The Medicaid and CHIP Payment and Access Commission (MACPAC) recently released their June 2018 Report to Congress on Medicaid and CHIP. The report not only includes analysis from the Commission, but also outlines several recommendations for Congress on four broad topics: (1) ensuring more accurate drug rebates; (2) reforming communication among health care providers under Part 2 regulations; (3) continuing to monitor managed long-term services and supports (MLTSS) in state Medicaid programs; and (4) further analysis on the IMD exclusion and opioid care. This article is a companion to a previously published article on Chapter 2, and focuses on Chapter 4.
Chapter 4 builds on analysis found in the June 2017 Report to Congress, which found that access to care may be impeded by factors ranging from fear about the stigma of having a substance use disorder (SUD) to a fragmented and poorly funded delivery system.
MACPAC’s review of state policies in the June 2018 report to Congress shows that only 12 states pay for the full array of clinical services to treat substance use disorders, which includes outpatient and residential treatment with varying degrees of intensity, as well as medication-assisted treatment. While states can cover many of these services—including residential treatment services in institutions for mental diseases (IMDs)—they choose not to for a variety of reasons.
Further, while the IMD exclusion is often cited as a barrier to paying for residential services, states may currently pay for these services under some conditions through Section 1115 demonstrations and managed care. Twenty-three states have sought federal approval for Section 1115 demonstrations to implement comprehensive strategies to improve SUD care. Others have neither taken advantage of this opportunity nor used other Medicaid authorities to reduce gaps in the continuum of care. Early results from Section 1115 SUD demonstrations in California and Virginia indicate that implementing comprehensive strategies that include covering additional services and undertaking efforts to attract new providers can improve access to SUD treatment.
The largest caps in state clinical service coverage are for partial hospitalization and residential treatment, which creates a barrier to critical treatment for individuals with life-threatening withdrawal potential.
An inadequate supply of SUD treatment facilities and low provider participation rates in Medicaid also affect access to treatment – roughly 40 percent of counties do not have an outpatient SUD treatment program. Gaps are more pronounced for partial hospitalization and short-term residential treatment, with less than 15 percent of providers offering these services. Further complication the situation, only an estimated 6 in 10 specialty SUD treatment facilities accept Medicaid, but there is wide variation among states, with Medicaid participation as low as 29 percent.
Although the analysis focuses on the treatment of opioid use disorder, many of the concerns described in Chapter 4 apply to treatment of other SUDs that trouble many communities, such as those associated with cocaine and methamphetamines.
The chapter concludes not by issuing recommendations to Congress, by identifying areas for further study. It is likely that this topic will continue to be under review by MACPAC in the coming months and years.