State Medicaid Initiatives Targeting Substance Use Disorder in Criminal Legal Settings, 2021.

Objectives. To document state Medicaid pre- and postrelease initiatives for individuals in the criminal legal system with substance use disorder (SUD). Methods. An Internet-based survey was sent in 2021 to Medicaid directors in all 50 US states and the District of Columbia to determine whether they were pursuing initiatives for persons with SUD across 3 criminal legal settings: jails, prisons, and community corrections. A 90% response rate was obtained. Results. In 2021, the majority of states did not report any targeted Medicaid initiatives for persons with SUD residing in criminal legal settings. Eighteen states and the District of Columbia adopted at least 1 Medicaid initiative for persons with SUD across the 3 criminal legal settings. The most commonly adopted initiatives were in the areas of medication for opioid use disorder treatment and Medicaid enrollment. Out of 24 possible initiatives for each state (8 initiatives across 3 criminal legal settings), the 2 most commonly adopted were (1) provision of medication treatment of opioid use disorder before release from criminal legal settings (16 states) and (2) facilitation of Medicaid enrollment through suspension rather than termination of Medicaid enrollment upon entry to a criminal legal setting (14 states). Initiatives pertaining to Medicaid SUD care coordination were adopted by the fewest (9) states. Conclusions. In 2021, states' involvement in Medicaid SUD initiatives for criminal legal populations remained low. Increased adoption of Medicaid SUD initiatives across criminal legal settings is needed, especially knowing the high rate of overdose mortality among this group. (Am J Public Health. 2024;114(5):527-530. https://doi.org/10.2105/AJPH.2024.307604).

Increases in benzodiazepine prescribing for postpartum anxiety during COVID-19.

PURPOSE: Postpartum mood disorders affect many women following childbirth. Prescribing medication for depression and anxiety is one strategy for the effective treatment of postpartum mood disorders. Left untreated, mothers experiencing these disorders and their infants face increased risks of adverse health outcomes. Little is known about how diagnosis and treatment of postpartum mood disorders changed during COVID-19. METHODS: We used a retrospective pooled cross-sectional design in a sample of privately-insured postpartum women in U.S. claims data from January 1, 2016 to December 31, 2020. We measured changes in diagnoses of anxiety and depression and changes in prescription fills and days supplied of classes of medications used to treat these conditions (antidepressants, benzodiazepines, and z-drugs). We used ordinary least squares (OLS) regression for each outcome variable during the pre-pandemic period and forecast expected outcomes the observation period. Forecasted and actual values of the outcomes were then compared. RESULTS: Following the onset of the COVID-19 pandemic in March 2020, diagnoses of depression and anxiety were not significantly higher among privately insured postpartum women in the United States. The proportion of privately-insured postpartum women filling a benzodiazepine prescription increased by 15.2%. CONCLUSIONS: We find diagnosis of postpartum mood disorders did not increase after the onset of the COVID-19 pandemic, however, fills of benzodiazepines increased among privately-insured postpartum women. Given prior evidence of increased depressive and anxiety symptoms among postpartum women during COVID-19, this suggests increased barriers to appropriate diagnoses and treatment for depression during this period.

Are Policy Strategies for Addressing the Opioid Epidemic Partisan? A View from the States.

CONTEXT: In contrast to the Affordable Care Act, some have suggested the opioid epidemic represents an area of bipartisanship. This raises an important question: to what extent are Democrat-led and Republican-led states different or similar in their policy responses to the opioid epidemic? METHODS: Three main methodological approaches were used to assess state-level policy responses to the opioid epidemic: a legislative analysis across all 50 states, an online survey of 50 state Medicaid agencies, and in-depth case studies with policy stakeholders in five states. FINDINGS: Conservative states pursue hidden and targeted Medicaid expansions, and a number of legislative initiatives, to address the opioid crisis. However, the total fiscal commitment among these Republican-led states pales in comparison to states that adopt the ACA Medicaid expansion. Because the state legislative initiatives do not provide treatment, these states spend substantially less than states with Democratic control. CONCLUSIONS: Rather than persistently working to retrench all programs, conservatives have relied on policy designs that emphasize devolution, fragmentation, and inequality to both expand and retrench benefits. This strategy, which allocates benefits differentially to different social groups and obfuscates responsibility, allows conservatives to avoid political blame typically associated with retrenchment.

Changes in State Technical Assistance Priorities and Block Grant Funds for Addiction After ACA Implementation.

Objectives. To assess states' provision of technical assistance and allocation of block grants for treatment, prevention, and outreach after the expansion of health insurance coverage for addiction treatment in the United States under the Affordable Care Act (ACA). Methods. We used 2 waves of survey data collected from Single State Agencies in 2014 and 2017 as part of the National Drug Abuse Treatment System Survey. Results. The percentage of states providing technical assistance for cross-sector collaboration and workforce development increased. States also shifted funds from outpatient to residential treatment services. However, resources for opioid use disorder medications changed little. Subanalyses indicated that technical assistance priorities and allocation of funds for treatment services differed between Medicaid expansion and nonexpansion states. Public Health Implications. The ACA's infusion of new public and private funds enabled states to reallocate funds to residential services, which are not as likely to be covered by health insurance. The limited allocation of block grant funds for effective opioid medications is concerning in light of the opioid crisis, especially in states that did not implement the ACA's Medicaid expansion.

Impact of Medicaid Restrictions on Availability of Buprenorphine in Addiction Treatment Programs.

OBJECTIVES: To examine how utilization restrictions on state Medicaid benefits for buprenorphine are related to addiction treatment programs' decision to offer the drug. METHODS: We used data from 2 waves of the National Drug Abuse Treatment System Survey conducted in 2014 and 2017 in the United States to assess the relationship of utilization restrictions to buprenorphine availability. RESULTS: The proportion of programs offering buprenorphine was 43.2% in states that did not impose any utilization restrictions, 25.5% in states that imposed only annual limits, 17.3% in states that imposed only prior authorization, and 12.8% in states that imposed both. Programs in states requiring prior authorization from Medicaid had substantially lower odds of offering buprenorphine (odds ratio = 0.50; 95% confidence interval = 0.29, 0.87). CONCLUSIONS: Medicaid prior authorization was linked to lower odds of buprenorphine provision among addiction treatment programs. Public Health Implications. State Medicaid prior authorization requirements are linked to reduced odds of buprenorphine provision among addiction treatment programs and may discourage prescribing.

Benefit requirements for substance use disorder treatment in state health insurance exchanges.

BACKGROUND: Established in 2014, state health insurance exchanges have greatly expanded substance use disorder (SUD) treatment coverage in the United States as qualified health plans (QHPs) within the exchanges are required to conform to parity provisions laid out by the Affordable Care Act and the Mental Health Parity and Addiction Equity Act (MHPAEA). Coverage improvements, however, have not been even as states have wide discretion over how they meet these regulations. OBJECTIVE: How states regulate SUD treatment benefits offered by QHPs has implications for the accessibility and quality of care. In this study, we assessed the extent to which state insurance departments regulate the types of SUD services and medications plans must provide, as well as their use of utilization controls. METHODS: Data were collected as part of the National Drug Abuse Treatment System Survey, a nationally-representative, longitudinal study of substance use disorder treatment. Data were obtained from state Departments of Insurance via a 15-minute internet-based survey. RESULTS: States varied widely in regulations on QHPs' administration of SUD treatment benefits. Some states required plans to cover all 11 SUD treatment services and medications we assessed in the study, whereas others did not require plans to cover anything at all. Nearly all states allowed the plans to employ utilization controls, but reported little guidance regarding how they should be used. CONCLUSION: Although some states have taken full advantage of the health insurance exchanges to increase access to SUD treatment, others seem to have done the bare minimum required by the ACA. By not requiring coverage for the entire SUD continuum of care, states are hindering client access to appropriate types of care necessary for recovery.

Introduction of Medicare coverage in opioid treatment programs: Findings from the first three years.

BACKGROUND: Prior to January of 2020, there was no Medicare reimbursement for services delivered in opioid treatment programs (OTPs). OTPs are the only authorized providers of opioid use disorder (OUD) treatment with methadone, a critical tool to address the opioid overdose crisis. While prior research has examined the availability of MOUD other than methadone for Medicare beneficiaries, research has not identified organizational and local Medicare beneficiary characteristics associated with Medicare insurance acceptance among OTPs. OBJECTIVES: This study has two objectives: 1) to determine the extent to which OTPs began accepting Medicare insurance in the first three years following the new Medicare OTP benefit; and 2) to identify organizational characteristics and local Medicare beneficiary characteristics associated with OTP acceptance of Medicare. METHODS: We used data from the 2021-2023 National Directory of Drug and Alcohol Abuse Treatment Facilities to examine OTP acceptance of Medicare. We used logistic regression to identify organizational characteristics and local Medicare beneficiary characteristics associated with OTP acceptance of Medicare (n = 4630 OTPs). RESULTS: By 2022, about 78.7 % of OTPs accepted Medicare, compared to only 41.1 % of non-OTPs. The odds of Medicare acceptance were lower among for-profit OTPs, compared to non-profit OTPs, and higher among OTPs that accepted Medicaid and private insurance. Additionally, the odds of accepting Medicare were lower for OTPs located in the Northeast, Midwest, and South, compared to OTPs located in the West. Finally, the odds of accepting Medicare were higher for OTPs located in counties with higher percentages of Non-Hispanic White Medicare beneficiaries. CONCLUSIONS: We found high rates of Medicare acceptance among OTPs in the first three years of the Medicare OTP benefit, suggesting increased access to OUD treatment via OTPs for Medicare beneficiaries. While promising, results indicate potential geographic and racial/ethnic disparities in access to OTPs.

The Impact of State Medicaid Eligibility and Benefits Policy on Neonatal Abstinence Syndrome Hospitalizations.

Rates of neonatal abstinence syndrome (NAS) resulting from opioid misuse are rising. However, policies to treat opioid misuse during pregnancy are unclear. We apply a difference-in-differences design to national pediatric discharge records to examine the effects of state Medicaid policies on NAS. Among states in which Medicaid covered two clinically-recommended medications for treating opioid misuse (buprenorphine, methadone), the Affordable Care Act's Medicaid expansion reduced Medicaid-covered NAS hospitalizations. Medicaid expansion did not affect NAS hospitalizations in other expansion states. These findings imply a nuanced relationship between Medicaid policy and NAS that should be considered in addressing opioid misuse among pregnant women.

Effect of Milk Protein-Polyphenol Conjugate on the Regulation of GLP-1 Hormone.

Modern functional foods are designed to provide health benefits beyond basic nutrition. They are enriched with bioactive ingredients like probiotics, vitamins, minerals, and antioxidants. These foods support overall health, enhance immune function, and help prevent chronic diseases. Milk proteins and tea are known to influence satiety and regulate body weight. Studies have shown that green tea polyphenols, namely, (-)-epigallocatechin gallate (EGCG), and whey proteins, predominantly lactoferrin (LF) from milk, play a role in regulating satiety. This study aims to investigate the effect of conjugating EGCG with apo-lactoferrin (Apo-LF) and assessing these effects on satiety through monitoring glucagon-like peptide-1 (GLP-1) regulation in a human colon (NCI-H716) cell line. Apo-LF-EGCG conjugates were synthesized and characterized in terms of structural and functional properties. The effect on GLP-1 regulation was assessed by real-time quantitative reverse-transcription polymerase chain reaction (qRT-PCR) and enzyme-linked immunosorbent assay (ELISA) to monitor gene and protein expressions, respectively. The results revealed that the protein-polyphenol interaction occurs through the complex formation of hydrogen bonds at the O-H and carbonyl groups of EGCG. The conjugates also showed a significant up-regulation of gene and protein expression levels of GLP-1 while also preventing EGCG from degradation, thereby preserving its antioxidant properties. The Apo-LF-EGCG conjugates increase satiety via increasing GLP-1 secretion in human colon cells while simultaneously retaining the antioxidant properties of EGCG. Therefore, these conjugates show potential for use as dietary supplements to enhance satiety.

Concurrent Prescription Fills of Opioids and Benzodiazepines Among Postpartum Women During COVID-19.

Introduction: Concurrent prescribing of opioids and benzodiazepines is associated with increased risk of emergency department visits and overdose. Postpartum women commonly receive opioids for pain after delivery and are at risk for postpartum depression/anxiety. Although prior research finds increases in opioid prescribing and symptoms of depression/anxiety during COVID-19, concurrent prescribing among postpartum women has not been examined in the context of COVID-19. Methods: Using data from a large sample of privately insured postpartum women (N=514,120), the authors compared concurrent prescription fills of opioids and benzodiazepines before March 1, 2020, and after March 1, 2020. Primary outcome variables measured whether a patient ever filled concurrent opioid and benzodiazepine prescriptions and the number of concurrent prescription fills per patient in the 6 months after delivery. Results: Roughly 46.4% of postpartum women filled an opioid prescription, 2.4% filled a benzodiazepine prescription, and 1.2% of women filled a concurrent prescription. Among postpartum women filling a benzodiazepine prescription, 50.7% filled a concurrent opioid prescription. The number of concurrent fills among postpartum women significantly increased during the early period of COVID-19. On average, postpartum women filled 0.009 more concurrent prescriptions than expected on the basis of the preexisting trend, representing a 22.0% increase in the number of concurrent prescriptions relative to the sample mean. Conclusions: Concurrent prescribing of opioids and benzodiazepines places postpartum women at higher risk of emergency department visits and overdose. To reduce the harms associated with concurrent prescribing, clinicians should carefully consider whether opioids and/or benzodiazepines are clinically necessary for treatment and consult their state prescription drug monitoring program prior to prescribing these medications.

Most States Allow Medicaid Managed Care Plans Discretion To Restrict Substance Use Disorder Treatment Benefits.

Managed care plans, which contract with states to cover three-quarters of Medicaid enrollees, play a crucial role in addressing the drug epidemic in the United States. However, substance use disorder benefits vary across Medicaid managed care plans, and it is unclear what role states play in regulating their activities. To address this question, we surveyed thirty-three states and Washington, D.C., regarding their substance use disorder treatment coverage and utilization management requirements for Medicaid managed care plans in 2021. Most states mandated coverage of common forms of substance use disorder treatment and prohibited annual maximums and enrollee cost sharing in managed care. Fewer than one-third of states forbade managed care plans from imposing prior authorization for each treatment service. For most treatment medications, fewer than two-thirds of states prohibited prior authorization, drug testing, "fail first," or psychosocial therapy requirements in managed care. Our findings suggest that many states give managed care plans broad discretion to impose requirements on covered substance use disorder treatments, which may affect access to lifesaving care.

Medicaid Managed Care Prior Authorization For Buprenorphine Tied To State Partisanship And Health Plan Profit Status, 2018.

Buprenorphine is among the most effective drugs for treating opioid use disorder, yet only a quarter of Americans who need it receive it. Requiring prior authorization has been identified as an important barrier to buprenorphine access. However, the practice remains widespread in Medicaid-the largest insurer of Americans with opioid use disorder. In this study, we examined how prior authorization for buprenorphine is related to plan structure and state political environment, using data on all 266 comprehensive Medicaid managed care plans active in 2018. We found substantial variation in prior authorization use across states, with all plans requiring prior authorization in eleven states and no plans requiring it in thirteen other states. We found that for-profit plans and those located in Republican states were more likely to impose prior authorization policies. Our findings suggest that managed care plans' decisions regarding use of prior authorization may be shaped by internal pressures to control costs, as well as by differing partisan stances regarding the need to prevent criminal diversion of buprenorphine.

Statewide efforts to address the opioid epidemic: Results from a national survey of single state agencies.

BACKGROUND: Single State Agencies (SSAs) are at the forefront of efforts to address the nation's opioid epidemic, responsible for allocating billions of dollars in federal, state, and local funds to ensure service quality, promote best practices, and expand access to care. Federal expenditures to SSAs have more than tripled since the early years of the epidemic, yet, it is unclear what initiatives SSAs have undertaken to address the crisis and how they are financing these efforts. METHODS: This study used data from an internet-based survey of SSAs, conducted by the University of Chicago Survey Lab from January to December 2021 (response rate of 94 %). The survey included a set of 14 items identifying statewide efforts to address the opioid epidemic and six funding sources. We calculated the percentage of SSAs that supported each statewide effort and the percentage of SSAs reporting use of each source of funding across the 14 statewide efforts. RESULTS: Treatment of opioid-related overdose figured most prominently among statewide efforts, with all SSAs providing funding for naloxone distribution and all but one SSA supporting naloxone training. Recovery support services, Project ECHO, and Hub and Spoke models were supported by the vast majority of SSAs. Statewide efforts related to expanding access to medications for opioid use disorder (MOUD) received somewhat less support, with 45 % of SSAs supporting mobile methadone/MOUD clinics/programs and 70 % supporting buprenorphine in emergency departments. A relatively low proportion of SSAs (54 %) provided support for syringe services programs. State Opioid Response (SOR) funds were the most common funding source reported by SSAs (57 % of SSAs), followed by block grant funds (19 %) and other state funding (15 %). CONCLUSION: Results highlight a range of SSA efforts to address the nation's opioid epidemic. Limited adoption of efforts to expand access to MOUD and harm reduction services may represent missed opportunities. The uncertainty over reauthorization of the SOR grant post-2025 also raises concerns over sustainability of funding for many of these statewide initiatives.

Substance use disorder treatment carve outs in Medicaid managed care.

INTRODUCTION: Medicaid managed care organizations (MCO) play a major role in addressing the nation's epidemic of drug overdose and mortality by administering substance use disorder (SUD) treatment benefits for over 50 million Americans. While it is known that some Medicaid MCO plans delegate responsibility for managing SUD treatment benefits to an outside "carve out" entity, the extent and structure of such carve out arrangements are unknown. This is an important gap in knowledge, given that carve outs have been linked to reductions in rates of SUD treatment receipt in several studies. To address this gap, we examined carve out arrangements used by Medicaid MCO plans to administer SUD treatment benefits in ten states. METHODS: Data for this study was gleaned using a purposive sampling approach through content analysis of publicly available benefits information (e.g., member handbooks, provider manuals, prescription drug formularies) from 70 comprehensive Medicaid MCO plans in 10 selected states (FL, GA, IL, MD, MI, NH, OH, PA, UT, and WV) active in 2018. Each Medicaid MCO plan's documents were reviewed and coded to indicate whether a range of SUD treatment services (e.g., inpatient treatment, outpatient treatment, residential treatment) and medications were carved out, and if so, to what type of entity (e.g., behavioral health organization). RESULTS: A large majority of Medicaid MCO plans carved out at least some (28.6 %) or all (40.0 %) SUD treatment services, with nearly all plans carving out some (77.1 %) or all (14.3 %) medications, mainly due to the carving out of methadone treatment. Medicaid MCO plans most commonly carved out SUD treatment services to behavioral health organizations, while most medications were carved out to state Medicaid fee-for-service plans. CONCLUSIONS: Carve out arrangements for SUD treatment vary dramatically across states, across plans, and even within plans. Given that some studies have linked carve out arrangements to reductions in treatment access, their widespread use among Medicaid MCO plans is cause for further consideration by policymakers and other key interest groups. Moreover, reliance on such complex arrangements for administering care may create challenges for enrollees who seek to learn about and access plan benefits.

Biophysical Characterization and Cryopreservation of Mammalian Cells Using Ionic Liquids.

Ionic liquids (ILs) are a diverse class of solvents which can be selected for task-specific properties, making them attractive alternatives to traditional solvents. To tailor ILs for specific biological applications, it is necessary to understand the structure-property relationships of ILs and their interactions with cells. Here, a selection of carboxylate anion-based ILs were investigated as cryoprotectants, which are compounds added to cells before freezing to mitigate lethal freezing damage. The cytotoxicity, cell permeability, thermal behavior, and cryoprotective efficacy of the ILs were assessed with two model mammalian cell lines. We found that the biophysical interactions, including permeability of the ILs, were influenced by considering the IL pair together, rather than as single species acting independently. All of the ILs tested had high cytotoxicity, but ethylammonium acetate demonstrated good cryoprotective efficacy for both cell types tested. These results demonstrate that despite toxicity, ILs may be suitable for certain biological applications. It also demonstrates that more research is required to understand the contribution of ion pairs to structure-property relationships and that knowing the behavior of a single ionic species will not necessarily predict its behavior as part of an IL.

Social workers' knowledge and perceptions of effectiveness and acceptability of medication assisted treatment of substance use disorders.

Data from a national study of 345 privately funded, community-based substance use disorder (SUD) treatment centers were used to investigate social workers' knowledge, perceptions of effectiveness, and perceptions of the acceptability of medication assisted treatments (MATs) for SUDs. Results reveal the importance of exposure to MATs for social workers to develop a knowledge base regarding the effectiveness of various pharmacological agents. Results also underline the importance of social workers' perceptions of effectiveness in forming opinions regarding the acceptability of the use of MATs in SUD treatment. Lastly, a 12-Step orientation toward treatment has a negative influence on social workers' opinions regarding the acceptability of MATs.

Changes In County-Level Access To Medications For Opioid Use Disorder After Medicare Coverage Of Methadone Treatment Began.

In 2020 Medicare began reimbursing for opioid treatment program (OTP) services, including methadone maintenance treatment for opioid use disorder (OUD), for the first time. Methadone is highly effective for OUD, yet its availability is restricted to OTPs. We used 2021 data from the National Directory of Drug and Alcohol Abuse Treatment Facilities to examine county-level factors associated with OTPs accepting Medicare. In 2021, 16.3 percent of counties had at least one OTP that accepted Medicare. In 124 counties the OTP was the only specialty treatment facility offering any form of medication for opioid use disorder (MOUD). Regression results showed that the odds of a county having an OTP that accepted Medicare were lower for counties with higher versus lower percentages of rural residents and lower for counties located in the Midwest, South, and West compared with the Northeast. The new OTP benefit improved the availability of MOUD treatment for beneficiaries, although geographic gaps in access remain.

Comparison of Postpartum Opioid Prescriptions Before vs During the COVID-19 Pandemic.

Importance: The COVID-19 pandemic substantially disrupted routine health care and exacerbated existing barriers to health care access. Although postpartum women frequently experience pain that interferes with activities of daily living, which is often successfully treated with prescription opioid analgesics, they are also at high risk for opioid misuse. Objective: To compare postpartum opioid prescription fills after the onset of the COVID-19 pandemic in March 2020 with fills before the pandemic. Design, Setting, and Participants: In this cross-sectional study of 460 371 privately insured postpartum women who delivered a singleton live newborn between July 1, 2018, and December 31, 2020, postpartum opioid fills before March 1, 2020, were compared with fills after March 1, 2020. Statistical analysis was performed from December 1, 2021, to September 15, 2022. Exposure: COVID-19 pandemic onset in March 2020. Main Outcomes and Measures: The main outcome was postpartum opioid fills, defined as patient fills of opioid prescriptions during the 6 months after birth. Opioid prescriptions were explored in terms of 5 measures: mean number of fills per person, mean filled morphine milligram equivalents (MMEs) per day, mean days supplied, percentage of patients filling a prescription for a schedule II opioid, and percentage of patients filling a prescription for a schedule III or higher opioid. Results: Among 460 371 postpartum women (mean [SD] age at delivery, 29.0 [10.8] years), those who gave birth to a single, live newborn after March 2020 were 2.8 percentage points more likely to fill an opioid prescription than expected based on the preexisting trend (forecasted, 35.0% [95% CI, 34.0%-35.9%]; actual, 37.8% [95% CI, 36.8%-38.7%]). The COVID-19 period was also associated with an increase in MMEs per day (forecasted mean [SD], 34.1 [2.0] [95% CI, 33.6-34.7]; actual mean [SD], 35.8 [1.8] [95% CI, 35.3-36.3]), number of opioid fills per patient (forecasted, 0.49 [95% CI, 0.48-0.51]; actual, 0.54 [95% CI, 0.51-0.55]), and percentage of patients filling a schedule II opioid prescription (forecasted, 28.7% [95% CI, 27.9%-29.6%]; actual, 31.5% [95% CI, 30.6%-32.3%]). There was no significant association with days' suppy of opioids per prescription or percentage of patients filling a prescription for a schedule III or higher opioid. Results stratified by delivery modality showed that the observed increases were larger for patients who delivered by cesarean birth than those delivering vaginally. Conclusions and Relevance: This cross-sectional study suggests that the onset of the COVID-19 pandemic was associated with significant increases in postpartum opioid fills. Increases in opioid prescriptions may be associated with increased risk of opioid misuse, opioid use disorder, and opioid-related overdose among postpartum women.

Changes in Medicaid Fee-for-Service Benefit Design for Substance Use Disorder Treatment During the Opioid Crisis, 2014 to 2021.

Importance: Medicaid is the largest payer of substance use disorder treatment in the US and plays a key role in responding to the opioid epidemic. However, as recently as 2017, many state Medicaid programs still did not cover the full continuum of clinically recommended care. Objective: To determine whether state Medicaid fee-for-service (FFS) programs have expanded coverage and loosened restrictions on access to substance use disorder treatment in recent years. Design, Setting, and Participants: In 2014, 2017, and 2021, a survey on coverage for substance use disorder treatment was conducted among state Medicaid programs and the District of Columbia with FFS programs. This survey was completed by Medicaid program directors or knowledgeable staff. Data analysis was performed in 2022. Main Outcomes and Measures: The following were calculated for a variety of substance use disorder treatment services (individual and group outpatient, intensive outpatient, short-term and long-term residential, recovery support, inpatient treatment and detoxification, and outpatient detoxification) and medications (methadone, oral and injectable naltrexone, and buprenorphine): (1) the percentage of Medicaid FFS programs covering these services and medications and (2) the percentage of Medicaid FFS programs using utilization management policies, such as copayments, prior authorizations, and annual maximums. Results: This study had response rates of 92% in 2014 and 2017 (47 of 51 states) and 90% in 2021 (46 of 51 states). For the 2021 wave, data are reported for the 38 non-managed care organization plan-only states. Between 2017 and 2021, coverage of individual and group outpatient treatment increased to 100% of states, and use of annual maximums for medications decreased to 3% or less (n ≤ 1). However, important gaps in coverage persisted, particularly for more intensive services: 10% of Medicaid FFS programs (n = 4) did not cover intensive outpatient treatment, 13% (n = 5) did not cover short-term residential care, and 33% (n = 13) did not cover long-term residential care. Use of utilization controls, such as copays, prior authorizations, and annual maximums, decreased but continued to be widespread. Conclusions and Relevance: In this survey study of state Medicaid FFS programs, increases in coverage and decreases in use of utilization management policies over time were observed for substance use disorder treatment and medications. However, these findings suggest that some states still lag behind and impose barriers to treatment. Future research should work to identify the long-term ramifications of these barriers for patients.

State Funding For Substance Use Disorder Treatment Declined In The Wake Of Medicaid Expansion.

The US continues to grapple with an escalating epidemic of opioid-related overdose and mortality. State funds, which are the second-largest source of public funding for substance use disorder (SUD) treatment and prevention, play a critically important role in responding to this crisis. Despite their importance, little is known about how these funds are allocated and how they have changed over time, particularly within the context of Medicaid expansion. In this study we assessed trends in state funds during the period 2010-19, using difference-in-differences regression and event history models. Our findings reveal dramatic variation in state funding across states, from a low of $0.61 per capita in Arizona to a high of $51.11 per capita in Wyoming in 2019. Moreover, state funding declined during the period after Medicaid expansion by an average of $9.95 million in expansion states (relative to nonexpansion states), especially in states that expanded eligibility under Republican-controlled legislatures, where it declined by an average of $15.94 million. Medicaid substitution strategies, which, in effect, shift some of the financial burden for financing SUD treatment from the state to the federal level, may erode resources for broader system-level efforts that are urgently needed in the midst of the opioid epidemic.