Today President Trump signed the “SUPPORT for Patients and Communities Act” into law. SUPPORT is an acronym for “Substance Use—Disorder Prevention that Promotes Opioid Recovery and Treatment.” The bill, which passed with overwhelming bipartisan support in both the House (396-14) and the Senate (98-1), is 250 pages long. It affects a broad array of federal laws, ranging from Medicaid and Medicare to the Public Health Service Act to the Family First Prevention Services Act to the U.S. criminal code.
This blog is about the Medicaid provisions, which accounted for most of the federal spending in the Act—$2.1 billion over 10 years—as well as most of the offsets to pay for the spending—$2.7 billion over 10 years. (The $600 million in excess savings was used to pay for non-Medicaid spending elsewhere in the bill).
The good news is that no Medicaid beneficiaries—children, parents, or other adults—are likely to be harmed under this legislation. In fact, depending on successful implementation by the Centers for Medicare & Medicaid Services (CMS) and state Medicaid agencies, a significant number of beneficiaries could be helped. There’s no bad news, which is nothing short of miraculous, given that this is the same Congress that almost capped the Medicaid program last year and the same President who signed the budget bill into law that proposed to cut federal Medicaid payments to states by $1.4 trillion over the next 10 years.
A total of 26 different Medicaid provisions are scattered throughout the Act. Five require studies and reports by the Government Accountability Office (GAO), and two require reports by the Medicaid and CHIP Payment and Access Commission (MACPAC). Seven require the issuance of reports or guidance by CMS, and five require the issuance of guidance, reports, or action plans by the Secretary. A number of these focus in whole or in part on kids. Rest assured that there will be no shortage of official paper on the Medicaid program and the opioid epidemic over the next few years.
It’s hard to predict how the other Medicaid provisions will play out, but at this point it seems like the provision that has the potential to have the greatest positive impact is the requirement in section 1006(b) of the Act that all states cover medication-assisted treatment (MAT) services for the 5-year period October 1, 2020 through September 30, 2025. MAT, which combines medication with counseling, behavioral therapies, and recovery support services, is the gold standard for treatment of individuals with opioid use disorder. MACPAC found that Medicaid coverage of MAT components varies considerably from state to state. Section 1006(b) has the potential to reduce that variation, so that access to MAT by Medicaid-eligible parents with opioid use disorder does not vary by state. (Of course, the provision does nothing to extend Medicaid coverage, much less MAT, to parents or other low-income adults who live in one of the 17 states that have not taken up the Medicaid expansion and have incomes too high for Medicaid but too low for marketplace subsidies).
Here are the Medicaid provisions that directly affect children:
- Infants with Neonatal Abstinence Syndrome. Section 1007 of the Act gives states the option of covering inpatient or outpatient services to infants with NAS at residential pediatric recovery centers. The services can include counseling for mothers of infants receiving treatment. The option is effective on enactment (10/24/2018). Section 1005 directs the Secretary to issue guidance to improve care for infants with NAS and their families and directs GAO to report to Congress on gaps in coverage for pregnant and postpartum women with substance use disorder.
- Pregnant Women in Residential Treatment Facilities. Medicaid payments are generally not available for services to individuals who are patients in residential treatment facilities with 16 or more beds, even if the services are provided outside the facility. Section 1012 creates an exception for pregnant women who are in residential treatment for substance use disorder to allow Medicaid to pay for services provided outside the facility. The provision is effective upon enactment (10/24/2018). (Section 5052 of the Act carves out a broader, time-limited exception to the exclusion of coverage for residential treatment services for all non-elderly adults with a substance use disorder).
- Former Foster Youth. The ACA required states to extend Medicaid coverage to individuals after leaving foster care up to age 26, but due to a technical error, states are only required to cover former foster youth who reached age 18 while residing within their borders. While states have the option to cover former foster youth from other states, the large majority do not. Section 1002 extends the coverage extension to all youth in foster care at age 18, regardless of the state in which they were in foster care. But the provision is not effective until January 1, 2023 and only applies to youth who turn 18 on or after that date.
- Antipsychotic Medication Use by Children. Section 1004 of the Act requires states, through their Drug Utilization Review (DUR) programs, to monitor and manage the use of antipsychotic medications by children under 18, including children in foster care, and to report annually to CMS. The requirement takes effect October 1, 2019.
- Justice-involved Youth. Under section 1001 of the Act, states may suspend, but not terminate, Medicaid eligibility for juveniles under age 21 who are placed in juvenile detention or other correctional facilities. Prior to the juvenile’s release from the facility, states must conduct an eligibility redetermination, and if the juvenile is eligible, restore Medicaid coverage upon release. This will better ensure continuity of coverage for juveniles post-detention. The requirement is effective with respect to juveniles who become inmates on or after October 24, 2019 (one year after enactment).
These provisions will not end the opioid epidemic. Nor will they substantially reduce the risk that it poses to infants and children. And it is troubling that a number of the provisions only take effect several years from now and sunset in 2025 (the epidemic may not be over by then). That said, if properly implemented, they could result in providing greater access to needed services for at-risk children (and their parents). Moreover these provisions do not take away Medicaid coverage from children or reduce their access to services. And that, without more, would be cause for celebration.