The new opioid legislation takes important steps toward expanding treatment and coverage
The new opioid legislation—the Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT Act)—signed into law on October 24 includes targeted expansions in treatment, including provisions that provide funding or flexibility to states to expand access to treatment for substance use disorders (SUD), including opioid use disorder (OUD), and health care more generally in Medicaid and Medicare. These incremental steps are important first steps, but on their own, they will not be enough to close the gaps in OUD services and treatment.
Here is what the bill does and why it matters.
The bill expands access to a full continuum of outpatient SUD treatment services in Medicaid for four years from October 2019 through September 2023 by allowing states to use federal Medicaid funds to pay for SUD treatment in large residential facilities, known as institutions for mental disease. States that opt to cover these institutions’ services must use facilities that follow evidence-based practices and offer at least two types of medication-assisted treatment (MAT), including at least one opioid agonist therapy (i.e., buprenorphine or methadone).
In addition, these states will be required to cover all outpatient SUD treatment services in Medicaid. This means more people may be able to access treatment in residential settings, in addition to services in outpatient settings as appropriate. But as others have warned, if patients who could be treated with inexpensive outpatient SUD care are instead treated in residential facilities, unnecessary spending on residential treatment could crowd out important investments in other less costly SUD treatment services.
The bill expands coverage for medications to treat OUD in Medicaid by mandating that state Medicaid programs cover all Food and Drug Administration–approved drugs for MAT for five years from October 2020 through September 2025, except if states document a shortage of MAT providers. While all state Medicaid programs cover buprenorphine, and most cover naltrexone, 11 states do not cover methadone in 2018.
The bill ensures Medicaid coverage for former foster youth by fixing loopholes in existing law. Even though the Affordable Care Act had previously expanded Medicaid coverage for foster youth up to age 26, a technical error in the way the law was written allowed states to terminate Medicaid coverage for former foster care youth who moved to a different state.
In addition, the SUPPORT Act removes a requirement for states to screen former foster care youth for eligibility in other Medicaid categories (e.g., a pregnant woman or a low-income parent), which streamlines Medicaid enrollment and protects young people fresh out of the foster care system from inadvertently becoming uninsured when their circumstances change.
The bill ensures access to medical services for incarcerated juveniles upon reentry by barring states from terminating Medicaid coverage for juveniles during incarceration. Instead, states can now suspend Medicaid benefits for the duration of incarceration and reactivate coverage for eligible juveniles upon release.
This provision eliminates the need for a juvenile to reapply for Medicaid coverage and allows for seamless transition to community and immediate access to medical care, including SUD treatment.
The bill improves access to care for mothers and babies affected by SUD by permitting Medicaid to pay for prenatal and postpartum care provided to pregnant and postpartum women who are in substance use disorder treatment at institutions for mental disease, and by allowing Medicaid to pay for health care services provided to infants born with neonatal abstinence syndrome in residential pediatric recovery centers, in addition to hospital care.
Pregnant women with SUD and their babies are at high risk for poor maternal and infant health outcomes, and access to comprehensive care during and after pregnancy is critical. It is critical that these residential pediatric recovery centers provide care that optimizes outcomes for the mother–infant dyad as a whole, including effective nonpharmacologic treatments for neonatal abstinence syndrome.
The bill expands access to integrated and coordinated care for Medicaid enrollees with SUD by increasing funding to states that implement Medicaid health home programs to treat patients with SUD, even for state Medicaid programs that already implemented health homes for other patients. The health home model integrates physical, mental, and behavioral health; substance use treatment and recovery care; and supports and services that address social determinants of health. Our researchers have previously explored this promising model of care for people with OUD and ideas for boosting the model’s impact.
The bill expands access to effective, evidence-based OUD treatment for Medicare beneficiaries by requiring that Medicare covers methadone treatment at opioid treatment programs, fixing a long-standing gap in care for vulnerable elderly people, many of whom may have been stable in methadone treatment for years or decades before reaching Medicare eligibility. Previously, Medicare was not allowed to reimburse methadone treatment for OUD, even as the prevalence of OUD among Medicare beneficiaries has increased.
In addition, the SUPPORT Act mandates that Medicare beneficiaries are screened for SUD during initial preventive exams and annual wellness visits, including reviewing current opioid prescriptions and assessing risk factors for OUD, and expands the use of telehealth services for SUD treatment in Medicare.
The bill expands buprenorphine prescribing among midlevel providers by extending temporary (five-year) buprenorphine prescribing authority to nurse anesthetists, nurse midwives, and clinical nurse specialists, and permanently authorizing nurse practitioners and physician assistants to prescribe buprenorphine.
In addition, the SUPPORT Act allows waivered practitioners to immediately treat 100 patients (skipping the 30-patient limit) if they are board certified in addiction medicine or addiction psychiatry or provide buprenorphine in a qualified practice setting.
These provisions could significantly expand access to buprenorphine maintenance treatment and care in a regular office-based outpatient setting for patients who are stabilized and require less intense services, although restrictions on midlevel prescribing authority vary by state, limiting the impact in some states. In states where midlevel practitioners can prescribe buprenorphine without a physician’s supervision, nurse practitioners could set up treatment facilities, expanding access in rural and underserved areas.
The bill expands access to buprenorphine treatment at safety net clinics by providing one-time payments to federally qualified health centers and rural health clinics for each prescriber that obtains a first-time buprenorphine waiver after January 1, 2019. Because funding is limited to $6 million for federally qualified health centers and $2 million for rural health centers, the effect of this provision on buprenorphine treatment capacity could be short-lived.
The bill provides funding to develop, test, and implement evidence-based programs to expand prevention, treatment, and recovery services for people with OUD, including funding for Medicaid and Medicare demonstrations focused on increasing SUD treatment capacity; grants to states to implement comprehensive prevention and recovery support programs for children, adolescents, and young adults; and a pilot program to provide housing to people recovering from SUD.
Even as drug-related overdose deaths appear to be leveling off, they are still at record levels, and substance use disorder is a lifetime chronic condition, often requiring continuous treatment and recovery support. Combined, expenditures on the SUPPORT Act’s treatment provisions total an estimated $2.6 billion over 10 years. This amount falls far short of the funding needed to effectively treat and prevent opioid use disorder, estimated at $190 billion over 10 years by Richard Frank at Harvard University.
As families and communities deal with the opioid epidemic and face its aftermath, expansive policies beyond those contained in the SUPPORT Act will be required to ensure broad access to MAT, reduce treatment barriers related to stigma, and provide the supports and services that effectively address health and psychosocial needs of people with OUD.
In an upcoming post on Urban Wire, we will discuss policies that are missing from the SUPPORT Act that could make a meaningful impact on the opioid epidemic.
Dr. Laura Kehoe talks to a patient during his appointment as Mass. General Hospital in Boston on April 27, 2018. The patient takes Suboxone, a medicine that contains buprenorphine and naloxone, to treat his substance use disorder. Photo by Craig F. Walker/The Boston Globe via Getty Images.