Healthcare providers fighting the opioid epidemic should be alarmed by a growing trend amongst states to adopt work requirements for Medicaid eligibility. On May 7th, New Hampshire joined a growing number of states now authorized to include a work requirement for Medicaid eligibility by the Centers for Medicaid and Medicare Services (CMS). Last month, the Michigan state senate also passed a bill that would require certain Medicaid beneficiaries to work in order to maintain coverage. The Michigan Chamber of Commerce has supported the bill, describing the requirement as “commonsense.” It is not, and this CMS-approved trend among some states—imposing work requirements as a condition for receiving basic health insurance coverage—will have a detrimental impact on the fight against the opioid epidemic.
During his campaign and after taking office, President Trump vowed to prioritize action to alleviate the opioid epidemic. Last year, he directed the Department of Health and Human Services to declare the epidemic a public health emergency. And with good reason – over 2 million people in the United States have opioid use disorder (OUD), and on average, 115 people die every day from opioid overdose. The Center for Disease Control recently published that emergency department visits for opioid overdoses increased by 30 percent between July 2016 and September 2017. Three of the four states with Medicaid work requirements had statistically significant increases in opioid overdose deaths in 2016. Two of those states, Kentucky and New Hampshire, have some of the highest opioid overdose deaths in the country.
Unfortunately, despite the President’s early signals suggesting bold substantive action, the administration’s own CMS seems determined to both undermine the President’s promise and handicap healthcare providers struggling to stem the tide against the epidemic. The Medicaid work requirement will disproportionately impact Americans with opioid use disorder. According to the Kaiser Family Foundation, Medicaid covers nearly 4 out of 10 non-elderly adults with opioid addiction. While CMS policy confines the work requirement to people without disabilities, individuals suffering from OUD will not be automatically exempt because substance use disorders are not considered disabilities unless they are “chronic”, the parameters of which are not defined. People with OUD will fall into an “exemption gap” because their condition does not meet the rigorous criteria of the Social Security disability requirements but is disabling enough to prevent them from finding or keeping employment. Gaps in coverage can be devastating for people with OUD who are relying on medication-assisted treatments, which include medications such as methadone, buprenorphine, and naloxone, counseling, and behavioral therapy.
In addition to imposing one more bureaucratic barrier to patients seeking to obtain or maintain coverage, the added eligibility requirements will be costly to states. Kentucky has budgeted $170 million to implement the waiver. Virginia estimates that a work requirement would cost $100 million for the first two years of implementation. The Medicaid work requirement is likely to cost more to implement than it will save.
Data shows that the Medicaid expansion under the Affordable Care Act (ACA) has had a positive impact on the fight against the opioid epidemic because it has provided individuals with OUD access to needed treatment that would have been unavailable but for the coverage. The Center on Budget and Policy Priorities published in February that the share of hospitalizations for OUD in which the patient was uninsured decreased from 13.4% in 2013 to 2.9% in 2015 in Medicaid expansion states. This decrease was significantly lower in states that did not expand Medicaid, from 17.3% in 2013 to 16.4% in 2015. The rates of opioid related hospitalizations were also highest in expansion states, signaling that people with OUD who are gaining access to health insurance are also using that insurance to seek care.
Despite the gains made in fighting the opioid epidemic under the ACA, SAMHSA data from 2016 showed that only 10% of the 20 million people who needed OUD treatment received it. Barriers such as lack of insurance, prohibitive cost of treatment, or lack of availability continue to be a problem. Additional regulatory checkpoints, such as proof of meeting work-hour requirements, will only add to the difficulty of maintaining insurance coverage. And although CMS guidance allows states to include participation in certain types of OUD treatment programs in the eligibility criteria, a study published in the American Journal of Public Health showed that all but two states in the country have higher rates of OUD than potential treatment capacity. Unable to find work or treatment programs, individuals with OUD will lose Medicaid coverage.
Physician organizations are working hard to establish policies on opioid prescribing and guidelines for the identification and treatment of OUD. Hospitals and clinics have incorporated prescription drug monitoring programs to prevent the over-prescribing of prescription pain medications. While these steps on the clinical frontlines are important, healthcare providers must exercise the same vigilance on the civic front by urging lawmakers to expand health care coverage to vulnerable populations, including those with opioid use disorder. The Medicaid work requirement is an impediment at best and an incursion at worst to our efforts to fight the opioid epidemic.