Last week, the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA) held a workshop for state agency leaders on the opioid crisis.
HHS Secretary Price opened the meeting by outlining the Administration’s priorities for addressing the epidemic, noting that access to medication assisted treatment (MAT) is a key pillar of this strategy. Price also said the Administration is working to make it easier for states to receive Section 1115 substance use disorder (SUD) waivers.
Throughout the meeting, federal and state experts discussed their strategies to prevent addiction and treat it, such as leveraging data analytics for SUD, deploying alternative treatment for chronic pain, and putting in place opioid prescribing guidelines. They also emphasized the importance of cross-agency and cross-sector collaboration to make meaningful progress on this crisis.
President Trump Declares Opioid Crisis a National Emergency
President Donald Trump declared the opioid crisis a “national emergency” last week, directing the administration to use all appropriate authority to respond to the problem of opioid abuse. The emergency declaration comes after the White House’s Commission on Combating Drug Addiction and the Opioid Crisis recommended this action.
The President’s Commission on Combating Drug Addiction and the Opioid Crisis report’s recommendations also included:
Increasing treatment capacity by granting waiver approvals for all 50 states to eliminate barriers to treatment resulting from the Institutes for Mental Diseases (IMD) exclusion within Medicaid;
Mandating prescriber education initiatives to enhance prevention efforts, including mandating medical education training in opioid prescribing and risks;
Establishing and funding a federal incentive to enhance access to Medication-Assisted Treatment (MAT) and requiring that all modes of MAT are offered at every licensed MAT facility;
Providing model legislation for states to allow naloxone dispensing via standing orders and equipping all law enforcement officers with naloxone; and
Prioritizing funding to the Department of Homeland Security (DHS), Federal Bureau of Investigation (FBI) and the Drug Enforcement Agency (DEA) to develop fentanyl detection sensors and disseminate them to federal, state and local agencies.
District Court Rules State AGs May Intervene in House v. Price Cost Sharing Reduction Case
Recently, the U.S. Court of Appeals for the District of Columbia Circuit granted a motion by Democrat attorneys general in 17 states and D.C. to intervene in the House v. Price suit regarding Affordable Care Act cost-sharing subsidies. In granting the motion, the Court says the states “have standing and have demonstrated the appropriateness of their intervention” and would otherwise “suffer concrete injury.” The order moreover finds that:
States have shown “substantial risk” that ending the cost-sharing subsidies would “imminently to an increase in insurance prices, which in turn will increase the number of uninsured individuals for whom the States will have to provide health care”;
Ceasing the subsidies, as sought and obtained by the House at the District Court level, would “impair states’ interests.” The Court elaborates that HHS’ “claim that it could unilaterally suspend payments is a debated legal question, not an answer to the injury the States have evidenced” and notes that the House-sought injunction against the subsidies would preclude states from “persuading or compelling” HHS to make the payments;
States have “raised sufficient doubt concerning the adequacy of the Department’s representation of their interests,” with HHS “nowhere [arguing] in its intervention papers that it will adequately protect the States’ interests or even continue to prosecute the appeal”; and
States’ “motion is timely,” with states filing their motion within a “reasonable time from when their doubts about adequate representation arose due to accumulating public statements by high-level officials both about a potential change in position and the Department’s joinder with the House in an effort to terminate the appeal,” the order states.
Recently, CMS published an updated version of its Medicaid Enterprise Certification Toolkit (MECT), a tool to assist states in planning and developing their Medicaid Management Information Systems (MMIS). Version 2.2 of the MECT streamlines criteria for the five core checklists, provides additional guidance on submission requirements and process for setting development milestones, and a unified RFP guide, among other resources.
CMS Sends State Medicaid Director Letter on the 21st Century Cures Act
Last Wednesday, the Centers for Medicare & Medicaid Services (CMS) issued a State Medicaid Director Letter (SMDL) # 17-001 on the 21st Century Cures Act: Special Needs Trust. Section 5007 of the 21st Century Cures Act (the “Cures Act”), Pub. L. No. 114-255, supports the independence of individuals with disabilities by permitting them to set up a special needs trust on their own behalf, rather than having to rely on a third party to do so. Special needs trusts generally permit individuals living with disabilities who are under age 65 to set aside assets to meet their needs without impacting their eligibility for Medicaid. This letter provides guidance to states on the implications of section 5007 of the Cures Act, entitled “Fairness in Medicaid Supplemental Needs Trusts,” for individuals who have disabilities.
CMS Approves Florida Medicaid Demonstration Under New Era of State Flexibility
Last week, CMS a five-year extension of Florida’s Managed Medical Assistance (MMA) section 1115 demonstration that allows the state to operate a capitated Medicaid managed care program and a low-income pool (LIP) to provide continuing support for the safety net providers that furnish charity care to the uninsured. Importantly, the demonstration equips the state with new tools to help it meet the following goals:
Provides necessary financial support to public teaching hospitals, children’s hospitals, and other hospitals for the care they furnish to low-income uninsured Floridians; and
Strengthens the breadth of access to and quality of providers participating in Florida’s managed care program, including care provided by many Federally Qualified Health Centers (FQHC) and Rural Health Centers (RHC).
In the words of CMS Administrator Seema Verma, “This program gives Florida the ability to care for its most vulnerable and at-risk citizens. Its renewal also provides flexibility to use the funds in a way that meets the unique needs of the State while reducing burden by eliminating duplicative reporting and documentation requirements.”
Repeal and Replace Conversations Shift Towards Individual Market Stabilization as Congress Enters Recess
Recently, the Senate officially went into August recess, officially pausing repeal and replace activity until September. Senate Majority Leader Mitch McConnell (R-KY) stated that the Senate would move on from healthcare issues. However, Sens. Lindsey Graham (R-NC) and Bill Cassidy (R-LA) continue to work on an alternative repeal and replace proposal which would preserve most of the ACA’s taxes, block grant ACA funds to the states (including Medicaid expansion), allow states to preserve ACA regulations if they choose, and maintain the Better Care Reconciliation Act’s Medicaid per capita caps. This proposal is not expected to be sufficient to thread the needle of conservative and moderate Republican concerns that stymied previous repeal and replace efforts.
After the Senate’s dramatic failure to pass comprehensive repeal and replacement, conversations are now beginning around bipartisan steps to stabilize the individual insurance markets. In the House, the bipartisan Problem Solvers Caucus released a proposal which would fund cost-sharing reductions, repeal the medical device tax, and enhance flexibility under 1332 waivers, among other changes. In the Senate, both the Finance Committee and the Health, Labor, Education, and Pensions Committee announced hearings on individual market stabilization will take place in September.
Reps. Murphy, Blumenauer Introduce 42 CFR Part 2 Legislation
Recently, Representatives Tim Murphy (R-PA) and Earl Blumenauer (D-OR) introduced H.R. 3545, the Overdose Prevention and Patient Safety Act. The legislation would reform 42 CFR Part 2, which governs substance use disorder data sharing, by aligning disclosure rules with those stipulated by the Health Insurance Portability and Accountability Act (HIPAA). The legislation would also create protections for these disclosures by prohibiting them from being used to initiate or substantiate a criminal charge or investigation.
In the News
NPR: First Responders Spending More on Overdose Reversal Drug
In this article, NPR examines the growing cost of naloxone, the opioid-reserving drug, and its impact on first responders who are increasingly administering this life-saving medication. This price increase, NPR explains, has prompted concern from federal lawmakers. In a recent letter, for example, Sen. Clare McCaskill (D-MO) voiced concern that one naloxone auto-injector’s price rose from $288 in 2014 to more than $2,000.
As President Trump declares the opioid epidemic a national emergency, NPR explores how states are using similar declarations to respond to the crisis. It notes that at least six states have already made an emergency declaration. Arizona, for example, did so earlier this year, which has allowed them to secure additional resources and real-time data to respond to the opioid crisis.
Health Reform Roundtable Proposes Bipartisan Health Reforms
On August 8, the Health Reform Roundtable released a set of bipartisan health reform proposals which they recommend Congress pass before the end of FY 2017. The proposals are intended to stabilize the individual market and maintain coverage for individuals who currently have it. These proposals call for:
Extending funding for CHIP and FQHCs through 2019;
Fund cost-sharing reduction payments to insurers participating in the individual market, promote risk adjustment in the individual market, encourage states to explore stabilization strategies such as temporary reinsurance, and find a means to offer coverage in counties with no individual market participants;
Incentivize all Americans to obtain health insurance coverage, potentially via encouraging states to explore new designs for pooling populations under 1332 waivers;
Further modify 1332 waivers to allow integration of federal funding sources from Medicaid, CHIP, and the Exchanges, as well as bridge coverage elements and program design; and
NEJM Analyzes Potential for Partial ACA Medicaid Expansions
Recently, the New England Journal of Medicine published a perspective article titled “Small Change, Big Consequences – Partial Expansions under the ACA.” The piece analyzes state experiences with requesting partial Medicaid expansions, noting the Obama administration’s unwillingness to allow partial expansions and the likelihood of the Trump administration taking a different approach. The authors note that while partial expansions may increase overall federal spending via increased tax credits for Exchange coverage, and may also lead to higher costs for individuals who are moved to the Exchanges instead of Medicaid coverage. On the other hand, partial expansions could incentivize more states to expand Medicaid to at least 100% of FPL for adults.
New Interactive Map from AHRQ Highlights State-Specific Trends in Opioids-Related Hospital Care
A new interactive map from AHRQ enables users to explore state-specific information about opioid-related hospital stays. Including information on 44 states and the District of Columbia, the map highlights data from AHRQ’s Fast Stats, an online tool that offers national and state-specific data on hospital stays and emergency department visits, including data by age, gender, community-level income and urban versus rural residency. The map is the most recent example of AHRQ’s ongoing efforts to address the nation’s opioid epidemic.
National Bureau of Economic Research: Addressing the Opioid Epidemic – Is There a Role for Physician Education?
In a recent study using data on all opioid prescriptions written by physicians from 2006 to 2014, researchers from the National Bureau of Economic Research identified a striking relationship between opioid prescribing and medical school rank: Even within the same specialty and county of practice, physicians who complete their initial training at top medical schools write significantly fewer opioid prescriptions annually than physicians from lower ranked schools. As part of their conclusion, the authors indicate that some of this gradient represents a causal effect of education rather than patient selection across physicians or physician selection across medical schools, suggesting that altering physician education may be a useful policy tool in fighting the current epidemic.
Kaiser Family Foundation Examines the Opioid Epidemic and Medicaid’s Role in Treatment
In a new Slide Share presentation, the Kaiser Family Foundation investigates Medicaid’s instrumental role in addressing the opioid crisis. It reveals that Medicaid covered approximately a third of people with an opioid addiction in 2015, amounting to 2.3 million individuals and nearly double the share covered by Medicaid in 2005. Furthermore, Medicaid coverage of nonelderly adults receiving outpatient treatment for opioid addiction was nearly 40% in 2015, up from 27% in 2005. In assessing Medicaid’s role in addressing the opioid crisis, Kaiser articulates three ways in which the Senate’s Better Care Reconciliation Act (BRCA) could harmfully impact states’ ability to address the opioid epidemic:
Phase out the enhanced federal financing for Medicaid expansion;
Convert Medicaid to a per capita cap allotment; and
No longer require Medicaid expansion plans to cover addiction treatment services.
The National Association of Medicaid Directors (NAMD) seeks a Program Director to primarily oversee and support its growing Medicaid leadership portfolio, along with other initiatives.
The primary responsibility of the program director is to create a year-round program that offers multi-faceted leadership training for state Medicaid teams, including a mix of in-person events and virtual meetings; trainings geared toward teams, managers, and new Medicaid Directors; a mix of content and topics related to leadership; strategic communications around the portfolio; and other items.
Although this position is built primarily around leadership, the successful candidate will have a strong background in health care policy and Medicaid. Medicaid, health care, and policy impact everything NAMD does, and to be effective, the Program Director must already be well-steeped in these issues. Also, the leadership program will be offered within the context of topics such as leading effective managed care contracting, building effective partnerships with advocates, and forming a strong partnership with CMS.