Medicaid Applications Spike during Marketplace Open Enrollment: Lessons from Covered California.

The expansion of Medicaid coverage as part of the Affordable Care Act has insured millions of Americans and reduced costly churn in the program. A large increase in Medicaid applications during Marketplace open enrollment would indicate two potential information gaps: 1) individuals do not know that they are eligible, and/or 2) individuals do not know that they can enroll in Medicaid year-round. We used statewide monthly Medicaid applications data for California over a three-year period (July 2016 to June 2019) to assess whether Marketplace open enrollment influences Medicaid applications. Over one-third of all Medicaid applications (35.0%) were received during months with Marketplace open enrollment, and daily average Medicaid application volume was 32.5% higher in those months than in months outside of open enrollment. These findings generate concerns about whether there is enough consumer education and outreach to potential enrollees to limit coverage gaps and associated barriers in access to care.

Virtual Training Is More Cost-Effective Than In-Person Training for Preparing Staff to Implement Contingency Management.

Behavior therapy implementation relies in part on training to foster counselor skills in preparation for delivery with fidelity. Amidst Covid-19, the professional education arena witnessed a rapid shift from in-person to virtual training, yet these modalities' relative utility and expense is unknown. In the context of a cluster-randomized hybrid type 3 trial of contingency management (CM) implementation in opioid treatment programs (OTPs), a multi-cohort design presented rare opportunity to compare cost-effectiveness of virtual vs. in-person training. An initial counselor cohort (n = 26) from eight OTPs attended in-person training, and a subsequent cohort (n = 31) from ten OTPs attended virtual training. Common training elements were the facilitator, learning objectives, and educational strategies/activities. All clinicians submitted a post-training role-play, independently scored with a validated fidelity instrument for which performances were compared against benchmarks representing initial readiness and advanced proficiency. To examine the utility and expense of in-person and virtual trainings, cohort-specific rates for benchmark attainment were computed, and per-clinician expenses were estimated. Adjusted between-cohort differences were estimated via ordinary least squares, and an incremental cost effectiveness ratio (ICER) was calculated. Readiness and proficiency benchmarks were attained at rates 12-14% higher among clinicians attending virtual training, for which aggregated costs indicated a $399 per-clinician savings relative to in-person training. Accordingly, the ICER identified virtual training as the dominant strategy, reflecting greater cost-effectiveness across willingness-to-pay values. Study findings document greater utility, lesser expense, and cost-effectiveness of virtual training, which may inform post-pandemic dissemination of CM and other therapies.

The implementation & sustainment facilitation (ISF) strategy: Cost and cost-effectiveness results from a 39-site cluster randomized trial integrating substance use services in community-based HIV service organizations.

Background: As part of the Substance Abuse Treatment to HIV Care Project, the Implementation & Sustainment Facilitation (ISF) strategy was found to be an effective adjunct to the Addiction Technology Transfer Center (ATTC) strategy for integrating a motivational interviewing-based brief intervention (MIBI) for substance use disorders. This study presents the cost and cost-effectiveness results. Methods: Thirty-nine HIV service organizations were randomized to receive the ATTC-only condition or the ATTC + ISF condition. Two staff from each organization received the ATTC-training. In ATTC + ISF organizations, the same two staff and additional support staff participated in facilitation sessions to support MIBI implementation. We estimated costs using primary data on the time spent in each strategy and the time spent delivering 409 MIBIs to clients. We estimated staff-level cost-effectiveness for the number of MIBIs delivered, average MIBI quality scores, and total client days abstinent per staff. We used sensitivity analyses to test how changes to key variables affect the results. Results: Adjusted per-staff costs were $2,915 for the ATTC strategy and $5,371 for ATTC + ISF, resulting in an incremental cost of $2,457. ATTC + ISF significantly increased the number of MIBIs delivered (3.73) and the average MIBI quality score (61.45), yielding incremental cost effectiveness ratios (ICERs) of $659 and $40. Client days abstinent increased by 59 days per staff with a quality-adjusted life-year ICER of $40,578 (95% confidence interval $29,795-$61,031). Conclusions: From the perspective of federal policymakers, ISF as an adjunct to the ATTC strategy may be cost-effective for improving the integration of MIBIs within HIV service organizations, especially if scaled up to reach more clients. Travel accounted for nearly half of costs, and virtual implementation may further increase value. We also highlight two considerations for cost-effectiveness analysis with hybrid trials: study protocols kept recruitment low and modeling choices affect how we interpret the effects on client-level outcomes.

Association of Comorbid Behavioral and Medical Conditions With Cannabis Use Disorder in Pregnancy.

Importance: Prenatal cannabis use continues to increase, yet studies of the demographic, psychiatric, and medical characteristics associated with cannabis use in pregnancy are limited by size and use of self-report, and often do not consider cannabis use disorder (CUD) or concomitant substance use disorders (SUDs). Understanding the factors associated with CUD in pregnancy is paramount for designing targeted interventions. Objective: To examine the prevalence of co-occurring psychiatric and medical conditions of US pregnant individuals hospitalized with and without CUD by concomitant SUDs. Design, Setting, and Participants: The study analyzed restricted hospital discharge data from the 2010 to 2018 Healthcare Cost and Utilization Project State Inpatient Databases in 35 states. Data were analyzed from January to August 2021. Weighted linear regressions tested whether the prevalence of psychiatric and medical conditions differed between individuals with and without a CUD diagnosis at hospitalization. Inpatient hospitalizations of pregnant patients aged 15 to 44 years with a CUD diagnosis were identified. Pregnant patients aged 15 to 44 years without a CUD diagnosis were identified for comparison. Patients were further stratified based on concomitant SUD patterns: (1) other SUDs, including at least 1 controlled substance; (2) other SUDs, excluding controlled substances; and (3) no other SUDs. Exposures: CUD in pregnancy. Main Outcomes and Measures: Prevalence of demographic characteristics, psychiatric disorders (eg, depression and anxiety), and medical conditions (eg, epilepsy and vomiting). Results: The sample included 20 914 591 hospitalizations of individuals who were pregnant. The mean (SD) age was 28.24 (5.85) years. Of the total number of hospitalizations, 249 084 (1.19%) involved CUD and 20 665 507 (98.81%) did not. The proportion of prenatal hospitalizations involving CUD increased from 0.008 in 2010 to 0.02 in 2018. Analyses showed significant differences in the prevalence of almost every medical and psychiatric outcome examined between hospitalizations with and without CUD diagnoses, regardless of concomitant SUDs. Elevations were seen in depression (0.089; 95% CI, 0.083-0.095), anxiety (0.072; 95% CI, 0.066-0.076), and nausea (0.036; 95% CI, 0.033-0.040]) among individuals with CUD only at hospitalization compared with individuals with no SUDs at hospitalization. Conclusions and Relevance: Considerable growth was observed in the prevalence of CUD diagnoses among individuals hospitalized prenatally and in the prevalence of depression, anxiety, nausea, and other conditions in individuals with CUD at hospitalization. This study highlights the need for more screening, prevention, and treatment, particularly in populations with co-occurring CUD and psychiatric disorders. Research on the determinants and outcomes associated with CUD during pregnancy is needed to guide clinicians, policy makers, and patients in making informed decisions.

Addressing Barriers to Primary Care Screening and Referral to Prevention for Youth Risky Health Behaviors: Evidence Regarding Potential Cost-Savings and Provider Concerns.

Despite growing evidence and support for co-locating behavioral services in primary care to prevent risky health behaviors, implementation of these services has been limited due to a lack of reimbursement for services and negative perceptions among providers. We investigated potential to overcome these barriers based on new developments in healthcare funding and screening and referral to prevention (SRP) in primary care based on the Consolidated Framework for Implementation Research (CFIR), which could guide future SRP implementation strategies. To investigate the economic need for healthcare-based SRP, we quantified hospital charges to healthcare payors for services arising from adolescent risky behaviors (e.g., substance use, risky sex). Annual North Carolina (NC) hospital charges for these services exceeded $327 M (2019 dollars), suggesting high potential for cost savings if SRP can curb hospital services associated with risky behaviors. To investigate provider barriers and facilitators, we surveyed 151 NC pediatricians and 230 NC family therapists about their attitudes regarding a recently developed well-child visit SRP with family-based prevention. Both sets of professionals reported widespread need for and interest in the SRP but cited barriers of lack of reimbursement, training, and referrals to/from each other. Physicians, but not family therapists, reported concerns with poor patient or parent compliance. Many barriers could be resolved by co-locating family therapists in pediatric clinics to conduct well-child SRP. Our results support further research to develop business models for payor-funded SRP and CFIR-guided research to develop implementation strategies for primary care SRP to prevent adolescent risky health behaviors.

Marijuana liberalization policies and perinatal health.

We studied the effect of marijuana liberalization policies on perinatal health with a multiperiod difference-in-differences estimator that exploited variation in effective dates of medical marijuana laws (MML) and recreational marijuana laws (RML). We found that the proportion of maternal hospitalizations with marijuana use disorder increased by 23% (0.3 percentage points) in the first three years after RML implementation, with larger effects in states authorizing commercial sales of marijuana. This growth was accompanied by a 7% (0.4 percentage points) decline in tobacco use disorder hospitalizations, yielding a net zero effect over all substance use disorder hospitalizations. RMLs were not associated with statistically significant changes in newborn health. MMLs had no statistically significant effect on maternal substance use disorder hospitalizations nor on newborn health and fairly small effects could be ruled out. In absolute numbers, our findings implied modest or no adverse effects of marijuana liberalization policies on the array of perinatal outcomes considered.

Recreational cannabis laws and opioid-related emergency department visit rates.

The opioid epidemic in the United States has accelerated during the COVID-19 pandemic. As of 2021, roughly a third of Americans now live in a state with a recreational cannabis law (RCL). Recent evidence indicates RCLs could be a harm reduction tool to address the opioid epidemic. Individuals may use cannabis to manage pain, as well as to relieve opioid withdrawal symptoms, though it does not directly treat opioid use disorder. It is thus unclear whether RCLs are an effective policy tool to reduce adverse opioid-related health outcomes. In this study, we examine the impact of RCLs on a key opioid-related adverse health outcome: opioid-related emergency department (ED) visit rates. We estimate event study models using nearly comprehensive ED data from 29 states from 2011 to 2017. We find that RCLs reduce opioid-related ED visit rates by roughly 7.6% for two quarters after implementation. These effects are driven by men and adults aged 25-44. These effects dissipate after 6 months. Our estimates indicate RCLs did not increase opioid-related ED visits. We conclude that, while cannabis liberalization may offer some help in curbing the opioid epidemic, it is likely not a panacea.

Is implementation of ASAM-based addiction treatment assessments associated with improved 30-day retention and substance use?

BACKGROUND: The American Society of Addiction Medicine (ASAM) criteria were developed to provide a systematic, evidence-based, and transparent approach to addiction treatment assessment and level-of-care recommendations. In 2017, California began a Medicaid demonstration that required that providers in participating counties to adopt ASAM-based intake assessments and level-of-care criteria. We hypothesized that ASAM implementation would increase the proportion of patients retained in addiction treatment and successfully completing their treatment plan. METHODS: We implemented a comparative interrupted time series analysis with 407,792 treatment episodes by Medicaid beneficiaries in specialty addiction treatment settings from 2015 to mid-2019. We compared the change in retention rates and successful completion rates in counties that adopted ASAM-based assessments relative to counties that did not adopt ASAM-based assessments and used only clinical judgment for level-of-care decisions. Treatment retention was defined as staying in addiction treatment for at least 30 days. Successful completion of the treatment plan was determined by the patient's clinician. RESULTS: After one year, ASAM implementation was associated with a 9% increase in 30-day retention among treatment episodes that started in a residential setting, but no change in retention among episodes starting in outpatient settings. We found no statistically significant association between ASAM adoption and successful treatment completion. CONCLUSIONS: Implementation of ASAM-based assessment may lead to improved retention for individuals who begin treatment in residential treatment, which may be encouraging to the many state Medicaid programs that are adopting ASAM-based criteria. More research is needed to clarify the mechanism by which ASAM leads to improved outcomes and to clarify how to maximize the potential benefits of ASAM, such as through patient-centered implementation.

How Patient Centered Are Addiction Treatment Intake Processes?

OBJECTIVES: The substance use disorder (SUD) treatment field has conducted significant research on creating intake tools and processes that best match patients to the most appropriate treatment setting, but less research has been conducted on how those tools impact the patient experience. The study took advantage of a natural experiment in California to evaluate whether the implementation of American Society of Addiction Medicine (ASAM) assessment criteria and a computer-facilitated intake assessment based on the ASAM criteria affects patient experiences and patient-centeredness during intake relative to patients receiving intake assessments not based on ASAM criteria. METHODS: We analyzed surveys completed by 851 patients covered by Medi-Cal who were receiving specialty SUD treatment at 33 providers across 10 California counties about their experiences and perceptions of the intake assessment process. To account for differences in patient mix, we used inverse-probability weighting and computed differences in the weighted means for patients across non-ASAM, ASAM, and computerized-ASAM patients. RESULTS: We have found that patients who underwent intake based on ASAM assessment criteria or computerized ASAM assessment experienced a more patient-centered intake. We also found that patients who received ASAM-based assessments were more satisfied with their choice of treatment setting. CONCLUSIONS: This evidence is encouraging for the SUD treatment field, especially considering that many Medicaid programs are adopting ASAM or similar patient placement criteria and multidimensional assessments. Future research should consider whether increases in the patient-centeredness of assessments are associated with increased retention in SUD treatment and other positive treatment outcomes.

Implementation science on the margins: How do we demonstrate the value of implementation strategies?

Implementation science (IS) has developed as a field to assess effective ways to implement and disseminate evidence-based practices. Although the size and rigor of the field has improved, the economic evaluation of implementation strategies has lagged behind other areas of IS (Roberts, Healey, & Sevdalis, 2019). Beyond demonstrating the effectiveness of implementation strategies, there needs to be evidence that investments in these strategies are efficient or financially sustainable. In this editorial, we lay out conceptual challenges in applying economic evaluation to IS and the implications for conducting economic analyses in integrated primary care research. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Adherence to buprenorphine treatment guidelines among individuals with an opioid use disorder who have private insurance.

BACKGROUND: Although treatment of opioid use disorders (OUD) with medications is expanding, the extent to which practitioners are prescribing medications following best practices has received little attention. OBJECTIVE: The aim of this study was to determine the extent to which privately insured patients being treated for OUD with buprenorphine were treated in a manner consistent with practice guidelines. DESIGN: Longitudinal analyses of a large commercial claims dataset from 2012 to 2016. PARTICIPANTS: We analyzed data for 38,517 patients with an OUD diagnosis continuously enrolled for 3 months prior to and 6 months after an initial buprenorphine or buprenorphine-naloxone prescription fill. MAIN MEASURES: We evaluated whether practitioners tested patients for hepatitis B, hepatitis C, HIV, and liver function; how often they received urine drug screens; the frequency of outpatient visits; and the extent to which they filled prescriptions for buprenorphine for at least 6 months. KEY RESULTS: Practitioners tested approximately 4.7% of patients for hepatitis B, 6.5% for hepatitis C, and 29.3% for HIV; they tested 8.0% for liver functioning; and gave 33.3% urine drug tests. Approximately 76% of patients had at least one outpatient visit for their OUD. Among those with at least one visit, the mean number of visits was 7.38. After the initial prescription, 47.5% stayed on buprenorphine for at least 6 months. CONCLUSIONS: A large portion of privately insured patients receiving buprenorphine for OUD did not receive care consistent with guidelines.

Substance use disorder treatment services for pregnant and postpartum women in residential and outpatient settings.

The increasing prevalence of opioid use disorders among pregnant and postpartum women (PPW) has generated a need for greater availability of specialized programs offering evidence-based and comprehensive substance use disorder treatment services tailored to this population. In this study, we used data from the 2007 to 2018 National Survey of Substance Abuse Treatment Services to describe recent time trends and the geographic distribution of treatment facilities with specialized programs for PPW. We also compared differences in the availability of opioid agonist medication treatments (MT), key ancillary services, and health insurance acceptance between PPW Programs and Other Programs, overall and by residential and outpatient settings. We found that the prevalence of PPW Programs increased from 17% in 2007 to 23% in 2018, for a total of 3,429 PPW Programs and 11,230 Other Programs in 2018. The prevalence of PPW Programs was lowest in some states in the South and Midwest. Compared to Other Programs, PPW Programs were more likely to accept Medicaid (75% vs. 64%) and offer opioid agonist MTs methadone (24% vs. 6%), buprenorphine (44% vs. 30%), or both (18% vs. 4%). PPW Programs were also more likely to offer other key ancillary services such as childcare (16% vs. 3%), transportation (50% vs. 42%), and domestic violence assistance (51% vs. 35%). Compared to PPW Programs in outpatient settings, PPW Programs in residential settings were more likely to offer these key ancillary services but less likely to offer methadone or accept Medicaid. Our findings reflect considerable variation in the availability of PPW Programs over time and across states, as well as substantial gaps in key services offered in PPW Programs, let alone in Other Programs.

Did Arkansas' Medicaid Patient-Centered Medical Home Program Have Spillover Effects on Commercially Insured Enrollees?

Patient-centered medical homes are increasingly being implemented by state Medicaid programs to incentivize high-quality, coordinated care and ultimately lower health care spending. This study examined whether the Arkansas Medicaid Patient-Centered Medical Home Program's practice-wide transformation activities had spillover effects on commercial beneficiaries. We used difference-in-differences to compare utilization and expenditures of commercially insured enrollees as their practices received Medicaid patient-centered medical home certification on a rolling basis between 2014 and 2016. We found a 5.7% increase in outpatient visits and 13% higher expenditures among early adopting practices. Even without associated reductions in costly emergency department visits or inpatient hospital admissions, decisionmakers should not lose sight of the potential value of increased engagement in and coordination of professional services for a population with high unmet health needs. Our results also emphasize that states can leverage Medicaid to spur system-wide transformation, and the investments generate spillover effects beyond those covered directly by Medicaid.

Evaluating time in health care: What are we busy about?

At the end of the day, there are both economic and less tangible benefits to having predictable clinic operations in which people's medical and behavioral health needs are met. These different benefits, stemming from changes in how time is used, are relevant to a wide range of stakeholders including administrators, clinicians, and patients. In short, time is one of our most important resources in health care. Therefore, time studies have a crucial role to play in advancing the implementation of integrated care. In this editorial we describe several methods for measuring time and invite readers to consider which of these (or another method you're aware of) balances your needs for precision and feasibility of measurement. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Increasing Access to Opioid Use Disorder Treatment: Assessing State Policies and the Evidence Behind Them.

OBJECTIVE: Combatting the opioid epidemic requires systemic policy changes that address the underutilization of medication-assisted treatment, a therapy that is effective in treating opioid use disorder. In this study, we present approaches used in five states to increase medication-assisted treatment financing and access. METHOD: We conducted case studies in five U.S. states, interviewing key informants and reviewing the published literature and unpublished documents. RESULTS: In these states, Medicaid expansion was the most significant lever available to expand financing and access to medication-assisted treatment. Other key levers include Medicaid Section 1115 SUD demonstrations, State Targeted Response to the Opioid Crisis and State Opioid Response grants, state contracting mechanisms, and other state regulations. CONCLUSIONS: States in this study reported substantial progress in increasing access to medication-assisted treatment, but empirical evidence of their effects is still emerging.

Psychosocial Workplace Factors and Healthcare Utilization: A Study of Two Employers.

BACKGROUND: While a large literature links psychosocial workplace factors with health and health behaviors, there is very little work connecting psychosocial workplace factors to healthcare utilization. METHODS: Survey data were collected from two different employers using computer-assisted telephone interviewing as a part of the Work-Family Health Network (2008-2013): one in the information technology (IT) service industry and one that is responsible for a network of long-term care (LTC) facilities. Participants were surveyed four times at six month intervals. Responses in each wave were used to predict utilization in the following wave. Four utilization measures were outcomes: having at least one emergency room (ER)/Urgent care, having at least one other healthcare visit, number of ER/urgent care visits, and number of other healthcare visits. Population-averaged models using all four waves controlled for health and other factors associated with utilization. RESULTS: Having above median job demands was positively related to the odds of at least one healthcare visit, odds ratio [OR] 1.37 (P<.01), and the number of healthcare visits, incidence rate ratio (IRR) 1.36 (P<.05), in the LTC sample. Work-to-family conflict was positively associated with the odds of at least one ER/urgent care visit in the LTC sample, OR 1.15 (P<.05), at least one healthcare visit in the IT sample, OR 1.35 (P<.01), and with more visits in the IT sample, IRR 1.35 (P<.01). Greater schedule control was associated with reductions in the number of ER/urgent care visits, IRR 0.71 (P<.05), in the IT sample. CONCLUSION: Controlling for other factors, some psychosocial workplace factors were associated with future healthcare utilization. Additional research is needed.

Effects of a Flexibility/Support Intervention on Work Performance: Evidence From the Work, Family, and Health Network.

PURPOSE: To estimate the effects of a workplace initiative to reduce work-family conflict on employee performance. DESIGN: A group-randomized multisite controlled experimental study with longitudinal follow-up. SETTING: An information technology firm. PARTICIPANTS: Employees randomized to the intervention (n = 348) and control condition (n = 345). INTERVENTION: An intervention, "Start. Transform. Achieve. Results." to enhance employees' control over their work time, to increase supervisors' support for this change, and to increase employees' and supervisors' focus on results. METHODS: We estimated the effect of the intervention on 9 self-reported employee performance measures using a difference-in-differences approach with generalized linear mixed models. Performance measures included actual and expected hours worked, absenteeism, and presenteeism. RESULTS: This study found little evidence that an intervention targeting work-family conflict affected employee performance. The only significant effect of the intervention was an approximately 1-hour reduction in expected work hours. After Bonferroni correction, the intervention effect is marginally insignificant at 6 months and marginally significant at 12 and 18 months. CONCLUSION: The intervention reduced expected working time by 1 hour per week; effects on most other employee self-reported performance measures were statistically insignificant. When coupled with the other positive wellness and firm outcomes, this intervention may be useful for improving employee perceptions of increased access to personal time or personal wellness without sacrificing performance. The null effects on performance provide countervailing evidence to recent negative press on work-family and flex work initiatives.

Alcohol use and the wage returns to education and work experience.

Despite a widely held belief that alcohol use should negatively impact wages, much of the literature on the topic suggests a positive relationship between nonproblematic alcohol use and wages. Studies on the effect of alcohol use on educational attainment have also failed to find a consistent, negative effect of alcohol use on years of education. Thus, the connections between alcohol use, human capital, and wages remain a topic of debate in the literature. In this study, we use the 1997 cohort of the National Longitudinal Survey of Youth to estimate a theoretical model of wage determination that links alcohol use to wages via human capital. We find that nonbinge drinking is associated with lower wage returns to education whereas binge drinking is associated with increased wage returns to both education and work experience. We interpret these counterintuitive results as evidence that alcohol use affects wages through both the allocative and productive efficiency of human capital formation and that these effects operate in offsetting directions. We suggest that alcohol control policies should be more nuanced to target alcohol consumption in the contexts within which it causes harm.

Health Behavior Among Men With Multiple Family Roles: The Moderating Effects of Perceived Partner Relationship Quality.

Men in the United States are increasingly involved in their children's lives and currently represent 40% of informal caregivers to dependent relatives or friends aged 18 years and older. Yet much more is known about the health effects of varying family role occupancies for women relative to men. The present research sought to fill this empirical gap by first comparing the health behavior (sleep duration, cigarette smoking, alcohol consumption, exercise, fast food consumption) of men who only occupy partner roles and partnered men who also fill father, informal caregiver, or both father and informal caregiver (i.e., sandwiched) roles. The moderating effects of perceived partner relationship quality, conceptualized here as partner support and strain, on direct family role-health behavior linkages were also examined. A secondary analysis of survey data from 366 cohabiting and married men in the Work, Family and Health Study indicated that men's multiple family role occupancies were generally not associated with health behavior. With men continuing to take on more family responsibilities, as well as the serious health consequences of unhealthy behavior, the implications of these null effects are encouraging - additional family roles can be integrated into cohabiting and married men's role repertoires with minimal health behavior risks. Moderation analysis revealed, however, that men's perceived partner relationship quality constituted a significant factor in determining whether multiple family role occupancies had positive or negative consequences for sleep duration, alcohol consumption, and fast food consumption. These findings are discussed in terms of their empirical and practical implications for partnered men and their families.

The influence of state-level policy environments on the activation of the Medicaid SBIRT reimbursement codes.

AIMS: To examine how institutional constraints, comprising federal actions and states' substance abuse policy environments, influence states' decisions to activate Medicaid reimbursement codes for screening and brief intervention for risky substance use in the United States. METHODS: A discrete-time duration model was used to estimate the effect of institutional constraints on the likelihood of activating the Medicaid reimbursement codes. Primary constraints included federal Screening, Brief Intervention and Referral to Treatment (SBIRT) grant funding, substance abuse priority, economic climate, political climate and interstate diffusion. Study data came from publicly available secondary data sources. RESULTS: Federal SBIRT grant funding did not affect significantly the likelihood of activation (P = 0.628). A $1 increase in per-capita block grant funding was associated with a 10-percentage point reduction in the likelihood of activation (P = 0.003) and a $1 increase in per-capita state substance use disorder expenditures was associated with a 2-percentage point increase in the likelihood of activation (P = 0.004). States with enacted parity laws (P = 0.016) and a Democratic-controlled state government were also more likely to activate the codes. CONCLUSION: In the United States, the determinants of state activation of Medicaid Screening, Brief Intervention and Referral to Treatment (SBIRT) reimbursement codes are complex, and include more than financial considerations. Federal block grant funding is a strong disincentive to activating the SBIRT reimbursement codes, while more direct federal SBIRT grant funding has no detectable effects.