Category: National

By Lexington Souers

Policymakers and industry professionals gathered in Chicago April 29-30 to discuss the future of mental health policy with the State Exchange on Employment and Disability (SEED).

The National Task Force on Workforce Mental Health Policy reviewed presentations and expert panels before joining breakout sessions highlighting workforce mental health policy. Topics included behavioral health coverage, individual placement and support programs, and workplace care and support.

The task force first met in January to begin discussing mental health care in the workforce.

“When we met in January [in Charleston], it was just the beginning of [Maryland’s] session, so I had all of these great ideas…” said Maryland Sen. Katherine Klausmeier. “It was very enlightening for me to hear all the things we had talked about. Once I got back to session, it was all there. We really worked toward it.”

Following several panels and informational sessions, members gathered in four subcommittees to discuss key takeaways and policy goals.

“One of the things that caught my eye was the apprenticeships,” said Arkansas Rep. Frances Cavenaugh, referencing a panel on “Expanding the Behavioral Health Workforce.” “We’ve done a lot of the groundwork [in Arkansas]. Now, we need to look at pay and certification.”

Overall, policymakers recognize the importance of uniting all stakeholders for the betterment of mental health care, regardless of political affiliation.

“You’ve got to bring everyone to the table and say, ‘We’ve got a problem. How can we fix it?’” said Rep. Jim Gregory, sparking a discussion on how to better involve members from both parties. “My comment has no judgement to it. It’s just, lets recognize what we’re trying to accomplish.”

Contributing to discussion of another subcommittee was Washington Rep. Linh Thai, who serves as the task force’s co-chair. Thai recognizes the challenges those in the minority may face in implementing the task force’s recommendations.

“It was not always that we were the majority; we were in the minority…It should not ever be about the majority or the minority. It should not ever be about democrat or republican, because it’s a human issue,” Thai said. “At the same time, I recognize your work and your fight will be much harder than many of us, for that I am grateful that you continue to be in this space, doing this work, attempting to take whatever it is being recommended.”

Subcommittee members highlighted the need to promote task forces, grants for corporate businesses and loan repayment programs, along with modeling workplace policies, increasing employment for minorities and underserved populations with mental health disabilities, and including advertising or community outreach in a bill or programs administration. “I think the state has to model it. One person, one company can’t do everything,” said Nevada Rep. Pat Spearman. “When you put your money where your mouth is, you show you’re serious.”

By Valerie Newberg

Public records law, which is also recognized in select states as the Freedom of Information Act/Law, Sunshine Law, Right to Know Law or Open Records Law, is a tool intended to ensure government transparency and accountability by mandating the storage and release of documents to members of the public.

There are wide variations in each state’s version of the law. In certain states, agencies are required to respond within a timeframe ranging from three days to 12 weeks, while others designate maximum fees agencies may charge for the reproduction and transfer of records. Additionally, select states apply fees or criminal penalties to government agents who fail to comply with records requests. Some data is typically exempt from public records requests, including information that would constitute an invasion of privacy for institutions like hospitals, law enforcement agencies and schools, trade secrets, building maps, emergency procedures and firearms records.

Most laws are broadly inclusive of the state agencies subject to public records requests, with at least 19 states also setting statutory guidelines that explicitly require the category of quasi-governmental bodies, government sponsored entities and quasi nongovernmental agencies to comply with public records requests. For at least 12 states, court rulings have set criteria for nongovernmental bodies required to provide requested records. These bodies are typically defined as private entities including nonprofits, for-profits, tax districts and privatized government agencies that are partially supported by tax funding, use state resources, or perform some duties of the state. For example, Texas law defines governmental bodies as including nonprofit corporations that provide water and wastewater services, thus serving a public function.

Inclusion of Nongovernmental Bodies via Statute
Nineteen state statutes reference the participation of nongovernmental bodies in open records requests, while also providing financial or functional criteria for their inclusion. These states include:

• California.
• Delaware.
• Georgia.
• Indiana.
• Iowa.
• Kansas.
• Kentucky.
• Louisiana.
• Michigan.
• Missouri.
• Nebraska.
• North Dakota.
• Oklahoma.
• Rhode Island.
• South Carolina.
• Texas.
• Utah.
• Virginia.
• Wisconsin.

Financial standards for inclusion range from receipt of any government funding, like in North Dakota, to receipt of 33 ⅓% of its general operating budget from public funding, like in Georgia.

Functional guidelines are used in some states to determine a state’s inclusion; Missouri’s Sunshine Law states that a public body is one that performs a governmental function or enters into contracts with the government. States like Delaware combine these criteria, defining applicable nongovernmental entities as those who receive or disperse public funding, or who advise and contract with official government agencies.

Additionally, while Idaho does not explicitly include nongovernmental bodies in its statute, the state prohibits agencies from entering into contracts with them to avoid open records requests.

Inclusion of Nongovernmental Bodies via the Courts
In many states where public body or public entity is vaguely defined in the statute and may not explicitly include private organizations, the judiciary has settled disputes over the inclusion of these terms. In such legal decisions, judges typically apply a test consisting of between four and nine parts that set criteria for the entities’ definition as a public body. These tests were first employed by federal courts in clarifying application of the Federal Freedom of Information Act to nongovernmental entities but have since served as guidance for interpretation in state courts.

Connecticut, Ohio, Tennessee, Vermont and Washington use a four-part test defining nongovernmental agencies according to: (1) whether the entity performs a governmental function; (2) the level of governmental funding; (3) the extent of governmental involvement or regulation; and (4) whether the entity was created by the government.

West Virginia uses a five-part test that considers the composition of the entity’s governing board and if the entity operates statewide. Oregon uses a six-part test that also includes the ability of the entity to make binding government decisions, and the status of the entity’s employees as government or nongovernment employed. Colorado, Florida and New Mexico apply a slightly different nine-part test that also considers whether the entity mixes funds with the government through use of the state treasury, if the entity conducts business on publicly owned property, and whether the government has “substantial financial interest” in the entity.

Other state courts, like those of Arkansas, apply a simpler test permitting private agencies receiving public funds to be subject to open records requests. In Pennsylvania, any nongovernmental body performing government business or nonprofit renting public property for more than $1.5 million per year is required to abide by open records laws.

However, there remain states without guidance from judicial or legislative bodies on the inclusion of nongovernmental entities. In states like Alabama, Alaska, Arizona, Idaho, Mississippi, Montana, Nevada and South Dakota, the law does not specify a state’s inclusion and no court cases requiring private bodies to submit to records requests could be found. In Illinois, courts ruled that the receipt of public funding is insufficient in deeming a body public for the purpose of their law, and that the government must play a more active role in the decision-making and day-to-day operations of a company.

Participation of nongovernment entities in public records requests is only becoming more relevant as states look to privatize certain programs and agencies to decrease operating costs and risks. By setting clear statutory guidelines for inclusion and remaining informed on the issue, policymakers can anticipate how changes to the operation of their state will impact the distribution of information to taxpayers.

By Kamren Gilbard and Jane Koppelman

More than 500,000 people died from an opioid-related overdose in the U.S. between 1999 and 2020, a more than seven-fold increase, and an estimated 2.7 million people were diagnosed with opioid use disorder (OUD) in 2020.

Methadone and buprenorphine — medications approved by the Food and Drug Administration to treat OUD — are the most effective treatments, as they are proven to reduce overdose deaths and illicit drug use. However, access to these lifesaving treatments is limited, with only 22% of people with OUD receiving any form of medication in 2021. While methadone is only available at highly regulated clinics — known as opioid treatment programs — buprenorphine can be provided by physicians, nurse practitioners and physician assistants in a variety of settings, such as primary care clinics and physician’s offices. Despite this, prescription rates for buprenorphine are low. Forty percent of U.S. counties lacked a buprenorphine provider in 2018, the most recent year data is available. 

Striking disparities in buprenorphine access and use exist across racial groups. While OUD rates are fairly comparable among Black, Hispanic and white populations, buprenorphine providers are notably less likely to be located in communities of color. One national study of Medicaid beneficiaries diagnosed with OUD found that Black, Hispanic and Native American patients were significantly less likely to receive buprenorphine than white patients. Meanwhile, opioid fatalities are rising at faster rates for Black and Native American people than for white people. Research suggests there are numerous factors at play beyond the absence of prescribers, including a lack of culturally responsive or respectful care and a bias among providers who withhold buprenorphine from patients of color.

The Mainstreaming Addiction Treatment Act, which President Joe Biden signed into law as part of a larger omnibus spending bill in December 2022, intends to increase the number of providers willing to prescribe buprenorphine. The law removes a cumbersome requirement for providers to apply for a special Drug Enforcement Administration waiver (known as the X waiver), before they can prescribe the medication to patients with OUD. It also removes buprenorphine-specific training requirements for those prescribing the medication.  Still, this law does not supersede state laws placing registration and training requirements on buprenorphine providers. As of August 2020 — the most recent year state-by-state data was compiled — four states required prescribers to register with the state and six states required prescribers to complete additional clinical training beyond what the federal government required under the X waiver.

Other state-level rules create even more barriers to accessing buprenorphine. Some public and commercial state insurers require patients to receive preauthorization from their health care provider to obtain buprenorphine, which delays immediate access to medication. As of 2018, 16 states required patients to undergo counseling as a condition of receiving buprenorphine, despite research showing that medication alone — even without counseling — lowers OUD overdose death rates and improves treatment retention. Further, low Medicaid reimbursement rates at the state level can create prescribing disincentives for providers. Additionally, buprenorphine providers often lack the capacity to offer or coordinate wraparound services that patients with OUD may need, such as recovery housing or transportation. 

State Progress in Expanding Buprenorphine Access 
Due to rising opioid deaths and a significant racial gap in treatment for people with OUD, among other concerns, policymakers in many states are working to remove barriers to treatment and increase access to buprenorphine. 

Offering provider support
Many states implemented the hub-and-spoke model, which is designed to support providers treating patients with OUD. In the model, originally developed by the Vermont Department of Health, hubs are a small number of specialty treatment providers staffed to care for patients with severe and sometimes complex OUD. These hubs provide clinical guidance and a trusted referral to a buprenorphine provider. A larger number of spokes — primary care providers, OB-GYNs, community health center staff and others that can prescribe buprenorphine — are designed to support people with less severe OUD or for people transitioning out of hub care. The model encourages primary care providers acting as “spokes” to accept patients who they may have previously felt had overly complex medical circumstances. As of 2021, 27 states and territories have used State Opioid Response Grants from the Substance Abuse and Mental Health Services Administration to implement hub-and-spoke models. 

Raising provider reimbursement rates
States have leveraged Medicaid reimbursement rates to encourage more health care providers to prescribe buprenorphine for OUD. For example, Virginia’s Addiction and Recovery Treatment Services (ARTS)  program significantly raised Medicaid reimbursement rates for substance use counseling and allows Medicaid to cover care coordination and peer support services for OUD patients. Combined with other Medicaid reforms, ARTS increased the number of providers able to offer buprenorphine, as well as the number of individuals receiving medication.   

Granting immediate access to buprenorphine
Delaying the start of medication for OUD increases a person’s risk of overdose and death. In response, a number of states have placed limits on rules that interfere with a patient’s immediate access to buprenorphine — such as prior authorization, counseling and initial intake assessment requirements — and have adopted a low threshold strategy, which allows a provider to immediately prescribe buprenorphine the moment a patient wants treatment, at a cost the patient can afford and without the provider placing additional conditions on receiving the medication. Policymakers across the country have implemented elements of this approach. As of April 2020, 21 states and the District of Columbia had removed buprenorphine prior authorization requirements for public or commercial health plans. 

Missouri fully embraced low-threshold treatment methods. The state’s Department of Mental Health developed the Medication First program in 2017 for publicly funded treatment programs, which removed rules that required patients to either go to counseling or wait for an assessment visit before getting a buprenorphine prescription.  

Reducing racial access disparities
One strategy addressing racial disparities in buprenorphine access is to increase the level of culturally responsive care offered by providers. In Pennsylvania, Medicaid requires its managed care plans to achieve, or work toward, the National Committee for Quality Assurance’s Multicultural Health Care Distinction. Recipients awarded this designation established plans that disaggregate patient data by race, ethnicity and language; provide culturally and linguistically appropriate services; provide services in languages that patients use; collect race and ethnicity data of plan providers; and implement strategies to improve health disparities.

Conclusion
Through a variety of mechanisms, state policymakers can increase access to lifesaving medications for opioid use disorder. The strategies described above — which often involve maximizing Medicaid coverage, modifying state regulations, passing legislation or appropriating funds — are among the options that state legislators and executive branch officials can use to help more providers offer buprenorphine and allow patients quick access to evidence-based treatment. 

By Lexington Souers

Nearly 31% of the 37 million Americans with diabetes use insulin to manage the condition. Annually, patients spend an average of $434 on insulin. That amount nearly doubles for patients who are uninsured for an entire year. Between 2014 and 2017, uninsured people represented 80% of the diabetic population that paid full price for an insulin prescription, according to a study by the Commonwealth Fund. Estimates suggest around 27% of a patient’s total out-of-pocket health care spending went toward purchasing insulin. This high out-of-pocket cost can lead to insulin rationing, a dangerous decision that may result in higher medical costs. Rationing insulin can lead to emergency room visits, amputations and death. Uninsured American’s are more likely to ration their insulin. A 2021 survey found that of the 17% of insulin dependent patients that rationed their insulin, 29% were uninsured.

Beginning with Colorado in 2019, 22 states and the District of Columbia enacted price caps for insulin distributed to those who were insured. Legislation for insulin caps received broad bipartisan support from lawmakers, who recognize the dangers of insulin rationing because of cost. These caps range from $25 to $100 a month depending on the state. Many caps do not cover diabetes related equipment, with fewer than five states capping the cost of supplies or devices such as pumps, blood glucose monitors and syringes.

In 2023, 11 states proposed legislation to cap insulin prices and others have brought legislation to ease the costs of diabetes related equipment. Montana, Arizona and California proposed a $35 per 30-day supply cap, while Missouri lawmakers proposed a cap at $30 for a 30-day supply. Many states also allow patients to pay a lower copay, so long as the copay is less than the capped price. Nebraska has two bills up for debate during this year’s session. One bill would cap insulin at $35 for 30 days, while the other would cap the price at $100 for a 30-day supply. Both bills have received support from community stakeholders. Massachusetts lawmakers have filed legislation that would cap both insulin and the supplies needed. The proposed legislation would cap a 30-day supply of insulin at $25, oral medication at $50 per 30-days and equipment at $100.

States have recognized diabetes costs often extends past prescription drugs, given that other tools are often needed for the body to effectively utilize insulin. In 2022, Rhode Island capped diabetes equipment and supplies costs at $25 per 30-day supply for insured citizens. Connecticut, Delaware and the District of Columbia have similar caps on supplies. This year, Kansas and Kentucky lawmakers also filed legislation to cap the cost of diabetes equipment. Kentucky’s HB 376 did not receive a committee hearing, but the Kansas bill was sent to the Committee on Health and Human Services. Florida lawmakers introduced HB 967 which would provide coverage for continuous glucose monitors for Medicaid recipients meeting certain requirements.

While states with insulin caps are aiding insured Americans, there are limits on who legislation can help. Compliance with the Employee Retirement Income Security Act of 1974, known as ERISA, means states are unable to regulate self-insured plans, which comprise 64% of the total employer-based insurance market. State can create programs for the uninsured or underinsured. Only Colorado and Minnesota place caps on how much an uninsured or underinsured person pays for insulin. Pharmaceutical drug companies capped certain insulin types at $35 per 30-day supply or established assistance programs offering free insulin. Programs created by drug manufacturers often have complex requirements and lack transparency, disqualifying many who need access to insulin.

Insulin prices are due, in part, to the production process. Insulin is a biologic product, which is typically more expensive to make than chemically derived drugs. The three pharmaceutical companies that dominate the insulin market supply all of the insulin in the U.S., along with a majority of the global market. This allows those companies to set the market price, despite low production costs for insulin. Studies have found that an increase in biosimilar products would save payers, patients and other stakeholders an estimated $4.1 billion in savings over a five-year period.

By Ishara Nanayakkara

In October, The Pew Charitable Trusts released an analysis of the core measures states can identify to address and mitigate the opioid epidemic. The information included in this article originates from this analysis.

This article is the second in a three-part series. The first article can be viewed here.

In 2021, the U.S. set a record high for fatal opioid overdoses. However, when data is used to address opioid use disorder, effective change can be made. The Pew Charitable Trusts developed a series of recommendations for state policymakers to consider when implementing opioid use disorder treatment measures. The recommendations, which are addressed in Pew’s analysis, were developed by an expert panel along with a review of important literature. A summary of these recommendations can be found below.

1. Publicly Report Opioid Use Disorder and Treatment Data
In addition to publicly reporting overdose death statistics, states should also report several core measures, including availability of opioid use disorder measures and use by regions and demographic groups. Research found that public reporting results in improvements in outcomes.

2. Create a Plan to Use Opioid Use Disorder Treatment Data
Lawmakers responsible for addressing the crisis should regularly review available data and use it to inform policy decisions. A point person should be assigned to ensure data is updated and relevant, convene stakeholders across agencies, groups and communities and review resources available to support improvement efforts.

3. Disaggregate Data to Improve Health and Equity
There are significant differences in overdose death rates based on race and ethnicity. A study conducted by the CDC found that the overdose death rate increased most among Black individuals at 44% and American Indian/Alaskan Native people at 39%, while the increase for Caucasians was 22%. Additionally, due to barriers to treatment, Black and Hispanic people are less likely to seek and continue treatment. Disaggregating data by factors such as race, ethnicity, location, gender and age provides policymakers with information on where to best direct resources, which will help ensure that all people have access to services.

4. Integrate Community Members and Providers into Decision-making
People with lived experiences, including those with opioid use disorder and providers, provide valuable insight into effective areas of the treatment system and those requiring improvement. For instance, researchers in Minnesota found that members of tribal nations with opioid use disorder had a distrust and fear of the healthcare system and that treatment plans did not acknowledge or incorporate traditional healing systems. This information provides insight into how the treatment system can be altered to better meet the needs of tribal nations. Knowing similar information about other demographics may help policymakers target areas of concern.

In addition to providing policymakers with valuable information on how to best serve their constituents, community members also benefit from this information sharing process as they have their voices heard, gain new skills, and may be compensated.

Treatment providers should also be involved when analyzing metrics. Individuals moving through the cascade of care system will interact with multiple providers in varying settings, including emergency departments, peer recovery coaches, and opioid treatment providers. Professionals can work together to support patient’s smooth transitions from one part of the process to the next.

5. Address Data Challenges
The quality of data regarding race and ethnicity provided by insurers varies as many commercial health insurance plans do not collect data on these factors. State Medicaid agencies are required to collect demographic information and acquire self-reported data provided by patients during the application process. This means that data accuracy and completeness may vary across states. Researchers have raised “high concerns” about race or ethnicity information quality in 19 states due to missing data and mismatches between responses on Medicaid applications and Census Bureau surveys. To improve accuracy in reporting, experts recommend employing intake workers to help applicants fill out forms or utilizing standard reporting forms that provide more specificity instead of using broad ethnicity categories, such as Asian or Hispanic. States can also compare data and strategies on core performance measures to identify inequalities among communities and potential solutions.

To read about case studies, see The Pew Charitable Trusts issue brief, “States Should Measure Opioid Use Disorder Treatment to Improve Outcomes.” These examples depict success in areas where states collected and acted on data. By using the core opioid use disorder treatment measures, treatment systems can be reshaped to effectively address the crisis.