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States Respond to Opioid Crisis With Support Not Punishment

WASHINGTON — The country’s perception of the opioid crisis has shifted to regarding it as a health problem instead of a moral failing, according to the director of the Center for Health Policy Research and Ethics (CHPRE) at George Mason University in Fairfax, Virginia.

For instance, one reason Virginia passed Medicaid expansion was that leaders in the criminal justice system pressured the legislature to do so, said Len Nichols, PhD, who is also professor of health policy at the university. He explained that inmates in Virginia would arrive to serve their sentences with an opioid addiction, but they weren’t able to access Medicaid for treatment until after Virginia expanded the program.

Medicaid expansion includes coverage for behavioral treatment, and other support programs, he noted.

Nichols was one of many policy experts who discussed the role of Medicaid expansion, social determinants of health, and work requirements in the opioid crisis at the AcademyHealth National Health Policy Conference Monday.

Asked which states could be looked to as models for addressing substance use issues, Nichols said “the pathways that I’ve seen that are most successful are pathways that include … a job and a community that wraps around people like a bubble. So [opioid addicts] have a new network of people to protect them from the people who took them into the drugs in the first place.”

Hemi Tewarson, JD, of the National Governors Association, called attention to Massachusetts’ drug court system that identifies people with substance use disorders, and steers them away from the criminal justice system and into medication-assisted treatment (MAT) programs.

A lot of states are investing in recovery or transitional housing, where people with addiction have a chance to “stabilize” while receiving treatment and prepare for “the next step,” said panel moderator Joanne Kenen of Politico.

“Housing First” programs, when appropriately targeted towards people with substance use disorders or serious mental illness, have been tied to enough savings for the healthcare and criminal justice systems to make up for the investment, Nichols said.

Tewarson also highlighted the use of peer recovery specialists in Rhode Island emergency departments. These specialists speak directly with patients who have just overdosed and guide them toward counseling and treatment.

She noted that waivers to the Institutions for Mental Disease (IMD) exclusions allow states to provide more inpatient detox. Currently, eight states have been granted IMD waivers by CMS and 10 are pending, Tewarson added.

But comprehensive, long-term support is critical, she said, noting that recovery can take 2-3 years. “That’s a long investment. … We are not there yet as a country.”

Nichols said people on the frontlines of the opioid crisis stress that employment is critical for recovery, which is one reason work requirements for Medicaid eligibility are a good idea.

Asked about the impact of such requirements in Arkansas, where more than 17,000 people lost Medicaid coverage following implementation, Nichols argued that the problem in that state is not the work requirements themselves, but the way Medicaid enrollees are asked to report them.

Having state residents use an internet-based system for reporting in a state where internet service is unreliable was “not the smartest move,” he conceded, but that shouldn’t be an excuse for killing work requirements.

Grace-Marie Turner, president of the right-leaning Galen Institute, said states need to “step forward; figure out how do you make [work requirements] work.” She noted that people who lost their Medicaid coverage because they failed to report their work hours or other allowed activities for 3 consecutive months, were allowed to re-apply for Medicaid beginning in 2019.