Care Act (ACA) marketplaces. The proposal encourages the use of generic drugs over brand-name drugs by both health plans and enrollees in an effort to “bring down overall health plan costs and perhaps premium increases.”
For more information, read this summary of all of the provisions in the federal proposed rule. HHS is accepting comments on the rule until Tuesday, Feb. 19, 2019.
State officials need to consider whether the proposed changes will result in cost shifting from health plan premiums, which are subsidized for many individuals through advance premium tax credits, to consumers’ unsubsidized, out-of-pocket cost responsibilities. If this cost shifting occurs, how would it affect overall individual and small group market affordability? Or, are there ways to implement the proposed changes to minimize cost shifting onto consumers and truly reduce overall health expenditures? Below are some key policy issues that state officials should consider when reviewing the proposed rule.
The proposal allows health plans to eliminate brand-name drugs from essential health benefit (EHB) coverage requirements if a generic equivalent is available.
Under the proposed rule, if a health plan covers both a brand-name prescription drug and its generic equivalent, the plan could specify that only the generic drug would qualify as EHB, and the brand-name drug would no longer be considered part of EHB coverage. If a plan takes this option, premium tax credits and advanced premium tax credits (APTC) could not be applied to any portion of the premium attributable to coverage of brand-name drugs that are not considered EHB. Issuers would have to calculate that portion of the plan’s premiums and report it to the appropriate health insurance exchange for accurate APTC calculation.
It is also important to remember that lifetime and annual out-of-pocket limits only apply to cost sharing for benefits classified as EHB. Therefore, HHS is seeking comments on whether any portion of enrollees’ out-of-pocket expenditures for brand-name drugs not considered EHB should be counted toward out-of-pocket limits. One HHS proposed strategy would apply the cost of the generic toward the individual’s out-of-pocket limit and the other would not apply any portion of the brand-name drug cost toward an individual’s cost-sharing limit. Issuers pursuing this option would need to establish an appeals process for enrollees to petition for EHB coverage of brand-name drugs.
HHS notes these proposals will provide “additional flexibility for health plans in individual and small group markets that must provide coverage of the EHB to consumers to use more cost-effective generic drugs.” State officials may consider the following questions:
- Would it be possible for a state to carve out brand-name drugs from EHB, and would this rule preempt state laws, particularly in states that have already adopted their own list of essential health benefits in response to ACA challenges?
- Can issuers currently calculate the portion of a qualified health plan’s premiums spent on brand-name drugs excluded from EHB? If not, what would it cost to perform that calculation?
- How would this change be explained to enrollees? Would enrollees receive an advance notice that certain brand-name drugs would not be covered, along with information explaining how to pursue an exception process? Would enrollees be informed at the point of sale? Would enrollees purchasing brand-name drugs receive a summary of benefits that show which costs are attributed to lifetime and annual limits?
The proposal allows health plans to limit prescription drug coupons.
In another effort to encourage generic drug use, HHS proposes that amounts paid toward cost sharing using any manufacturer coupons for a brand-name drugs that have a generic equivalent not be counted toward enrollees’ annual limits on cost sharing. According to HHS, “the proliferation of drug coupons supports higher cost brand drugs when generic drugs are available, which in turn supports higher drug prices and increased costs to all Americans.”
This proposal addresses a concern that coupons can distort the true cost of drugs by offering limited-time cost reductions for enrollees’ out-of-pocket expenses, and manufacturer coupons may inflate drug prices that insurers pay. Limiting the use of coupons for brand-name drugs may steer consumers toward less-costly generic medications with lower cost-sharing responsibilities. Additionally, HHS suggests that not counting coupon amounts toward the annual cost-sharing limit would “promote prudent prescribing and purchasing choices by physicians and patients based on the true costs of drugs [as well as] price competition in the pharmaceutical market.”
HHS seeks comments on whether states should be able to decide how coupons are treated. This proposal reflects state legislative action on coupons. In 2017, California banned the use of manufacturer coupons when a generic equivalent is available. Since the 2019 legislative session began, both New Jersey and New Hampshire have proposed similar measures. State officials may want to consider:
- How difficult would it be for insurers to carve out manufacturer assistance from their pharmacy benefit and the annual limitation on cost sharing (as well as exceptions)?
- Would it be difficult for issuers to differentiate between manufacturer coupons and other types of assistance?
- What consumer education would be required?
The proposal explores implementing reference pricing for prescription drugs.
HHS is also exploring the possibility of implementing reference-based pricing for prescription drugs. Reference-based pricing, as described in the proposed rule, would allow an issuer covering a group of similar drugs (perhaps a therapeutic class of drugs) to set the price that its health plans would pay for those drugs. Enrollees would be responsible for paying the difference between the cost of a drug and the reference price that the health plan sets if enrollees desire a drug that exceeds the reference price. HHS notes that while reference-based pricing could “bring down overall health plan costs, and perhaps premium increases,” it could also increase consumer out-of-pocket costs if an enrollee opts for a drug priced above the reference price. When submitting comments, state officials might consider:
- How would issuers determine the reference prices? Would there be a standard process for selecting reference prices? What role would the states or HHS play in that process?
- Would enrollees’ entire out-of-pocket spending on drugs that exceeds the reference prices go toward their annual cost-sharing limit?
Under the proposed rule, HHS seeks to encourage use of generics over brand-name drugs to decrease overall spending on pharmaceuticals and reduce health plan premium price increases. The proposed rule would likely benefit plans by reducing spending on brand-name drugs, which could in turn lower premiums if savings are passed to enrollees. However, in the short-term, consumers could face increased out-of-pocket spending for brand-name drugs. Are there ways to minimize cost shifting and pursue such proposals to reduce overall costs?
For more information, read this summary of all of the provisions in the federal proposed rule. HHS is accepting comments on the rule until Tuesday, Feb. 19, 2019.
States Use Policy Levers and Emerging Research to Address Antipsychotic Use in Children in Foster Care
State policymakers must often take action during an emerging crisis even when evidence identifying the best policy approach is not be available. This report, Evidence-Based Policymaking Is an Iterative Process: A Case Study of Antipsychotic Use among Children in the Foster Care System, explores successful state responses to dramatic increases in antipsychotic prescription rates in Medicaid-enrolled children in foster care. It highlights several strategies, including payment reforms, delivery system innovations, and quality supports for clinical care.
The report results from a convening by the National Academy for State Health Policy of researchers and state officials with expertise in financing and operating Children’s Health Insurance Program and Medicaid programs, children’s health, and health policy and pharmacy research. The meeting preceded the release of a Patient-Centered Outcomes Research Institute-funded study, which examines the comparative effectiveness of state oversight systems in Ohio, Texas, Washington, and Wisconsin.
Read or download: Evidence-Based Policymaking Is an Iterative Process: A Case Study of Antipsychotic Use among Children in the Foster Care System
CMS Releases State Funding to Improve Integrated Care for Children and Pregnant and Postpartum Women Enrolled in Medicaid and CHIP
Last week, the Centers for Medicare & Medicaid Services (CMS) released two highly anticipated initiatives — the Maternal Opioid Misuse (MOM) Model and the Integrated Care for Kids (InCK) Model — which will provide multi-year funding to states to improve integrated care for maternal and child health populations enrolled in Medicaid and the Children’s Health Insurance Program (CHIP).
NASHP has been tracking these important initiatives since they were first announced by the CMS Center for Medicare and Medicaid Innovation (Innovation Center) last year and has compiled and promoted exemplary integrated care delivery models, strategies, and innovations for pregnant and postpartum women and children that states can consider as they develop their applications for these initiatives.
The MOM Model is designed to:
- Improve quality of care and reduce costs for pregnant and postpartum women with opioid use disorder (OUD) and their infants;
- Expand access, service-delivery capacity, and infrastructure based on state-specific needs; and
- Create sustainable coverage and payment strategies that support ongoing coordination and integration of care.
The CMS Innovation Center will award a maximum of $64.5 million through up to 12 cooperative agreements with state Medicaid agencies and their care delivery model partners for a five-year period. Applications for the MOM Model are due to CMS by 3 p.m. (EST), May 6, 2019. A CMS webinar about the MOM Model Notice of Funding Opportunity was held Feb. 21, 2019. The recording, slides, and transcript from the webinar are available here.
The InCK Model is designed to reduce expenditures and improve the quality of care for children under 21 years of age covered by Medicaid and CHIP through prevention, early identification, and treatment of behavioral and physical health needs. States and local organizations will work to conduct early identification and treatment of children with health-related needs across settings to:
- Increase behavioral health access;
- Respond to the opioid epidemic; and
- Improve child health outcomes.
The CMS Innovation Center will award a maximum of $128 million through eight cooperative agreements with state and local participants for a seven-year period (awarding up to $16 million per recipient). Applications to implement the InCK Model are due to CMS by 3 p.m. (EST), June 10, 2019. A CMS webinar about the InCK Model NOFO is scheduled for 2:30 to 4 p.m. (EST) Tuesday, Feb. 19, 2019.
Tackling the Opioid Crisis: What State Strategies Are Working?
Among the many issues confronting new state governors and their administrations, the opioid crisis may be one of the most urgent and complex, and may leave the most devastating legacy. Opioids kill 130 Americans every day. For state policy makers, the ripple effect of the crisis reaches beyond health care systems to impact public safety and corrections, child protective services, and other state agencies and functions.
What state strategies to combat the opioid crisis show promise?
- Tracking opioid prescribing
- Expanding access to Naloxone
- Increasing medication-assisted treatment
- Engaging corrections
- Ensuring treatment in rural areas
- Expanding Medicaid
As part of National Academy for State Health Policy’s (NASHP) work under a National Organizations of State and Local Officials cooperative agreement with the Health Resources and Services Administration, NASHP officials met with policy makers from a dozen states to talk about their challenges and most promising policy strategies to tackle the opioid crisis.
The group discussed and evaluated a range of policy approaches involving Medicaid, behavioral and public health departments, and governors’ offices. State leaders are on the front lines of the opioid crisis, and while the challenges and complexity of this work can be staggering, states generally share a few common goals: prevent addiction, stop people from dying, and get people into treatment.
With those common goals in mind, NASHP identified a few key strategies from the field that are showing results:
- Track opioid prescribing: While the majority of states now have prescription drug monitoring programs (PDMPs), Florida was one of the first states to establish a PDMP. Since establishing its program in 2009 (and continuously refining it over the last decade), Florida has achieved a 69.3 percent decrease in the number of individuals having “multiple prescriber episodes” – doctor-shopping for multiple opioid prescriptions. Florida also recently implemented one of the country’s strictest limits on opioid prescribing. Legislation passed in 2018 restricts opioid prescriptions to no more than a three-day supply, with certain exceptions, such as for palliative care.
- Invest in harm reduction: In Massachusetts, the Department of Health launched an Overdose Education and Naloxone Distribution (OEND) program. The program has trained more than 64,000 people to administer naloxone, invested in training for first responders, provided naloxone doses to community health centers, and participated in a bulk-purchasing program allowing communities to purchase naloxone at a significant discount. The program reports that close to 11,922 overdose reversals had occurred through the use of OEND naloxone kits.
- Build capacity for medication-assisted treatment (MAT). MAT– an approach that includes both medication, counseling, and other supports — is an effective and evidence-based treatment for opioid addiction. However, states have struggled to build sufficient capacity for MAT to address the enormous need created by the opioid crisis. Virginia is addressing this challenge and is starting to see results: the state implemented its Addiction, Recovery, and Treatment Services program through an 1115 waiver. The state is investing in a comprehensive continuum of care that supports primary care practices and a range of other community providers to deliver office-based MAT. Since implementing these wide-ranging delivery system reforms in 2017, the state has seen treatment rates for individuals with opioid disorders increase by more than 70 percent.
- Engage corrections: The first two weeks after release from a corrections facility can be one of the most lethal periods of time for individuals with opioid use disorder (OUD). States can take a number of steps to target and assist this high-risk population:
- Rhode Island offers MAT to inmates statewide. The program, which also includes linkages to continued treatment following release, has shown promising results. A recent study in the Journal of the American Medical Association reported a 60 percent reduction in post-incarceration, opioid-related deaths after the program was implemented.
- Although individuals are not permitted to receive Medicaid benefits while incarcerated, the Medicaid enrollment process can get started before their release. NASHP’s State Strategies to Enroll Justice-Involved Individuals in Health Coverage provides examples and resources for states to maximize Medicaid enrollment and link people to services as they leave corrections settings.
- Ensure access in rural areas: Access to addiction treatment in hard-hit, rural areas is especially challenging. Overcoming transportation barriers, attracting and supporting specialists, and combatting the stigma associated with accessing (and delivering) services, such as methadone treatment in smaller, more rural communities can be difficult. States are seeing success using the Project Echo model to help providers develop the capacity to deliver treatment. This model links clinical specialists with practitioners in rural areas, facilitating long-distance learning and peer-to-peer mentoring. New Mexico has used the Project Echo model for substance use disorder (SUD) since 2005, and ranks fourth in the country in the number of providers able to deliver MAT services, in spite of its ranking as one of the most rural states in the country.
- Expand Medicaid: States that have not expanded Medicaid may be missing an important policy lever to support access to SUD treatment. Recent research found that states that expanded Medicaid saw a significant increase in prescriptions used to treat opioid disorders. Prescriptions for opioids themselves experienced only a modest increase compared to other medications in those .
These strategies represent just a few of the many state innovations happening across the country as health policy makers confront the opioid epidemic. NASHP is continuing to work closely with states to support their opioid epidemic responses and will share other lessons learned in the months ahead.
Deadline Looms for State Comments on Fed’s Latest Insurance Rules
After a delay, the Department of Health and Human Services (HHS) has issued its proposed annual rule regulating state health insurance markets, including coverage sold through the Affordable Care Act (ACA) marketplaces.
View NASHP’s chart highlighting the rule’s provisions that impact states here.
The deadline to submit comments on the rule is Feb. 19, 2019.
The proposed rule and submission instructions are here.
The deadline to submit comments on the rule is Feb. 19, 2019.
The proposed rule and submission instructions are here.
These latest proposed changes could have significant impacts on state insurance markets and would:
- Impose new insurer requirements;
- Reduce premium tax credits; and
- Alter eligibility and outreach requirements for ACA marketplaces.
The rule also proposes changes to — and seeks feedback on — efforts to limit spending on prescription drugs, especially brand-name drugs.
Notably, the rule does not propose immediate changes to state and issuer policies to “silver load” or adjust premium rates to account for the loss of federal cost sharing reduction (CSR) payments — designed to help those with lower incomes afford coverage through the marketplaces. However, language in the proposed rule suggests HHS might take action in a future rule to address silver–loading if Congress does not take action regarding an appropriation for CSR payments.
The proposal also states that HHS also might take future action related to the practice of auto-enrollment in the insurance marketplaces.
The National Academy for State Health Policy has created a summary chart highlighting the provisions that impact states. Time is limited, with comments on the proposed regulation due to HHS by Feb 19, 2019.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
