A debate over freeing up more federal Medicaid dollars to cover addiction treatments in residential facilities may create a sticking point during House and Senate negotiations on policies to stem the opioid crisis. Lawmakers will have to decide whether to include a provision covering all substance-use disorders, or just certain ones, and how to pay for it.
In the House opioid bill, which cleared the chamber in June, federal Medicaid funds would be allowed to cover treatments for opioid-use and cocaine-use disorders in facilities with more than 16 beds for 30 days in a year. Supporters of the proposal argue that this will expand access to treatments for Medicaid-eligible patients.
The Senate does not have this provision in its package of proposals, which will likely be voted on this week. Sen. Rob Portman’s spokesman said the Ohio Republican will push for an expanded proposal that covers all substance-use disorders in conference. But the senator has acknowledged that pay-fors for such a proposal may be tricky.
Advocates and experts are split on how this provision should be written. A professional association is pushing for it to cover all substance-use disorders, while other experts are urging lawmakers to back off the idea entirely, worried that the cost would decrease resources for community outpatient services. The American Society of Addiction Medicine, which represents professionals in the field and has lobbied on this issue, is pressing for this provision to be expanded to deal with other drug addictions.
Yngvild Olsen, chair of ASAM’s Public Policy Committee, said the group supports the provision because the repeal of the prohibition on using Medicaid dollars is tied to assessments and the inclusion of effective treatments in these residential settings. “With the standardized assessments and the incorporation of effective treatment as part of the residential treatment setting, that then actually is a robust expansion of the continuum of care kind of across both outpatient and residential services,” she said.
The House provision even cites the group’s criteria for states to base their plans on when it comes to determining level of care and length of stay for patients. The proposal was also one of myriad issues that ASAM spent $70,000 lobbying on during the second quarter of this year, according to lobbying disclosure forms from the Center for Responsive Politics.
But an expanded approach to all substance-use disorders will be expensive. Portman discussed the challenge during a Senate Finance Committee markup in June, proposing an amendment that was ultimately not voted on.
“It is pretty expensive, to be honest, and the pay-fors are hard to get,” the senator said during the hearing. “We do have a different proposal we are working on … that would limit some of the costs of it, but through good policy, by saying that, ‘If you want to increase the cap beyond 16 beds, it could be without limit, but if you use all three methods of medication-assisted treatment,’ which I think is good policy. So methadone, Suboxone, and Vivitrol would all have to be offered in that kind of a treatment facility.”
Some health experts are urging lawmakers to back off the idea and instead rely on systems already in place that allow states to cover these treatments.
The House bill would not “require states to increase investments in community-based services, which are badly needed in many states,” said Hannah Katch, senior policy analyst at the Center on Budget and Policy Priorities.
“Community-based services are important to people who are not being treated in residential facilities, as well as people who leave residential treatment. They also will need community-based services to continue their treatment and recovery. So expanding access to community-based services should really be a key focus, and this bill could crowd out states’ investment in those needed community-based services,” she said.
Ahead of the Senate Finance Committee markup in June, the Bazelon Center for Mental Health Law also expressed concerns about this policy and how it will be paid for. The center said there’s already a way for states to use Medicaid funds to cover such services, making this change unnecessary.
The Obama and Trump administrations each released guidance for states that want to obtain waivers to use federal Medicaid funds for treatment of substance-abuse disorder in institutions with more than 16 beds. Under the House bill, states would no longer have to go through this process. If the provision is removed during conference, however, waivers would still be available.
“These demonstration waivers are not only an available option, but a better option than the amendment proposal,” the Bazelon Center said in a June letter commenting on Portman’s proposal. The center added that the waivers require a review from the Health and Human Services Department, “ensuring that states take a comprehensive and strategic approach to their behavioral health systems, including the expansion of community-based services.”
But several hospital organizations have voiced support for allowing Medicaid funds to cover such services. Hospital groups—including the American Hospital Association, the Association of American Medical Colleges, and America’s Essential Hospitals—wrote to House Energy and Commerce Committee leaders in May arguing that the prohibition must be repealed.
“The discriminatory [Institutions for Mental Diseases] policy was established at a time when SUDs were not considered medical conditions on the same level as physical health conditions,” they wrote. “Today, we know that SUD is a brain disease and that successful treatment requires access to the full continuum of care—namely, inpatient care, partial hospitalization, residential treatment, and outpatient services.”