Associates in Action: Gilead Named Top Funder for HIV-Related Philanthropy

By Katie Boggs

Gilead Sciences, Inc., a CSG Associate, replaced The Bill & Melinda Gates Foundation as the top funder for HIV-related philanthropy, according to the Funders Concerned About AIDS (FCAA) 19th annual report.

The 2020 FCAA’s Philanthropic Support to Address HIV and AIDS Report was the first to examine the response of HIV-related philanthropy through the COVID-19 pandemic. Results showed that there is a shrinking pool of funders for this cause, as there was only a 1% increase in revenue compared to 2019, and 67% of the funding under this analysis was derived from the aforementioned top two funders.

Gilead’s donation in 2020 had an increase of $116 million compared to the previous year. On the other hand, 13 of the top 20 funders reportedly decreased donations in comparison to the 2019 report. Data showed that other private foundations also significantly reduced philanthropic spending on HIV or removed themselves entirely.

“The concentration of funding at the top is not a new headline, but it became starker in 2020,” said Channing Wickham, FCAA’s board chair and executive director of the Washington AIDS Partnership. “A shift in resources away from HIV, or other action with economic fallout from one of these top grantmakers could devastate future funding levels.”

Regardless of the statistics, Gilead continues to advocate and spread awareness of HIV and AIDS. In 2020, amidst the height of the pandemic, Gilead shared stories of its community partners that kept going during the difficult time on World AIDS Day. Aside from philanthropy, the company’s efforts are also evident in providing resources, programs and initiatives to support the cause globally.

“Gilead’s support for community organizations is part of our enduring commitment to ending the HIV epidemic,” said Daniel O’Day, Gilead Sciences chairman and chief executive officer. “We believe that real progress is only possible through collaboration and partnership. That is why we invest in the extraordinary efforts our partners are undertaking to reach underserved populations, eliminate barriers to care and educate communities. It is inspiring to see the work that goes on across these groups and we are proud to play a role in supporting them.”

For more information, please visit

About Gilead Sciences, Inc.

Gilead Sciences, Inc. is a biopharmaceutical company that has pursued and achieved breakthroughs in medicine for more than three decades, with the goal of creating a healthier world for all people. The company is committed to advancing innovative medicines to prevent and treat life-threatening diseases, including HIV, viral hepatitis and cancer. Gilead operates in more than 35 countries worldwide, with headquarters in Foster City, California.

About the Philanthropic Support to Address HIV and AIDS Report

About the Philanthropic Support to Address HIV and AIDS Report FCAA first began its annual analysis of private funding to address HIV and AIDS in the year 2000. The current report captures data on more than 5,000 grants, awarded by 323 foundations in 10 countries, and identifies gaps, trends, and opportunities in HIV-related philanthropy. Sharing this study with funders enables them to make informed decisions about where their resources would make the most difference.

About FCAA

About FCAA Funders Concerned About AIDS (FCAA) is a philanthropy-serving organization (PSO) founded in 1987 to take bold actions and push philanthropy to respond to HIV. FCAA informs, connects, and supports philanthropy to mobilize resources to end the global HIV pandemic and build the social, political and economic commitments necessary to attain health, human rights, and justice for all.

About CSG Associates in Action

Associates in Action articles highlight CSG Associates’ philanthropic efforts and public-private partnerships throughout the states.

Protecting Disabled Veterans in the Workforce

By Joe Paul

As long as there has been war, veterans have been coming home. Many have injuries that make work difficult or make some careers impossible. Questions surround veterans who have sustained physical or mental injury in service of their country. Will I be able to work? How can I provide for my family? Will someone hire a veteran with injuries? Given the prevalence of these concerns, there is a federal support system in place to assist veterans.

The two laws integral to protecting veterans in the workplace are the Uniformed Services Employment and Reemployment Rights Act (USERRA) and the Americans with Disabilities Act. USERRA provides requirements for reemploying veterans both with and without service-related injuries, while Title I of the ADA outlines what qualifies as disabilities and accommodations. USERRA is enforced by the U.S. Department of Labor and the U.S. Department of Justice.

USERRA prohibits employers from discriminating against employees or applicants for employment based on their military status, including military obligations resulting from duties as part of the National Guard or Reserves. Reemployment protection for persons with or without service-related disabilities is also included.

All veterans are covered under USERRA regardless of disability status. The veteran is also protected by ADA if their disability falls under the ADA. Employers must make “reasonable efforts” to help a veteran returning to employment become qualified to perform the position they would have had if employment had not been interrupted by military service or if they sustained a disability during their military service.

Title I of the ADA, enforced by the Equal Employment Opportunity Commission and applying to all workers, prohibits private, state and local government employers with 15 or more employees from discriminating against individuals based on disability. Having a disability or having a history of disability cannot factor into any aspect of employment, such as hiring, promotions, assignments, training, termination, or any other terms, conditions or privileges of employment, including questions of access to training or social events that are employer sponsored.

If a veteran is diagnosed with PTSD, or if the employer believes that the veteran may have PTSD, it is illegal for the employer to refuse to hire the veteran if they are otherwise qualified for the job. The ADA also limits the types of medical information employers can obtain and strictly prohibits disability related harassment and retaliation. Section 501 applies those standards to the federal executive branch and U.S. Postal Service, among others.

If an employer can prove that employment of a person with disabilities would cause an undue hardship, employers can propose reasonable alternatives. Generally, undue hardships come at significant difficulty or expense to the employer. The ADA National Network defines “undue hardship” as an “action requiring significant difficulty or expense” given any number of circumstances. The size, resources, nature and structure of the employer’s operation must be considered. Many, if not all, of these provisions do not apply to employers of less than 15 employees. For example: if a chair lift is requested, an employer could propose a ramp as a reasonable alternative.

Many veterans self-eliminate themselves from viable career opportunities by thinking their injuries either disqualify them for a job or that performing the job would not be possible given their injuries. The reality is that veterans are protected if they meet the ADA’s definition, and the veteran is otherwise qualified for the job. An individual with a disability is a person who (1) has a physical or mental impairment that substantially limits one or more major life activities; (2) has a record of such an impairment, such as a substantial limitation prior to undergoing rehabilitation; and (3) is regarded or treated by an employer as having such an impairment, even if no substantial limitation exists.

If the veteran is qualified for the job by meeting the employer’s requirements for education, training, experience, skills, licensure or other requirements, and would be successful in the position with or without accommodations, they must be considered. There are additional requirements if the employer is the recipient of federal funds.

Disabled veterans should be aware of the 2008 ADA Amendments Act which added the term “major life activities,” and defined them to include not only activities such as walking, seeing, hearing and concentrating, but also the operation of major functions of the brain and neurological system. A list of reasonable accommodations for veterans with any of these disabilities can be found on the U.S. Equal Employment Opportunity Commission’s website.

An impairment should not prevent or severely or significantly restrict a veteran’s performance of a major life activity to be considered substantially limiting. The determination of whether an impairment substantially limits a major life activity must be made without regard to any mitigating measures, including medications or assistive devices such as prosthetic limbs, that you may use to lessen your impairment’s effects. Impairments that are episodic or in remission, such as epilepsy or PTSD, are considered disabilities if they would be substantially limiting when active.

CSG, Colorado Partner to Implement Civic Sector Apprenticeships

By Mary Wurtz

State and local governments across the country are beginning to use apprenticeships to address public sector workforce shortages. Aspects of registered apprenticeships, like paid on-the-job learning, low- to no-cost training and mentorship, can create new pathways to public service careers for individuals who otherwise cannot access traditional education or credentials. This is especially true for historically underserved and low-income communities.

Governments use apprenticeship to fill shortages in trade industries, like construction, but also in non-traditional fields for apprenticeship, like information technology, human resources and health care. Registered Apprenticeship Programs, or RAPs, offer high-quality career opportunities that address such trade industry shortages. RAPs are industry-vetted and approved by the U.S. Department of Labor or a state apprenticeship agency. Individuals in apprenticeship programs obtain paid work experience, receive progressive wage increases, earn a nationally recognized portable credential and potentially earn college credit.

On June 16, 2022, Gov. Jared Polis signed Executive Order D 2022-027 to expand the use of Registered Apprenticeship Programs, or RAPs, for Colorado’s state workforce. The order set a goal to increase the number of RAPs offered by state agencies and departments by 20% by the end of fiscal year 2022-23. The Colorado Department of Labor and Employment and the Department of Personnel and Administration are responsible for meeting the goal, which includes:

  • Removing administrative and statutory barriers to RAPs.
  • Coordinating with related instruction providers, such as institutions of higher education, to enhance RAPs with additional credentials and certifications.
  • Developing an equity-driven recruitment and retention strategy.
  • Providing state agencies with technical assistance and resources.

The Council of State Governments Center of Innovation worked with Apprenticeship Colorado, which is a program of the Department of Labor and Employment, and the Department of Personnel and Administration, to develop a Civic Sector Apprenticeship Toolkit. The toolkit, spanning more than 70 pages, covers the basic components of Registered Apprenticeship; how to sponsor or join an existing RAP; funding apprenticeship programs; recruitment and hiring of apprentices; supporting and protecting apprentices; and advancing apprentices within the State of Colorado personnel system.

The Civic Sector Apprenticeship Toolkit is geared toward state agency leadership and program developers and is tailored to the requirements of Colorado’s personnel system. Designed as a living document, the toolkit can be adapted by Apprenticeship Colorado and the Department of Personnel and Administration as its apprenticeship policies change.

CSG reviewed the state’s personnel system and collective bargaining agreement for state employees to identify barriers to implementing state government RAPs and potential solutions for overcoming them. As part of this work, CSG also partnered with Gov. Polis’ office to develop resources on aligning Registered Apprenticeship Programs with AmeriCorps service.

In total, Colorado has six apprenticeship programs sponsored by state agencies, including programs within the Department of Transportation, Department of Corrections and Office of Information Technology. In addition to filling personnel needs, state agencies began leveraging the RAP model to deliver core programs, like the Department of Labor and Employment’s Workforce Development Professional program for One Stop Centers and the Department of Local Affairs Operations Manager Program.

Apprenticeship Colorado at the Colorado Department of Labor and Employment is committed to expanding the RAP model across both the public and private sector within the state. Their team offers customized assistance to employers and organizations that want to build their own RAP or join an existing program, as well as supportive services to programs post-registration. Colorado employers are encouraged to contact Apprenticeship Colorado to access its services. The CSG Center of Innovation wants to help states continue to address their own workforce challenges through apprenticeships, work-based learning and other evidence-based career pathways. To learn more about how the Center of Innovation can partner with states on similar work, contact Mary Wurtz via email at [email protected].

Unfunded Pension Liabilities: The Growing Cost of Retirement

By Grace Harrison

State and local pension plans provide retirement benefits and payments to more than 20 million individuals. These obligations are not always fully funded, though, resulting in a projected cumulative $1.3 trillion funding gap for states following negative fiscal year 2022 returns. The stability and participation rates of defined-benefit pension plans vary over time, making investment returns and available assets a cause for concern. Each state has created and executed its plans and funding in differing ways, which allows for detailed comparisons of these plans, their policies and the health of asset holdings.

Putting Pension Plans into Perspective
Pension systems primarily derive revenue from investment returns on assets, which are subject to investment risk, interest rates and economic volatility. For instance, during the 2007-09 financial crisis pension investments lost $889 billion in value after initially standing at $3.2 trillion in 2007. While pension plan values have largely recovered — reaching nearly $3 trillion in 2013 — not all losses have been recouped. In 2021, investment returns reduced outstanding pension plan debt below $1 trillion; however, a rise in aggregate pension debt occurred in 2022, bringing its total to nearly $1.3 trillion.

Assessing Pension Plan Health with Funding Ratios
A pension’s funding ratio is a widely used way of assessing the plan’s overall health. This ratio measures the extent to which a plan’s required payouts are covered by what is currently held as assets. Estimates compiled by the Equable Institute through Dec. 31, 2022, detail state-by-state funding ratios and estimated liabilities using data from 76.4% of retirement systems that provide investment reports. State pension plans range from 103% funded to 47% funded (See Map 1).

Another way to assess pension plan health is by examining pension debt as a share of states’ personal income, which consists of the combined wages, salaries and supplementary benefits of all state residents. According to 2019 data from The Pew Charitable Trusts, the aggregate share of this debt was 6.8%. That percentage is consistently larger than the other two main sources of state debt: unfunded retiree health care and overall outstanding debt, which are respectively 4% and 3%. Across the country, this debt varies by state (See Map 2).

How States Can Address Unfunded Pension Liabilities
States have implemented various reforms in recent years. These reforms include improved risk assessment through stress tests, more realistic projections of investment returns, and costs passed on to public higher education institutions and taxpayers.

A Pew assessment of the 2018 pension funding gap stated that the risk of unfunded liabilities can be reduced by decreasing return goals and discount rates. Since projected returns on pension plans once averaged around 8%, many states have maintained that benchmark. However, recent data predicts rates of return will fall closer to 6.5%. Making this adjustment by decreasing the discount rate would help eliminate some of the gap between calculated liabilities and contributions.

A second option for states to better adjust to economic conditions is to conduct stress tests. The National Conference of State Legislatures explained this as “evaluating how pension systems would respond to a variety of potential scenarios,” such as changing market conditions. Thirteen states now require stress testing for public retirement pension systems, according to the National Conference of State Legislatures. These states include Arizona, California, Colorado, Connecticut, Hawaii, Indiana, Maryland, Montana, New Jersey, North Carolina, Pennsylvania, Virginia and Washington.

Stress test methodology can vary, but analyses generally involve testing the sensitivity of individual variables such as inflation and returns on investment, determining the outcome of scenarios on multiple variables at a time, and/or determining composite results of thousands of random simulations like stochastic modeling. Results from these tests guide the decisions and expectations of lawmakers and advisors as they adjust investments and holdings to be more resilient in future economic downturns.

Impacts of Unfunded Pension Liabilities
There are severe risks that come with underfunded pension plans. Like other gaps in funding, states must either find ways to increase revenue or adjust existing expenditures. The latter has had a detrimental effect on school systems via increased class sizes and cuts to necessary extracurricular and health services.

Public university systems are also impacted by gaps in pension funding on both the administrative and student sides. Professors and university employees can be at risk of losing their expected pension benefits, while students are faced with potential tuition hikes to combat those losses. For instance, Illinois universities have seen an exodus of professors and employees anxious to secure their pension benefits before cuts or changes can be made, even though they otherwise would have delayed retirement. While states previously funded the majority of public pensions, colleges are now facing expectations to fund pensions from a larger percentage of their payrolls. Consequently, universities are turning to increasing tuition rates and decreased rates of funding for educational programs.

In addition to damage to public schools and universities, taxpayers also experience the increased burden from these state pension debts. In California, taxpayer support for state pensions increased from $611 million to $3.5 billion over nine years (2001-10). While adjusting revenue in other sectors might be challenging, increasing taxpayer shares is often less difficult, and thus, a more common option when finding a way to finance rising pension costs.

Looking Ahead
The $1.3 trillion pension debt across more than 5,500 state and local pension plans will not disappear overnight. Existing state law and legal protections can limit what reforms states are able to enact. Some states provide protection for pension plans in their state constitutions, while others treat them as contracts protected by state and federal law. These limitations, in combination with rising cost of living over time and longer lifespans for pension recipients, indicate that more rigorous efforts are needed to close the unfunded pension liability gap.

Task Force Convenes to Learn, Improve Mental Health Policy

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.”

Associates in Action: NASPO Launches Program Supporting Member Certification

By Julie Stahl

The National Association of State Procurement Officials launched a new reimbursement program for public procurement professionals in March as part of its celebration of National Procurement Month. NASPO is a CSG Associate and nonprofit association committed to supporting public procurement leaders and promoting government excellence by delivering superior procurement solutions for public benefit.

The new NASPO program offers full reimbursement of the application and examination fees for qualified candidates in 2023 who pass the certification exams offered by the Universal Public Procurement Certification Council, or UPPCC. The UPPCC is an independent organization formed to govern and administer the Certified Public Procurement Officer and Certified Professional Public Buyer certification programs.

“Now is a great time for CSG members to encourage their procurement personnel to consider certification,” said David Gragan, NASPO chief administrative and strategic operations officer. “Those who pass the public procurement certification exams offered by the UPPCC can receive 100% reimbursement provided by the National Association of State Procurement Officials. This is another example of how NASPO strives daily to elevate the public procurement profession.”

The Certified Public Procurement Officer exam focuses on the six UPPCC Body of Knowledge and Competency domain areas: legal framework, procurement planning and analysis, sourcing and solicitation, contract development and management, leadership and business principles. The Certified Professional Public Buyer exam tests practice-level knowledge of the domain areas required for proficiency. The UPPCC Body of Knowledge and Competency domain areas for both exams can be found here.

NASPO provides its membership with highly beneficial programs, research, publications, innovative procurement strategies and professional development opportunities. Procurement professionals seek to serve as champions of the populace’s interests and demonstrate dedication to ethical best practices. NASPO continues to promote their mission and values by curating beneficial programs elevating the public procurement profession. For further information about UPPCC and procurement certifications, please visit

Nongovernment Entities’ Inclusion in Public Records Law

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.

State Options to Expand Buprenorphine Treatment for Opioid Use Disorder

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.

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. 

State Legislation Provides Hope for Rising Insulin Costs

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.

Map courtesy of The Pew Charitable Trusts:

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.

Recommendations for Implementing Opioid Use Disorder Treatment Measures

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.