Medicaid Expansion Impact on Access to OUD Therapy for Criminal Justice Referrals

A recent study showed that Medicaid expansion opened treatment options for more individuals referred by the criminal justice system, but not as much as it did for other beneficiaries. With insight from a panel of experts, we look at why this is; analyze barriers to access; and discuss what these disparities mean for the patient population and payers covering it. 

In April, Health Affairs published the results of an analysis evaluating the impact of Medicaid expansion on the availability of opioid use disorder (OUD) treatment among individuals referred by the criminal justice system [Khatri U, Howell B, Winkelman T. Medicaid expansion increased medications for opioid use disorder among adults referred by criminal justice agencies. Health Affairs. 2021;40(4):562-570. doi:10.1377/hlthaff.2020.01251]. The results were mixed. 

While access to treatment increased for justice system-referred individuals in states that expanded Medicaid compared with those in nonexpansion states, availability did not improve as much for justice-referred individuals as it did for those referred by noncriminal justice system sources. We asked a panel of experts, including the study’s lead author, to analyze the results, address access barriers, and discuss potential solutions. Our panelists include:

• Melissa Andel, principal, Common Health Solutions, Washington, DC 
• Charles Karnack, PharmD, BCNSP, assistant professor of clinical pharmacy, Duquesne University, Pittsburgh, PA
• Utsha Khatri, MD, emergency medicine physician, University of Pennsylvania’s Perelman School of Medicine, and research fellow, National Clinical Scholars Program, Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, PA
• David Marcus, director of employee benefits, National Railway Labor Conference, Washington, DC
• Edmund J Pezalla, founder and CEO at Enlightenment Bioconsult, Hartford, CT
• Arthur Shinn, PharmD, president, Managed Pharmacy Consultants, Lake Worth, FL

What do these results convey to you about Medicaid expansion and the treatment of OUD in certain at-risk populations? 

Dr Khatri: Since the passage of the Affordable Care Act, hundreds of studies have demonstrated that Medicaid expansion helps low-income individuals and families improve their health and financial well-being through both direct and spill-over effects. In our study, we demonstrate that Medicaid expansion led to the increased receipt of evidence-based treatment for medications for OUD among individuals with criminal justice involvement. Both addiction and justice involvement are quite costly, not just in terms of dollars, but also in terms of health and well-being of individuals and their communities. Any policy that improves access to treatment known to save lives, reduce costly acute care utilization, and mitigate the risk of re-incarceration should be considered valuable. 

Mr Marcus: The study highlights the effectiveness of high value services delivered within a managed care delivery system. Managed care entities recognize that spending relatively small amounts of money on prescriptions for the treatment of OUD will significantly reduce the chances of far more expensive treatments down the road. It is a good practice that is generalizable for screenings and other conditions, such as HPV vaccinations and early detection of cancer.

Dr Karnack: There is no doubt that with diseases such as oncology, early diagnosis and treatment benefit the patient and the payer. Data may not be as strong with OUD, but Medicaid expansion increases the safety net and covers more patients, including those released and referred by justice and nonjustice systems.  

Dr Pezalla: I find it interesting that the justice-involved individuals who were referred for treatment were younger than nonjustice referred persons, suggesting that there is a potential for treatment earlier in the disorder and to help those individuals have a more successful re-entry. Early treatment and treatment of younger individuals may have an impact, not just on OUD but also on their opportunity for improved employment and education. 

Ms Andel: Even individuals with few barriers to resources struggle to access effective substance use disorder treatment. For that reason, Medicaid expansion must be coupled with increased access to the supply of quality treatment. And that requires not only money, but a wholesale cultural change around substance use disorder treatment. 

Dr Shinn: I agree that Medicaid expansion certainly helps this population, but what happens when these individuals are not a part of the justice system anymore? Are they going to continue to be compliant? 

Ms Andel: Right. Keep in mind that no one cures substance use disorder. It is something that the individual and his or her community support system will be managing for the rest of that person’s life.

You have started to address some of the challenges of treating OUD in this population. What other hurdles must be overcome? 

Dr Karnack: Referral source is critical. Community-based referral agencies often have more knowledge and experience with community-based OUD treatment programs. Justice based referral sources, which might be geographically removed, often do not have the same level of knowledge and experience. A program based in a middle-class suburban community may not work as well in an urban neighborhood or rural community. Location, logistics, treatment programs, maintenance and follow-up, and dropout rates should influence the referring agency. 

Dr Pezalla: There may also be competitive factors. Alcoholics Anonymous and AA-based substance abuse programs are often available in prison. Proponents of those programs may oppose referral to medication-assisted treatment (MAT) programs, leading to more referrals to non-MAT providers. 

Ms Andel: Yes, there are challenges beyond Medicaid expansion. We know, for example, that Medicaid expansion does not reach all eligible individuals, for different reasons. It is more than simply expanding access—it’s increasing supply of quality treatment options and the willingness of all stakeholders to embrace and accept evidence-based practice.

Dr Khatri, your study references a number of these challenges, including geographic hurdles and lack of control over preferred referral patterns and treatment plans. Are these issues largely out of Medicaid’s hands? 

Dr Khatri: It is not entirely in Medicaid’s hands since criminal justice policies and practices on addiction treatment are often developed in the silos of these institutions. However, Medicaid still has a role it can play in improving access to care for individuals involved with the justice system. 

One of the most important changes needed within the federal Medicaid program is a repeal of the Federal Medicaid Inmate Exclusion Policy, which terminates Medicaid health benefits to individuals who are incarcerated, whether they have been convicted of any crimes or not. This creates avoidable disruptions in access to care, which limits treatment options for OUD. 

Mr Marcus: State and federal management of Medicaid programs certainly complicates the development of novel, innovative approaches. It seems to me that there is an opportunity to outsource OUD treatment referral to entities outside of criminal justice. It is simply not in the wheelhouse of the criminal justice system.

Dr Karnack: Unfortunately, 50 states handle these justice referrals in what seems to be 50 different ways—and sometimes they have ulterior motives due to vested interests. Pennsylvania has a history of judicial referrals profiting those who do the referring. There should be federal standards or guidelines to help states, counties, and other local judicial agencies make decisions based on location, OUD treatment availability, and outcomes. 

Dr Pezalla: Medicaid in its current form has limited options but could still have an impact on treatment. For instance, rather than cancelling health benefits when an individual enters prison, states could suspend coverage instead. Medicaid could increase payments for MAT for OUD, which might increase the number of available providers. Medicaid could also consider an extra form of support or top-up payments for public hospitals/clinics with disproportionate Medicaid
numbers

Ms Andel: I think the focus needs to be on MAT. While it is certainly not the only factor, it is a critical part of an individual’s success for entering remission for substance use disorder. 

Dr Pezalla: Policymakers may want to use this opportunity to reconsider how we view Medicaid. We tend to look at it as health insurance without considering how much it overlaps with public health. Closer liaison or cooperation with state public health functions, including mental health and addiction treatment, could assure better access by increasing the funding flow to those facilities.

The study points out that incarceration stigma might impact how treatment facilities and providers approach treatment for these individuals. Is there anything Medicaid can do about this? 

Ms Andel: I think there is only so much that we can expect state Medicaid agencies to do. That is not a slight toward them—but they are incredibly underfunded and simply don’t have the resources. Our criminal justice system is supposed to be based on reform, not an endless cycle of recidivism. Ideally, the priority would be on interventions that have been shown to be the most effective.

Dr Karnack: I agree that much of the stigma problem is out of Medicaid’s hands. However, the issue should be addressed. Acknowledgement by stakeholders is the first step in minimizing the stigma.   

Dr Pezalla: Stigma cannot be fully addressed by Medicaid. The data suggest stigma from both incarceration and race. Racial bias has been observed in medical decision-making with some treatments not offered to those who providers feel will not take care of themselves. One way for Medicaid to overcome this and some other issues would be to offer an incentive for evaluation of those leaving prison. This could encourage more referrals to the appropriate facilities and take some of the choice of facilities out of the hands of the prison system.  

Mr Marcus: It is true that Medicaid programs could help increase access to such services, but the criminal justice system needs to be an active participant if these interventions are to succeed. 

While it would be great to invest heavily in all areas of need for the vulnerable, resources are not infinite. Is this a matter of Medicaid having to pick its battles in terms of improving outcomes? 

Mr Marcus: Medicaid entities need to be careful as their rates are established based upon the services that they are expected to provide to a population. But in the case of OUD, the low cost of the medication is well worth the cost avoidance of other service types. Moreover, the treatment of such diseases and conditions are anticipated and are in the rate build.

Dr Karnack: Medicaid should concentrate on the comprehensive, outcomes-based programs that have a documented track record and are well accepted in the community. The federal guidelines I mentioned earlier could help get us there. Judicial entities within the criminal justice system could be shown the benefits of well-documented, community-accepted programs.  

Dr Shinn: It is important to note that the federal government funds Medicaid with supplemental payments that total about $50 billion a year. States allocate these dollars, so it could be that states are prioritizing allocation in a way that does not benefit those referred by the justice system as much as it benefits others. 

Yet, a heavier investment in those referred by the criminal justice system improve the odds of a positive outcome for the patients and the reduce the likelihood of recidivism.

Dr Shinn: Absolutely. This is a population in which we want to do everything we can to change detrimental behavior. It is the right thing to do for the individual and for the system as a whole. 

Mr Marcus: I agree and must point out that more investment does not necessarily mean a higher spend. The investment needs to be efficient and evidence based. 

Dr Pezalla: Earlier investment in referrals to more effective therapy could lead to reduced overdoses and other acute medical care situations and may save money for Medicaid. It could also improve the rate of employment and reduce recidivism. More collaboration between health-related state agencies and funding for joint programs would help. This could start with increased federal funds for OUD treatment that are earmarked for cooperative programs. 

It seems that a rising tide lifts all boats. Medicaid expansion is increasing access to treatment for OUD for those in need including those referred by the justice system, even though it appears that individuals benefit less than others. 

Dr Khatri: Yes. Medicaid expansion is certainly increasing access to treatment for OUD and should be a policy priority for any state that has yet to expand coverage. In our study, access to medications for OUD improved for everyone, both individuals with and those without justice involvement, after Medicaid expansion. On the other hand, utilization of these lifesaving medications has remained stagnant in nonexpansion states over several years. 

Ms Andel: The benefit of Medicaid expansion goes well beyond additional access to substance abuse disorder treatment. The study results published by Dr Khatri and colleagues add to the evidence showing that the expansion is worthwhile. This is the case even when outcomes are improved by only a modest amount.

Dr Pezalla: Access to health insurance will improve treatment, both because more people are covered and because there will be more providers to meet the demand. 

Dr Karnack: I agree that a rising tide lifts all boats, but often the process is slow and influenced by the way practitioners and the judiciary are taught. Regional educational differences, state judicial guidelines, and local regional cultures often result in care disparities, especially among those referred by the justice system.  

While this study involved Medicaid recipients, is there a message for commercial and private payers in the findings? 

Dr Pezalla: A major issue for commercial payers in OUD treatment is availability of providers who use MAT. Commercial plans could collaborate more with government agencies and providers to increase access to OUD treatment. 

Mr Marcus: It seems obvious, but plan sponsors and insurers need to make sure that their members have access to treatments that are appropriate for their disease progression and make sure that short-sighted treatment decisions are not being made.

Ms Andel: I go back to the fact that the biggest obstacles are a lack of adequate supply of quality treatment programs. To the extent that commercial and private payers can help connect their members or employees to that, I think it would pay off in the long run. But I don’t know how much influence they have over the supply issue itself.

Dr Karnack: The ultimate message for any payer is that prevention saves cost downstream in certain disease states. It is noteworthy that in the United States we are increasing expenditures for mental health treatments as a result of the opioid epidemic and the COVID-19 pandemic. As a result, more individuals will be treated for OUD. It will be interesting to see the outcomes data that results from this policy change.

For example?  

Dr Karnack: Appropriate referral and treatment of OUD by locally recognized agencies may lead the managed care community to cover their members.  Especially in areas of the country where specific commercial and private payers have many members, funding nonprofit referral treatment agencies and programs is good public relations. It also reflects positively on the insurers’ bottom lines.   

Dr Pezalla: Policy changes due to COVID have made receiving treatment for OUD easier. There are fewer restrictions on the physicians who prescribe buprenorphine and other medications, and more opportunity for remote visits. State Medicaid programs should follow the lead of commercial insurers and consider expanding their payment policies to encourage these activities now and after the pandemic emergency is over. 

Ms Andel: I am encouraged that our culture is evolving to accept that substance abuse disorder is a disease and not a personal or moral failing. With that said, stigma still persists. Plus, there are those who believe the response is too little too late. Their point is well taken, particularly when you consider our approaches to previous drug epidemics. But we can’t let the fact that we erred in the past prevent us from growing and doing the right thing going forward. Surely that will help people struggling with this disease today and in the future.