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Anne Dwyer: Hi all, welcome to today's Medicaid Connections webinar. I'll just give folks another 30 seconds or so to get into the room before we kick it off.

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Anne Dwyer: Okay, we're gonna go ahead and get started.

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Anne Dwyer: Hi all, thank you for coming to today's Medicaid Connections webinar on Substance Use, health, and justice. I'm Ann Dwyer, Associate Research Professor here at the Center for Children and Families at the Georgetown McCourt School of Public Policy.

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Anne Dwyer: Next slide, please.

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Anne Dwyer: So, for those of you who may have been tracking, we've been holding a series of Medicaid Connections webinars every third Tuesday of the month at 2 p.m, and today is that day, and we're looking forward to focusing on substance use today. Excuse me, next slide.

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Anne Dwyer: So, a little bit of background about the Medicaid Connection Series, in case you haven't been tracking. We have more on this slide. We also have a Medicaid Connection Series website, on the CCF website, a homepage, where we have recordings of past sessions. We will also be recording this session and posting it on that page as well.

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Anne Dwyer: But really, the Medicaid Connection Series is a place for those of you who are not long-term health advocates, as well as those of you who are, who really want to come together to ensure that people who rely on Medicaid, directly and indirectly, can access those benefits, for themselves and their loved ones, and really improve their health and well-being.

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Anne Dwyer: Next slide, please.

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Anne Dwyer: So, as I mentioned, today's webinar will be focused on substance use. We've also had past webinars focused on children, maternal health, and just noting that

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Anne Dwyer: These topics are not siloed, you know, we really don't view these topics in isolation, so some areas within these topics that we cover may be also be covered in other sections and vice versa. So just noting that the healthcare system is complex, Medicaid is complex, and these topics are complex, so that there may be some overlap as we have our discussions, both today and in other webinars.

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Anne Dwyer: But as you can see on this slide, we have a number of future topics. Just keep that in mind, that should be… will be coming up, again, on that third Tuesday of the month, and look forward to you being able to join those, too, if you are interested and available. Next slide, please.

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Anne Dwyer: So, today, these will be our speakers. We have a jam-packed session, so what we'll do is put their bios in the chat today, but a really great panel, some of these faces you've seen, some are new, but really looking forward to digging in more. Next slide.

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Anne Dwyer: And for today's plan, we'll first hear from Kay about a brief history of substance use policy and practices. We'll move on to Medicaid's role for covering substance use disorder treatment. Kima will really focus on some of the threats for people who use drugs. We'll then move on to a panel discussion, including Silvana, and then move on to audience Q&A. And just as a reminder, this is a webinar, so if you wouldn't mind putting your

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Anne Dwyer: questions for any Q&A that, you're interested in.

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Anne Dwyer: and, being part of, put those… please put those in the Q&A section of the bar below. It might be under the three dots in the More tab if you don't see it, but again, if you could throw those questions in the Q&A section, that would be great.

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Anne Dwyer: Next slide.

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Anne Dwyer: So with that, I will pass it over to Kay to kick us off on some of the historical perspectives on mental health and substance use policy and Medicaid.

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Anne Dwyer: Kate, take it away.

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Kay Johnson: Thank you so much. I'm really delighted to give a little, brief, historical perspective about, substance use and Medicaid policy. Next slide, please.

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Kay Johnson: This slide looks at a long period. There were a few federal policies about mental health before 1960. Most of them were terrible for humans, and too many people were living in institutions in poor conditions. President Kennedy had a commitment to mental health.

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Kay Johnson: Because there were mental health concerns in his family, and he signed the Community Mental Health Act, frankly, a couple of days before he was killed. And LBJ, in ref… in… in…

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Kay Johnson: really reverence for and ensuring the legacy, made sure that there was funding for grants. And then in 1965, we had Medicare and Medicaid created. Medicaid, of course, dedicated more to poor people, only some poor people. And then it also… but it restricted funds for people in mental institutions, so it caused a shift

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Kay Johnson: Of people from some kinds of facilities to other kinds of facilities.

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Kay Johnson: In 1967, the EPST child health benefits were created under Medicaid, and then there was a series of defunding and cuts in the Nixon and Ford administration for the Community Mental Health Act programs.

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Kay Johnson: President Carter, and his wife, Roslyn Carter, had a commitment

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Kay Johnson: To mental health, and again, there was a commission headed by Rosalind Carter, and the Community Mental Health Systems Act, more… the bricks and mortar side of things was created.

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Kay Johnson: Between 1984 and 1990, there were 6 incremental expansions of Medicaid for mothers, infants, and children that, by and large, included an expansion of substance use and mental health benefits, and

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Kay Johnson: then a further press on 1989 to get… to ensure that EPSGT provided all medically necessary care.

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Kay Johnson: And in 1990, the Americans with Disabilities Act came in and applied both to mental and physical disabilities.

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Kay Johnson: Clinton vetoed the Medicaid Block Grant in 1995, and then the initial Mental Health Parity Act was signed into law, but just really for group plans. There were other activities in this period as well. Next slide, please.

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Kay Johnson: In 2008, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act was signed by President Bush.

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Kay Johnson: And it required parity in the group coverage further for mental health and SUD benefits, and the CHIPRA reauthorization of CHIP strengthened the parity obligations also. We had the Affordable Care Act in 2010, which mandated mental health and substance use disorder coverage for small group and individual plans, and of course, extended

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Kay Johnson: some additional requirements to Medicaid MCOs, and created the Medicaid expansion. So it's this combination, then, of the Affordable Care Act and both

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Kay Johnson: Pushing on the coverage side, the obligation for parity side, but also pushing on the expanded number of people who could be covered.

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Kay Johnson: By 2016, the final rule for mental health parity finally brought in, many years, but, really brought clarity about Medicaid managed care organizations and SHIP.

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Kay Johnson: The 21st Century Cures Act provided for some maternal and child health aspects.

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Kay Johnson: of, of, care and coverage and grants to states, that we had then, by 2020, an amendment, to the Mental Health Parity Addiction Equity Act, and there were new rules in 2024, which, really, didn't apply to Medicaid or CHIP, but were important clarifications.

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Kay Johnson: We had the COVID protections uncovered, and then the unwinding. And last year, of course, we had the Medicaid work requirements and other provisions of the One Big Beautiful Bill Act, or H.R. 1, creating new hurdles for eligibility, enrollment, and participation in Medicaid. We also had, on the positive side, the Centers for Medicaid and Medicare Services issuing

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Kay Johnson: an EPSTT Behavioral Health Toolkit, and other guidance that affirmed the role of EPSTT in behavioral health for children. Next slide, please.

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Kay Johnson: Just to give you this range of the things that are in parity, I'm not going to read this slide, but reinforcing about what's in for kids.

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Kay Johnson: about pressure on parity and cost sharing, and restriction on treatment, and prior authorization, and criteria for medical necessity and out-of-network coverage. Really clarifying also the responsibility of the state Medicaid agencies to use clear contract language

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Kay Johnson: and effectively monitor what is happening. Next slide, please.

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Kay Johnson: This slide just gives you a little bit of the rollercoaster of recent congressional action related to maternal mental health.

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Kay Johnson: Particularly the establishment of the state grants, through, HRSA, and then other pieces that, really, the program being reauthorized, funding for treatment, looking at, military moms.

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Kay Johnson: And a pending Moms Matter Act this year. I would just note those FY26 appropriations for the hotline $8 million

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Kay Johnson: For the Maternal Mental Health and Substance Use Disorders program, $12 million. Very little money. Medicaid's where the action is here. Next slide, please.

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Kay Johnson: I'm not going to talk about all of these examples now, but only to say that there have been EPSDT lawsuits and settlements

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Kay Johnson: that really dealt with the overall responsibility to provide coverage for all medically necessary treatment. But particularly in these examples, home and community-based services, chemical dependency treatment, therapeutic foster care services, a long series, decades, of these lawsuits really making sure that services that children were entitled

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Kay Johnson: who they were receiving. Next slide, please.

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Kay Johnson: I want to finish my section of this conversation by talking about the, how we can, really honor, I'm going to start my video and just say, that I want to honor, Kima George Taylor's contribution to this work.

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Kay Johnson: And, she's a leader, she's a change agent. In her own words, she's a health policy, clinical care, and public health subject matter expert with the ability to translate complex policy and provide strategic planning to ensure equitable and positive outcomes.

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Kay Johnson: She's worked as a clinician, she's worked for a member of Congress, she's worked in community, creating programs and systems and supports for families. She has her consulting firm, Anka Consulting, which is a co-host of this webinar series.

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Kay Johnson: And she really, more than that, she envisioned and anchored this series of events that bring people together from various fields.

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Kay Johnson: those concerned about children and families, really to highlight how Medicaid affects the programs you care about and the justice work you pursue. She's a scholar.

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Kay Johnson: She has done remarkable work on translating the term equity into a sense of policy that makes sense. I'm not going to read this quote, but we are going to post our article that has it, and I encourage everyone to actually read the article. And with that, I'm going to turn it over to you, Kima.

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Kima Taylor: Thank you so much, Kay. And I really want to thank everyone for coming to the talk today. As Kay mentioned, you know, we put this together, and I'm really excited, because in the end, what I envision is not that everyone has to be a health expert.

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Kima Taylor: It's really to say, how do we come together to ensure and improve well-being for all of the communities we serve?

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Kima Taylor: Including ourselves, and do it in a way that has equitable outcomes. Next slide. So this conversation is about Medicaid. And as many of you know, anyone who's come to these talks before has seen this slide, but it's really to give an idea of how entrenched Medicaid is.

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Kima Taylor: And all that we do in the healthcare system.

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Kima Taylor: And people often think… only think of their population, I think particularly for… I'm a pediatrician, so for moms and babies, we unfortunately think of them distinctly, but this serves our whole nation. Medicaid does, and so to understand Medicaid and the threat it's under is really important, because it doesn't just affect people's

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Kima Taylor: health outcomes, it affects their health and well-being, their ability to go to work, and everything else. Next slide.

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Kima Taylor: So, in substance use, we really do have a holistic threat. You know, one of… Anne, who's going to be the panel, co-host, was saying, like, sometimes this is the doom and gloom tour, and I feel that way a little bit, but…

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Kima Taylor: there really is a holistic threat for wellness of people who use drugs. It's out of vogue. It's a real threat. You know, people will say, oh, you're being paranoid. Do not let them make you think that way, because there are real threats out there to folks' well-being.

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Kima Taylor: And we know that people are more than their substance use, but people are threatened with punitive responses because of their substance use. Even though people say, oh, we understand it's a public health concern, you don't put other public health concerns in jail.

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Kima Taylor: So, these punitive responses are a real threat because of their substance use and not many of the other health concerns, which is why we're having this conversation.

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Kima Taylor: And the other pieces that are being taken away cut, also one-way ticket to punitive systems, which is then reinforced for people who use substances. So, if you are unhoused, that is becoming criminalized, and people are going to jail, but your jail terms and some of the outcomes and effects are reinforced for people who use substances, particularly those with melanin. Next slide.

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Kima Taylor: And I will try to slow down. And I know what we're about to talk about is a lot.

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Kima Taylor: And I'm asking people to try not to tune out. Often when you talk about Medicaid, people are like, ugh, it's too… I can't be bothered.

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Kima Taylor: And I know there's a lot of information and impacts, but this is what people face every single day without reprieve, without the ability to tune out. You know, the Medicaid, SNAP, the education system falling apart. So I ask you all, please try not to tune out, and know that you'll have these slides afterwards.

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Kima Taylor: And I also want people to think about the fact that tunneled silo visions is really a luxury right now.

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Kima Taylor: I'm in a lot of spaces where people are like, well, this is what my contract is for, so I'll only focus on that. Or I only focus on infants or pregnancy, so I'm only going to focus on that. That is a luxury right now. The house is burning, and it's really important that we recognize and understand how lives and all these policies interact.

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Kima Taylor: So that we can really not just improve one single aspect of health, but really improve health overall, so people can not just survive, though sometimes that's a win, but ultimately thrive. Next slide.

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Kima Taylor: So anyone who knows me know that I always start with history. And history's important now, because much of the history that Kay put through, and that I'm going to give you now, did not leave us in a place where we really had equitable outcomes today.

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Kima Taylor: So we need to think about that history to make sure, as we're doing harm mitigation or any of the policy work we're doing, to save and ultimately dream anew includes that deep need for equitable outcomes. But also, we need to know history because we seem to be going back there.

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Kima Taylor: There seems to be a move for, really, a punishment response, so we have to know where we came from and what some of the pushes were against that, some of the changes.

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Kima Taylor: So, as many of you know, drug use is rarely treated as a health concern. It was used as a tool to battle communities for moral, racist, protectionist reasons.

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Kima Taylor: And truly, you know, even back to the opium Dins, and ultimately the Chinese Exclusion Act, which were some of the first, hostile drug policy

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Kima Taylor: it was really about people being afraid of people taking jobs, people using racist tropes in order to change policy to get the outcomes they wanted from an economic, from a social perspective, not from a health and well-being. So it was rarely treated as a health concern.

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Kima Taylor: And this historical reality has had huge ramifications for everything we do. For research, there's not enough research. Honest.

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Kima Taylor: true research, that demonstrates, like, the health

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Kima Taylor: issues and benefits around substance use. There's… that historical reality has huge ramifications for the legislation that has been put in place, the administrative and social and clinical responses.

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Kima Taylor: And so that's often meant when changes are made, because you have this system that baked in.

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Kima Taylor: Baked-in negative outcomes, inevitable negative outcomes, and quite frankly, hostility, even when you tinker around the sides, it's going to be harder to have something that leads to something positive.

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Kima Taylor: We know, historically, this is not the first substance use or even opioid use epidemic. Look back to the Civil War.

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Kima Taylor: It's not the first time doctors have fueled that opioid epidemic. For instance, in the Civil War, when a lot of soldiers were given morphine for pain. And when I say a lot of soldiers, a lot of white soldiers, because it was felt that Black soldiers could tolerate pain more. So not the first time it's been done inequitably.

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Kima Taylor: It's not the first time we sought to regulate prescriptions and found that people then turned to illicit drugs. So, like, you know, when we put… made you give a license for pseudafedrone because we were stopping people from manufacturing and ultimately using methamphetamine. Well, that did not work.

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Kima Taylor: Right? People, because it's a substance use disorder, found other ways to manufacture and ultimately get methamphetamine, and the same thing happened with opioids when prescription pills, were taken away.

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Kima Taylor: It's not the first time response and concern differed based on demographics.

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Kima Taylor: But it's not the first time slow progress has been made only to face

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Kima Taylor: hostile punitive backlash. And it always amazes me, like, why do we have to be hostile? And it's really important that we recognize that a lot of policies that are put in are simply being put in because people do not like people who use drugs. And we have to fight against that, but that's also why we need folks at the table, at these policy tables.

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Kima Taylor: Next slide.

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Kima Taylor: So our past responsive has repeatedly been inadequate, stepwise, races, not evidence-informed. We're just, like, doing stuff.

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Kima Taylor: And though at times they included appropriate clinical social responses for some populations, like there was some morphine replacement until policymakers shut that down and put providers in jail.

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Kima Taylor: There were these often glimmers. There was pretended criminalization, there was this pretend that criminalization and justice response was a treatment response. For years, we funded studies that say, was going to jail and prison more effective or less effective than getting actual treatment?

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Kima Taylor: Really? That's a question we have to ask. But we actually acted like that was a treatment response. We're slow to provide type of care to those who aren't ready to enter treatment. And I'm not even talking about substance use services, though we were slow to…

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Kima Taylor: provide evidence-informed secondary prevention, harm reduction, early intervention services. But we were slow to provide physical health services to people who use drugs. We were slow to provide mental health services. Like we said, people are more than their substance use, and they need responses for their whole health and well-being, and historically, didn't do it.

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Kima Taylor: Even when… while we knew that alcoholism and substance use were chronic health concerns. So, next slide. I'm not going to read this, but we have a long history of knowing that,

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Kima Taylor: Alcohol, Substance Use, or chronic diseases.

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Kima Taylor: And we chose to ignore it. Next slide, much as we're kind of choosing to… moving towards ignoring it now.

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Kima Taylor: So why is this conversation important? And I say, and it is explicitly a race conversation, it is explicitly a class conversation.

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Kima Taylor: Because we knew, like I said, that this was a health concern, but we created these policies that purposely included racial animus. We talked about opium DIN regulations, but we… but what about Harry Anslinger and taking out,

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Kima Taylor: Lady Day. It's like, we created… he created drug policy based on his hatred of people of color, Black people in particular. The war on drugs, again, I'm not gonna read this quote, but they knew that they were taking out anti-war left and Black people. They knew they couldn't make it a war against Black people, but chose to do it anyways.

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Kima Taylor: This history is not by accident. We knew in the HIV epidemic that government

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Kima Taylor: despite the fact that we seem to have changed history, government was not engaged in improving well-being during the HIV epidemic. In fact, it promoted and enforced discrimination. It promoted and enforced not telling people… not helping people, not helping people even to die in a peaceful way with the people they love.

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Kima Taylor: So we have to learn lessons from this history. We have to learn that, one, we can do better, how to move and how to move if we want equitable outcomes, and how to move during these perilous times to ensure that while we're mitigating harm, that they're going to lead to equitable outcomes.

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Kima Taylor: And so it's not an accident, and I just, again, want to go back to that hostile response.

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Kima Taylor: as I said, in certain spaces, some people got won out… they were using drugs, and they had access to treatment. Other people had access to prison because of how we viewed people.

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Kima Taylor: If we truly believe this is a health concern, that would never happen, because we don't say to people of type 1 diabetes, okay, you're going to have access to insulin, and you're going to have access to prison. So let's learn from where we came from. And the one piece I do want to add to the fact of where we came from is there is some positive history. But next slide.

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Kima Taylor: We have a horrible sequelae from our legal responses. I'm not going to go through all of them, but I will say, at the end of the day, we do not have a robust and culturally and linguistically effective full continuum of health and social services for something we claim we know as a health and social concern. And that's a lot of words up there, but the reason I use cultural and linguistically effective, as opposed to,

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Kima Taylor: just saying they need to be responsive, is having, you know, worked in a bilingual clinic, you can talk a different language right next to someone. It doesn't mean they understand. It doesn't mean you're engaging, doesn't mean you understand the culture of engaging. So a lot of what it is, is how do you work together in partnership to create an effective solution? How do you shut up, listen, have the capacity to work together to create an effective

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Kima Taylor: outcomes that are going to improve health, and that efficacy is not defined

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Kima Taylor: By me, it's this partnered efficacy, right? So this legal response left us in some pretty shady places, where with child welfare, foster care inequities, criminal legal inequities, we treat something as a health and social concern, supposedly, but put in punitive spaces.

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Kima Taylor: But I want to note, and this is where I want you to mine as we move forward, the fact that there were some current… there was some positive history, because community stepped up.

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Kima Taylor: They said, nope, you're not going to treat us that way. You're not going to treat our loved ones this way. So they created community solutions. They created ways to reach out and ensure that people who use drugs, ensure that people who've been historically and systematically excluded have access to community-based care that's kind.

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Kima Taylor: Non-punitive, non-judgmental. They get ignored often.

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Kima Taylor: And honestly, because that they have been ignored, our whole society has gotten worse outcomes, but now's the time to listen, because it has been done. Next slide.

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Kima Taylor: So I'm just going to move quickly to our current opioid crisis, because I really want to state that it's not the aha moment that people pretend. People are like, oh my gosh, it's a, health concern. And that quote-unquote aha moment is really more a reflection of fear of being

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Kima Taylor: introspective, the fear of not being able to look to these communities that have been vilified to understand they hold solutions that can improve the well-being for all of us, whether people use opioids, methamphetamine, caffeine, alcohol, etc.

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Kima Taylor: And the fact that folks have ignored these positive responses is something we cannot afford to do now. Next slide.

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Kima Taylor: And you're going to have access to these slides, so I'm going through many of them somewhat quickly, because you will have access, and I want us to get to the panel.

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Kima Taylor: But let's talk about the current opioid crisis, because it…

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Kima Taylor: In… if you don't think deeply, you will think that this pullback is solely about this current opioid crisis. And so we have to understand that… understand how we not only make sure that the opioid crisis can have equitable outcomes that are positive, but we have a substance use system at large.

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Kima Taylor: So, this is not, as I said, this was deemed originally as a prescription drug epidemic, and those who had access to

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Kima Taylor: excuse me, insurance had access to prescription drugs. There was many people with lots of pain, particularly those of color, that needed access to opioids and weren't receiving it. So there was this built-in dichotomy.

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Kima Taylor: But it was deemed first as a prescription drug epidemic, and seen as being caused by providers and manufacturers in a way that, though, providers and manufacturers definitely at fault, but in a way that closed conversations about caring for people with other types of substance use. So if you're a prescription drug.

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Kima Taylor: you were good and deserved a public health response. If you were using heroin, you were bad and deserved to go to prison, right? It created this false dichotomy that's… that's kind of a lie on what substance use disorder actually is.

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Kima Taylor: It was manifested and recognized in white population in ways that reinforce racial bias. Started to move those with a moral frame around drug use to the public health frame for some, but not others.

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Kima Taylor: Policymakers, providers, all these folks that never talked about drug use entered the picture, but rarely looked at past history or effective evidence-informed community responses, meaning they provided narrow responses which reinforced inequities and poor outcomes for certain populations. The ways they were implemented were chaotic.

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Kima Taylor: often relearning of known solutions, be it syringe exchange or other pieces.

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Kima Taylor: The prescription drug monitoring programs were often owned by law enforcement, really embracing that legal response, which we, again, is not a response to a health and social concern, as opposed to health departments. So we actually went back and had to relearn a lot.

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Kima Taylor: And then societal indecision. I'm a pediatrician, I do a lot with pregnant and parenting, folks, and societal indecision around pregnant parents. Do you treat it as chronic disease or criminalized? Unfortunately, society seems to be going back to criminalization, using the mother parent as a pawn.

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Kima Taylor: So what we did in this current crisis, even as we see overdoses going down, which is really important, is we created an opioid use disorder system, not a substance use disorder system, and an equitable one at that. So when people are like, oh, overdose rates are going down, for some populations.

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Kima Taylor: And even when they started responding to overdose rates, it was very much for white populations, and then everyone acted surprised when the overdose rates for Black populations or Indigenous populations were going up.

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Kima Taylor: In a time of scarcity, we can't have that nonsense. We really have to make sure, no matter who's sitting to your left or your right, has the same opportunity to have positive outcomes. Next slide.

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Kima Taylor: So let's talk Medicaid, and Kay went through the legislative history. I want to add a few pieces. For the Affordable Care Act of 2010 and parity expansion, this was huge, because in addition, substance use became an essential benefit.

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Kima Taylor: the expansion population had access to substance use services. We do know there's not necessarily the robust, all the continuum of substance use services, and that's partly because of that past history, but it is the right to have it.

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Kima Taylor: It spread to Medicaid as

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Kima Taylor: That's what I say, MCOs, as Kay alluded to. But I do another kind of warning, and I said this was a doom and gloom tour, as people go and do things fast, you will note that in the Affordable Care Act, cigarette use, which is a substance use disorder, was allowed to have higher premiums.

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Kima Taylor: And so that's why we need to talk about a substance use system and not just an opioid use system, because that discrimination, that disdain can creep its way back in.

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Kima Taylor: And the other big thing I would say that happened, which was a shift from public health block grants to Medicaid reimbursement for substance use providers, and this was a huge shift, and our panelists today, Silvana, can talk even a little bit about that, but it was a huge learning curve, and it's like, just do it, because you're going to have repeatable and reliable funding from Medicaid, and now folks are trying to take Medicaid.

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Kima Taylor: So it's really important to fight back. Next slide.

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Kima Taylor: So you're thinking, alright.

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Kima Taylor: If I care about non-punitive health and social-based social use services, in my opinion, the full continuum, why should I care about Medicaid?

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Kima Taylor: Well, this is why. It is the largest payer for behavioral health services. And you will note this conversation is on substance use, and behavioral health is mental health and substance use, but it is the largest payer for substance use services. And 21% of those covered by Medicaid have a mild, moderate, severe SUD that doesn't include alcohol.

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Kima Taylor: You should care about Medicaid because it covers the cost of medications for use disorders, be they alcohol use disorders, nicotine use disorder, opioid use disorders. And when I first started doing this work, you know.

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Kima Taylor: medications for opioid use disorders were seen as that evil harm reduction, right? And now people are like, oh, it's the gold standard, like, they were always behind it, and that kind of change allowed for coverage

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Kima Taylor: of…

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Kima Taylor: those drugs with Medicaid, and the coverage of drugs in a way that really has made it so people go back to work… can go back to work easily, they can, you know, keep their kids out of family, out of child welfare, and I'm not saying that's the only reason that should happen, because there's many things that do not have treatments that are medications, but if we're honest, right, it was a big boon, and it's expensive, so it needs to be covered. It covers

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Kima Taylor: naloxone to reverse things.

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Kima Taylor: To reverse opioids, excuse me.

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Kima Taylor: pays for the behavioral health therapies. The cognitive behavioral therapies, counseling, etc. And in some places, through waivers, which you won't get into, it covers contingency management.

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Kima Taylor: And the places where it doesn't cover contingency management, and maybe other grants are, you need Medicaid to cover these other pieces so those other grants can cover contingency management. Next slide.

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Kima Taylor: Other reasons to care, is it really can be a backbone of some of the programming that is removing substance use from these punitive systems? To decrease the contact with punitive systems.

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Kima Taylor: What are the collateral consequences that comes from that contact? And that's going to be really important. Better to not have contact with the criminal legal system, because when you get out, it's even harder to get a job. Better to not have contact with a child welfare system when not needed, because

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Kima Taylor: Because you need to have… because you want to keep your family together and not have that surveillance.

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Kima Taylor: And again, cost savings from these deepened systems. If you don't have to go to criminal legal, if someone isn't in child welfare, you have cost savings that can be utilized for some of the other supports that people need.

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Kima Taylor: In order to, again, not just survive and thrive. And the last piece I want to address is this fraud story. And there's this idea going around that these Medicaid cuts are because there's so much fraud in the system.

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Kima Taylor: But if you look at their own documents, their own Congressional Budget Office scoring, it is not about vast amount of money coming from insurance companies that are conducting fraud, or providers are conducting fraud. The vast amount of savings are coming from more people being uninsured.

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Kima Taylor: More people not having access to life-saving services that they need and deserve to, again, not just have health, but to be able to be involved in all the other aspects of life.

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Kima Taylor: So, do not let them gaslight you with a fraud story. This is a story about harm done to people. Next slide.

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Kima Taylor: Now we're gonna get a little deep into Medicaid. Stay with us.

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Kima Taylor: The important piece here is Medicaid is an entitlement. Anyone who's eligible can apply. That is not like your block grants. You all know how it is. If you have block grants, and you can provide us, like, services to 10 people, when you get to the 11th person, they're on a wait list. Medicaid is an entitlement. If you're eligible, you can apply.

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Kima Taylor: So that is why their little shenanigans are important. Eligibility rules are important. Medicaid expansion was important because it increased that eligibility, which means you're entitled to Medicaid. You deserve to have Medicaid.

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Kima Taylor: I believe everyone deserves insurance, but just for… for now, you deserve to have the Medicaid. Barriers and hoops are important. Even if you're eligible.

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Kima Taylor: If you… if there's too many berries and hoops, then you can't get that entitlement that you deserve.

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Kima Taylor: As opposed to grant funding, entitlements have that built-in sustainability feature, repeatable, reliable funding for you, access to services for clients. And it's important to note that there's not all of a sudden going to be an onslaught of grant funding when these cuts occur. It is not going to be okay, well, now we're cutting Medicaid

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Kima Taylor: states and localities and federal government are going to have huge portions of money that they're providing for, all these services that are no longer there. That money is not there, it's not going to happen. So we have to save this floor.

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Kima Taylor: In addition, the way it's, it's kind of… the floor is being shaken, is there… Medicaid is a federal-state arrangement. Feds pay some, states pay some, it depends where you are. Low-income states get a higher match. Territories are not so lucky at all, unfortunately, and that…

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Kima Taylor: also has to do with historical hostilities. But, but, if a state spends less, the federal government gives them less. So when the government makes it harder, for states to pay full entitlement, the feds save money, and this is going to be important, we can't go into all the details.

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Kima Taylor: But the Center for Children and Families, who are hosting this webinar, have tons of resources so you can understand this. So they're like, blah blah blah, provider taxes. That's actually really important, because if the states are paying less, the federal government pays less. This is not about fraud, this is about saving money by keeping people off.

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Kima Taylor: And all of the savings is at the cost of wellness and lives, which, as I said, have that rippling effect. Next slide.

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Kima Taylor: We're going to talk about what's changing, and we're not going to spend much time on work requirements, because a lot of people are talking about those. And there's some links on the bottom from CCF, but it's out there. But I do want to touch on, a little bit in the sense of

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Kima Taylor: If you need work requirements, and you have a criminal legal history, and particularly often made more complicated if you have a substance use history, it is hard to find employment. It is hard to find employment because of all this historical prejudices, prejudices and stigma. So, when they're like, just start working.

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Kima Taylor: And you'll be able to get your Medicaid, there's an extra ripple of complications. And the response people often say is, like, well, it's okay, you can get Medicaid if you have substance use, we'll talk about that. But this work requirement is a big thing, particularly as we know our populations have had difficulty, having fair access to work already.

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Kima Taylor: There's eligibility changes. Remember how I said if you're eligible, you're entitled? Well, if they change the eligibility, that changes whether you're entitled

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Kima Taylor: to Medicaid. And that's particularly, important, right? If you, as I said, need those substance use treatments and services, and now you can't afford them anymore, they're expensive. All of healthcare is expensive, and so not having insurance means you can't have access to the things that are keeping you healthy.

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Kima Taylor: Lastly, benefit packages can change. At the best of times, as I mentioned, substance use services have not been holistically included. The full range of evidence-informed benefits are not covered. So, for goodness sakes, let's not let them change the benefit packages that exist. Let's have as many of those as possible. Next slide.

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Kima Taylor: And so now I want to talk a little bit just briefly about these, exemptions, because a lot of times when I say, look, we have to be really careful, folks are like, it's okay, we got exemptions. Pregnant folks got exemptions, medically feral, so that includes substance use, parents.

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Kima Taylor: Devil's in the details. Devil is in how these are put together. One thing we know that postpartum for maternal and child health, a lot of the maternal deaths are caused by behavioral health concerns.

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Kima Taylor: We have a lot of work to do with maternal child health, and we've been working on it, and one way we worked on it was to allow people to have postpartum services, through their first year.

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Kima Taylor: You have to make sure that that is kept.

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Kima Taylor: Because that… it's not required. If funding gets tight, it can go away, but that is one of those aspects that you need to make sure people have that continual access to the behavioral health services they need.

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Kima Taylor: The other thing that keeps me up at night, you can see a lot of things keep me up at night, miscarriages are wicked common. When people use substances, those miscarriages are often erroneously criminalized.

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Kima Taylor: And then, when they're criminalized, people have enter into these punitive systems unjustly, right?

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Kima Taylor: If people had substance use exemption, they know that they have that miscarriage and it was mixed with substances. Whether it was truly caused or not, often it wasn't.

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Kima Taylor: And so this can lead to unfair consequences. The idea of medically frail, folks are like, it's okay. If you have a substance use, it's medical, you know, that's medical frail, you'll get exemption. Not true. Their definitions are wickedly narrow.

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Kima Taylor: Even how you prove that, the first time you can say you have a substance use disorder, but then you have to have 6 months recertification, you have to have, you know, Medicaid claims data is what it's going to be in many instances.

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Kima Taylor: What does it mean for someone with substance use who's not interested in Medicaid billable treatment, but still needs their services? One example, contingency management. Evidence-informed and proven to… to be helpful.

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Kima Taylor: for methamphetamine, among other, substances, but it's not Medicaid billable because of some of the things we talked about. That's what you need, but there's not a claim form, right? There's all these pieces, and importantly, again, if substance use is what is on your record, how does that affect you when you then become pregnant? And whether it's fair or not, people decide they need to call child welfare. How does that affect you if,

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Kima Taylor: How does that affect you if all of a sudden you're looking for employment and that employer says, no, we don't want you because you have a history of substance use? I'm not saying that's legal, but I am saying it happens, right? And then similarly, for parents and caregivers for children under 14,

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Kima Taylor: Great, but still, if you know that the person has a history of substance use.

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Kima Taylor: Referrals to child welfare are not solely done in pregnancy, even though sometimes we seem to pretend they do, right? But a lot are in schools and other systems, and now it is all over the chart that you have a history of substance use. What does that mean? Stigma and racism are pervasive in all of these systems. Next slide.

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Kima Taylor: Don't worry, we're almost through.

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Kima Taylor: So what… and so one more thing I want us to think about, the other thing folks say to me, well, it's okay. And this I find really scary. People are like, it's okay, uninsured will be covered. And the one that's worse is when people are like, it's okay. In the United States, if you don't have insurance, you can still go to the ER and get care.

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Kima Taylor: Okay, one, you can't go to the ER to get chronic care. Can't get… go to the ER for regular chronic, substance use disorder services. You can't go to the ER for cancer, like, don't… don't repeat that. But the other thing that people say

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Kima Taylor: Is that… well, that's okay, because the federally qualified health centers and certified community behavioral health clinics will serve as a backstop.

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Kima Taylor: They can't. They're awesome. I used to be an FQHC doctor, but so many more people are becoming uninsured. They're gonna be… and they're already challenged, they're gonna be overwhelmed. People read, yay, FQHCs are getting more money. That money is going to keep much of it level.

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Kima Taylor: And so you can't rely on that. They need Medicaid, too, to keep their doors open.

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Kima Taylor: And one thing I would note when people are uninsured, FKTs are really about access to primary care. If you have cancer, and you are uninsured, you are not getting cancer treatments.

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Kima Taylor: If you need, excuse me, ongoing buprenorphine, you may have to get… you may not be covered by a 340B program, you may have to pay for that out of pocket, because FQHCs are not full service.

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Kima Taylor: primary and secondary care. For certified community behavioral health clinics, these are inextricably linked to Medicaid. They don't have bundles of extra money to care for uninsured, so they need you supporting Medicaid, too.

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Kima Taylor: And there's gonna be, as I mentioned before, limited grant funding. It's not… there's not gonna all of a sudden be an inflow of grant funding to preserve these services. Next slide.

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Kima Taylor: Lastly, I just want to talk about the workforce. Medicaid does not pay providers, the same rate as other insurers, so there's fewer providers. And when you're looking for money, what often happens is you cut funding to providers, so there are even fewer providers, right? So, and people are like, well.

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Kima Taylor: You know, it's okay, we already didn't have enough providers and substance use services, certainly didn't have enough cultural and linguistically effective substance use service providers that are offering the full capacity of, evidence-informed services, and so we can't afford to lose more.

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Kima Taylor: Next slide. So again, we need that Medicaid payment.

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Kima Taylor: Lastly, the things that keep me up at night. Data, and this is something that, really, I roll over over and again, and I've alluded to it previously.

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Kima Taylor: One, on one hand, we need robust private disaggregated data, including but not limited to overdose rates. I told you how historically led to inequitable outcomes. We need private disaggregated data to see if we're creating equitable outcomes.

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Kima Taylor: But on the flip side, as many people are like, we want to get as many people enrolled as possible, let's just get this data, that data from here, that, and the other.

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Kima Taylor: Data can be dangerous when you have a substance use disorder. We know this from HIV, right? We don't have to pretend we're learning something new. We know there… data just out in the ether, again, and we're learning this with immigration, data out in the ether with people who are out to

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Kima Taylor: not care for, not provide services, often do harm, can be dangerous. So we need to have really intelligent, logical conversations around data privacy.

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Kima Taylor: how to understand data that's had all of the names taken away so we can see if we're having the outcomes we want to while not putting people in danger. And as I said, again, communities do know how to do this, right? HIV was a time when government was hostile. You had to figure out how to serve your patients, make sure you're serving

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Kima Taylor: An equitable manner, and they had tools for keeping data anonymous and confidential.

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Kima Taylor: We have to talk about,

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Kima Taylor: how to find… how to find, different ways to resource that data. People are like, let's look at claims data, incarceration data, school attendance data, all of those can come with dangers. So, we know there's a school-to-prison pipeline.

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Kima Taylor: you're pulling school attention, like, this person has a substance use school-prison pipeline, woo, just revved up, right? Well, how do we think about that? What if free flows of data mean in an era where harm reduction is not supported and substance use is being more severely punished?

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Kima Taylor: Next slide.

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Kima Taylor: So all this history holds lessons on how to advocate for services, how to work with healthcare and other systems to implement these lessons during these times of change, can't be silos.

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Kima Taylor: Medicaid changed the reality for many. If it disappears, we're back where we are, and I will say we're actually worse. But if it's changed without impacted voices.

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Kima Taylor: If we change without the people who've been historically impacted, and impacted hostily, and those… and not just people in recovery, people who are still actively using, if we don't include those voices.

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Kima Taylor: Change isn't gonna be… isn't gonna lead us where we need to be, and equitable outcomes are not gonna be achieved.

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Kima Taylor: If Medicaid goes away, we're not just talking about increased overdoses, which is horrific, but we're also talking about increased HIV rates, hepatitis C rates, and other poor physical health outcomes, be it diabetes, be it, high blood pressure for people who use drugs. We'll have increased family separations, and again, most likely inequal.

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Kima Taylor: Increased criminal legal exposure and consequences, and increased harm and decreased well-being for people who are loved ones, right?

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Kima Taylor: Medicaid is not perfect, but it has to be saved. A lot of people then say, well, if it's not, you know, it's not working the way it needs to work, so let's just throw it away. I promise you, as a clinician, it can often be the difference between life and death. If you're uninsured with cancer.

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Kima Taylor: you're dead. And I've had to tell people how they're dying. If you have Medicaid with cancer, you are going to an oncologist and have a shot.

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Kima Taylor: So lives depend on an existence. We have to preserve what we have now, but we can still dream and build another tomorrow. While we're doing this, let's hold what could be. Next slide.

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Kima Taylor: So this is a lot. These are exhausting times with all of the mixes going on. I would say finding the opportunities, if and where they exist, and they do exist.

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Kima Taylor: And keep creating and dreaming on what could be, even as you may have to focus on mitigating harm for now. And then just go to the… skip the next slide and go to the next slide. I just want to leave you with a poem.

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Kima Taylor: Sir George, I'm… yeah, next slide. While we get the panel ready, and it's by Shel Silverstein. Listen to the mustn't child, listen to the don'ts. Listen to the shouldn'ts, the impossible, the won'ts. Listen to the never-haves, then listen close to me.

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Kima Taylor: Anything can happen, Sheld. Anything can be. And this is a mantra I've used for decades, and so I feel like we need it and hold it now. So now we're going to pass over to the…

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Kima Taylor: Panel, and I'm sorry for talking so long.

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Anne Dwyer: Kima, no apologies, Nanea was such wonderful, amazing information, and such a helpful… such helpful context for today's conversation.

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Anne Dwyer: I wanted to pull a little bit, on a thread that you mentioned at the end about that one thing that keeps you awake at night, so…

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Anne Dwyer: We have, obviously, federal legislation, you know, both state and federal administrative actions, state changes, funding changes, executive orders, all kind of looking to actively roll back

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Anne Dwyer: coverage or funding, whether that be directly for Medicaid or programs that really wrap around and support Medicaid. So recognizing the environment in which… which we are right now.

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Anne Dwyer: Can you speak a little bit about, kind of, the one thing, and maybe I'll kick it off to you first, Silvana, since we haven't heard from you yet, that kind of keeps you up at night related to substance use health? And any ideas, on a more positive note, that, may decrease that threat, or kind of…

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Anne Dwyer: improve that proposal, help the outcome. I think we're kind of thinking… trying to think about, of course, a little bit, as you mentioned, Kima, a doom and gloom tour, but we are also, I know all of us collectively, are problem solvers.

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Anne Dwyer: And, ultimately positive thinkers. And so, you know, recognizing the realities in which we are, also want to recognize there are still opportunities there. So, with that kind of framing, Silvana would love to kind of get your input, on, you know, maybe one or two things that keeps you up and how you're thinking about that.

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Silvana Mazzella: So, hello everyone, and thank you for putting on this, most important event.

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Silvana Mazzella: Can you hear me?

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Anne Dwyer: We can.

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Silvana Mazzella: Okay, great.

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Kay Johnson: Yes.

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Silvana Mazzella: There are so many things keeping me up at night. First and foremost, the amount of people that stand to potentially lose coverage.

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Silvana Mazzella: We have people getting notification right now.

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Silvana Mazzella: But the amount of work that will be required for people to walk around themselves and make themselves eligible for benefits.

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Silvana Mazzella: is enormous. People have to do it at least

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Silvana Mazzella: You know, a month in advance. As was already stated, there might be certain, exclusions for being in a work program or work environment.

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Silvana Mazzella: People need financial assistance to enroll in a school program or other things.

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Silvana Mazzella: And I think the… the burden, having seen this happen, years ago in nonprofits and, employment and other settings.

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Silvana Mazzella: The burden is going to be on nonprofits, community-based organizations.

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Silvana Mazzella: Hospitals, mental health clinics, and substance use treatment facilities, many of whom are not funded with, wraparound funding.

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Silvana Mazzella: Many of whom are…

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Silvana Mazzella: Billing for what they can that are going to end up taking up these activities of being, benefits advocates for people.

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Silvana Mazzella: And I think to the previous comment about, you know.

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Silvana Mazzella: fraud, right? The onslaught on community-based providers to provide a safety net, to provide medical services, substance use treatment services, mental health services, and most importantly, one of the most un…

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Silvana Mazzella: Funded and unconsidered,

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Silvana Mazzella: Acts of caring for people is all of the case management, recovery, support, and navigation that wraps around medical and other services.

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Silvana Mazzella: So, all of us and other agencies serving people and housing people are going to be, you know.

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Silvana Mazzella: Doing that additional work.

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Silvana Mazzella: We also know that

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Silvana Mazzella: we are going to lose people from treatment programs, right? We'll lose people from the roles, and

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Silvana Mazzella: Providers will be scrambling to re-engage people, And, we really…

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Silvana Mazzella: you know, that is probably the thing that keeps me most up at night, is how are we going to keep people engaged in life-saving care, in life-saving medication that, without Medicaid insurance, people would not be able to have and stay alive with?

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Anne Dwyer: Thank you for that, prospectus, Silvana. Kay, do you have anything to add?

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Kay Johnson: I would, you know, I would only add that I think this is… what Silvana is saying is exactly right, and it, you know, to Kima's many points, the greater intensity for those who have substance use or mental health conditions that lead them to these settings.

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Kay Johnson: The same thing as Kima said, is going to happen in community health centers. It's going to happen in all of what I call the publicly accessible system. People who see people, providers who see people, without

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Kay Johnson: regard to their ability to pay are going to be overwhelmed. And it's already starting, the avalanche is already starting, and it's starting in some states, and it's starting because of the immigration issues, and it's starting because

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Kay Johnson: people hear it so much on the news, they think they can't get Medicaid anymore because they're not working, but all the documentation and navigation, and at the same time, trying to still deliver the care and help people be well and thrive, it's going to be an extraordinary pressure. It really is going to take all hands on deck.

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Kima Taylor: You're muted, Ian.

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Kay Johnson: You're unmute.

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Anne Dwyer: Sorry, thank you. Following up on kind of some of what you mentioned around case management and supports, I think one dynamic that we also often run into when it comes to Medicaid, it is really a state-federal partnership.

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Anne Dwyer: And each state…

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Anne Dwyer: many states call their Medicaid program, not Medicaid, they call it something else, right? Like, so in Wisconsin, you might be on BadgerCare, or in California, Medi-Cal.

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Anne Dwyer: And even for an individual, you know, majority of those covered under Medicaid are enrolled in a managed care plan, so they might even get a card that says Blue Cross Blue Shield on it. They're like, well, I don't have Medicaid, I have Blue Cross Blue Shield, or I don't have Medicaid, I have BowderCare.

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Anne Dwyer: So, I think, you know, obviously, you talked about some of these supports. We kind of hear about, you know, Medicaid really does play this huge role, but it's not always realized. Can you speak a little bit more about how you kind of see the way that Medicaid really serves the community and supports the community you work with, maybe in some of these hidden or less hidden ways?

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Silvana Mazzella: Sure. So, in terms of… you know, I, I think,

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Silvana Mazzella: So, I'll give you an example. We were renegotiating an agreement with one of our managed care entities for some of the services that we have with another one that they were not paying for. And we had to explain and show them what it takes to actually get a person

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Silvana Mazzella: Who's asked for medical care, or substance use treatment, or mental health services.

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Silvana Mazzella: into the actual clinic room from the point that they ask for care, and then in with a provider, and then through the entire visit, and then to a pharmacy or to wait for medication to be dropped off, etc. And so, you know, the work of a navigator or medical case manager

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Silvana Mazzella: is one of those unhidden services, that most, right, and so if many of our area hospitals do have social work services.

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Silvana Mazzella: But many clinics don't have that, and so especially in really low-barrier mental health, substance use treatment, and medical settings, you need all of those extra layers. And…

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Silvana Mazzella: So those services, like, for many smaller clinics like ours, we provided those because it was the right thing to do, and the only way to get people through care. Then you get a quote-unquote rate for that service. You're able to provide a slightly different service. But those are all of the hidden costs, and

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Silvana Mazzella: One of the other things that… that can potentially happen with this is… in…

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Silvana Mazzella: Maybe higher barrier settings, larger clinics, other services.

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Silvana Mazzella: Where some of that hidden navigation and medical case management doesn't exist.

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Silvana Mazzella: You stand to really,

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Silvana Mazzella: lose more people from care, and lose people at all of the various steps, so I'm not sure if I quite answered your, question, but…

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Silvana Mazzella: I think that's also where we're going to really see

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Silvana Mazzella: the impact and where we're going to really see the tax on community-based providers and smaller substance use treatment programs, including programs that aren't formal OTPs, aren't formal opioid treatment programs, but they're, medical providers providing this

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Silvana Mazzella: Within primary care, within some other type of specialty medical service.

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Silvana Mazzella: For a population that is very difficult to stay engaged in care.

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Anne Dwyer: Yeah, and I think, Silvana, you know, turning to you, Kay, Silvana mentioned, you know, all the hurdles that folks have to go through to maybe get coverage sometimes, especially now with some of these changes. At the same time, prior to 2010,

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Anne Dwyer: in 2014, really, we didn't have the Medicaid expansion, and so there weren't even heard, you know, there wasn't even a way to get that coverage. Can you just talk, just for kind of a historical perspective of where we've come from since passes of the ACA, and why Medicaid expansion is so important for individuals with…

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Anne Dwyer: Substance Use, conditions, or trying to kind of improve their health.

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Kay Johnson: Absolutely, and I think that the biggest thing to say for me, in some ways, is to talk about the young adults, right? People who hadn't had a child, people who were working at entry-level jobs.

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Kay Johnson: young men and young women. A lot of my work has been around those younger… younger women, or people who were going to become pregnant, and you say, we weren't, you know, if the person had a car accident, if the person had a pregnancy, if the person had a substance use or a mental health condition, if they needed to take, you know, themselves… I mean, we were so far away from even talking about preventive services.

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Kay Johnson: They were just ending up in the emergency room, and the absolute worst happened.

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Kay Johnson: Or, you know, God forbid, as Kima said, they got cancer, and there was no cancer treatment for them if they were uninsured. So that role in covering the adults where we could do prevention, where we could intervene as needed, where people could get some health coverage, even though they were low income, they were working in jobs that didn't have

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Kay Johnson: coverage for them, or not coverage that they could afford to pay for, and that we were doing something at the front end of their lives. I think the same thing holds true for some people who are, let's say, between 50 and 60, who are

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Kay Johnson: aging out of their job, or no longer able to work in the job that they worked on, and they've lost their insurance, and they're 15…

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Kay Johnson: 10 years away from a Medicare card. And so this gets a little bit to me, Anne, at the answer.

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Kay Johnson: to the person who said, you know, what do I say to legislatures who think this is for the age-blind and disabled? And I think one of the things to say is that, it is intentionally, by decisions of Congress.

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Kay Johnson: And by decisions of states, because so many… so much of what's been done has been done at state option. But these decisions have been made very intentionally, because they're good for the health of people, they're good for the health of workers, they do help keep people working, they do help keep families whole and reduce costs.

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Kay Johnson: For things that are needed to be done in schools.

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Kay Johnson: It's gonna be cost… more cost-effective to do this through coverage than to try to just salvage things when they go terribly wrong.

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Anne Dwyer: You know, building off that a little bit, Kima, I'm curious from your clinical perspective, and Kay you mentioned this, but I think, you know, so often, you know, when we talk about healthcare coverage, it's for… we think about the coverage for that one individual, and we know that individuals live in families, they live in communities.

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Anne Dwyer: Can you just talk a little… you know, at CCF, we always say healthy kids need healthy parents. Can you talk a little bit about, you know, the Medicaid expansion and how that's translated to the health of

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Anne Dwyer: Not only the individual, but the family, for those that were able to gain that more consistent coverage, and not just, you know, waiting to maybe for it to get bad enough to show up in an emergency room.

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Kima Taylor: Absolutely, and Kay alluded to it, I think, with pregnant folks. People who don't know they're pregnant.

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Kima Taylor: And you have Medicaid, and you can be healthier before you become pregnant, you actually have better pregnancy outcomes, right? And that's whether you're using substances or not, but particularly if you're using substances, you now have access to substance use services you wouldn't have had before.

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Kima Taylor: I think it also… so now you have access to substance use services, you can get a job.

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Kima Taylor: you can, avoid child welfare, you can have a robust family that is doing better, kids go to school, you're starting the next generation off in a way that they can have improved health outcomes. And it's not even just, that, again, that individual families, that's communities. So you can go to the job, that is the grocery store, and people can keep coming to it because you're not as ill as you were. It really was that Medicaid expansion was huge, and particularly

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Kima Taylor: with substance use, because we had such a punitive history, and because of that criminal legal engagement, right?

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Kima Taylor: none of those folks had access to insurance, because we're so employer-based in the U.S, and many folks couldn't get a job because of that criminal legal history. Well, now you can get access to healthcare, you can ideally get access to substance use services in a way that decreases the overdoses that often happen when you come out of the criminal legal system, and voila! You can start engaging with your family. You can start looking for a job, and not

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Kima Taylor: even, and as I said, not even that you stop using substances, you can go and get your diabetes taken care of, so you don't have an amputation, or you don't become blind. It's like you… right? It's really a big, it's quite a big boon that I fear.

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Kima Taylor: people don't even realize. I mean, that's the beauty of Kay's historical knowledge, and frankly, all the folks on the call are pre-ACA, but it's become so baked in, people don't realize what didn't exist, and it was a horror show.

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Kay Johnson: It was.

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Anne Dwyer: You know, on that note, Silvana, I'm curious to get your thoughts, you know,

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Anne Dwyer: you know, as healthcare workers, social services advocates, really think about how they start to enroll clients. Obviously, we have these new barriers, but we still have Medicaid expansion, coverage still exists, we'll talk a little bit more about, you know, the dynamics of, some of the, the, the,

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Anne Dwyer: threats from H.R. 1, the reconciliation bill, but we do still have that base coverage there, and we want to make sure we educate folks so they understand

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Anne Dwyer: Still apply, still answer the questions, still show up. But just kind of curious as you, you know, enroll clients and work with clients to keep coverage.

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Anne Dwyer: How are some of the ways that, you know, you're thinking differently, but still ensuring eligibility and enrollment? So, are there ways that you're trying to,

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Anne Dwyer: help support clients in accessing other services. As Kima mentioned, you know, obviously you're working with clients in one area of their health. Are there ways that you're able to leverage Medicaid or case management to support them if they do have diabetes with other services in the healthcare system? Can you just talk a little bit about what that looks like on the ground?

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Silvana Mazzella: Yeah, I think one of the scariest things right now is that there's so much information out there, and maybe not a lot of specific information on what exactly is going to happen next.

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Silvana Mazzella: how are you going to get to the next step? How are you going to ensure eligibility, etc. And the same is true for community-based providers.

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Silvana Mazzella: We are, you know, working, and there are many legal advocates in Philly and Pennsylvania, and clinic advocates and medical providers, community-based nonprofits, advocates who are…

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Silvana Mazzella: You know, really working hard to put the information out there that, yes, there is still coverage, and you are likely

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Silvana Mazzella: In a, you know, in a group that will still be covered, but let us help you and find out, right? So I, I think,

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Silvana Mazzella: One of the things that we and many other programs in the area are doing, working with people, we are lucky, we have, we have a mail service here for people. People can actually come and pick up mail, use the mailing address to get benefits, right? So, how can we help you

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Silvana Mazzella: this is what's happening. Are you aware? Let us help you open up your mail. Let us help you see what you need to do in the next step. Everyone coming for a clinic or navigation or case management visit.

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Silvana Mazzella: Someone is, either at the reception desk or in the context of one-on-one work before or after they see a provider is checking benefits and, you know, really trying to work with people around eligibility dates.

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Silvana Mazzella: Do they meet

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Silvana Mazzella: one of the exemption criteria, right? So, are they likely to be able to keep benefits? If not, how can we help get you through a provider notification or filling out forms?

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Silvana Mazzella: We are worried that there will be some individuals that right now don't meet those criteria, and in the larger public, and so we're working with them around how to be eligible for an exemption.

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Silvana Mazzella: So that's, I think, a lot of the work. You know, I've seen documentation around the possibility of additional verification of conditions, right? So, making sure that conditions are documented, in, in a way by a medical provider, right? It's not just a statement.

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Silvana Mazzella: Trying to work with people to maybe not have substance use disorder be the first condition if they have another condition that qualifies, because there may or may not be implications to that long term.

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Silvana Mazzella: So I think that's a lot of the work, and I… I don't know if I fully answered, but I… I did want to just add from the previous, question and discussion that

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Silvana Mazzella: I think it was already mentioned, but we are really, really concerned about the aging population, and I see the City of Philadelphia, the Department of Behavioral Health and Health Department, doing a lot of work around the aging population. Many of our jurisdictions have an aging population.

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Silvana Mazzella: That is on long-term medication for opioid use disorder, right?

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Kay Johnson: Hmm.

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Silvana Mazzella: People that are in long-term recovery, people that, may be housed in a subsidized program where they're reliant on benefits.

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Silvana Mazzella: but we'll need additional supports that would be paid for by Medicaid and Medicaid wraparound services just for mobility to be able to get in and out of housing, etc. And so, you know, like, really rethinking

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Silvana Mazzella: We can't…

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Silvana Mazzella: We can't do everything for everyone, but maybe really looking within our shops at the most likely impacted individuals, and then just having an overall organizational approach to look at the impact and help people.

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Kay Johnson: And can I jump in about the… about the outreach and the notice? Of course. The, your center has a new, piece up about the outreach that… and many people don't know, I think, probably many of our participants don't know, that states have already begun.

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Kay Johnson: to do their outreach. In fact, they're more or less obliged under the timeline to start to do the outreach and informing for people about the Medicaid work reporting requirements.

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Kay Johnson: The Center for Children and Families put together a very, very easy-to-access blog, a very easy-to-access spreadsheet. I went in this morning, I live in Vermont, I went in and I found the Vermont piece, I sent it to my colleague in North Carolina who's been working with community, and I'll say she's an academic.

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Kay Johnson: She's reached out, and she's mobilized in several communities to get really understandable information on the ground. If you are an academic who has that community relationship piece to your role, or if you are a state or community-based advocate, getting involved in this outreach to better inform, states are not going to be doing a great job.

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Kay Johnson: It's not all very accessible and well-worded. I think that's one of the headlines and key findings in the blog.

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Kay Johnson: But we could all do more to help people in a variety of roles, whether it's a pregnant or postpartum woman, and Elisabeth and I have written a piece about that, or this new piece that just hooks you right into, what does your state's website say, and how could you help either get that information out, or do something better, or do a fact sheet that goes to your church, or your community center, or your provider setting?

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Anne Dwyer: Thank you so much.

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Kima Taylor: I got to that end, I'm sorry.

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Anne Dwyer: Of course.

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Kima Taylor: Totally agree with everything that's said, and I think that's another instance of where you don't have to do it alone, right? And so being able to work with people to be like, where are those resources? Even if you have to tailor what's been done a little bit from the website, still a huge lift, right? It just, allows for some economies of scale, and then you're meeting the people who are creating those for some of the other things coming down the pike.

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Anne Dwyer: Thanks so much.

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Anne Dwyer: you know, kind of shifting gears a little bit, you know, Silvana kind of talked about how a lot of older adults are kind of on longer-term opioid treatment programs, which is great, and in fact, the Support Act 2018 made medication-assisted treatment in,

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Anne Dwyer: medication-assisted treatment and Medicaid mandatory, so no longer an optional benefit, but again, you need that coverage to access that. Part of this kind of grew out of, you know, with the prescription drug crisis, there was a shift away from the way people talked about substance use.

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Anne Dwyer: And this was, of course, welcome, but in some ways, it also… in a number of ways, it also reinforced some existing inequities. So, you know, recognizing that, you know, there is, you know, this MAP benefit, that obviously there's a lot more hoops to jump through with Medicaid.

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Anne Dwyer: Under some of these new requirements, under the reconciliation bill, and increased pressures, the program is still, gonna play a, incredibly important role in providing access to medication. Kima

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Anne Dwyer: I would just love your thoughts on how we can ensure that, whether it be access to appropriate medication or through enrollment and eligibility, that we're reducing some of these disparities.

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Kima Taylor: Yeah, and I think, one, some of that comes from, again, working with communities who've done this before, and what that VIN will mean, they're doing outreach in a more broad way.

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Kima Taylor: I… but the second piece that's really important to me is that when we're having these conversations, we talk about a substance use system, not an opioid use system, right? Because folks need medications for their alcohol, they need medications for their nicotine, they need contingency management, cognitive behavioral therapy, and I have this

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Kima Taylor: one, maybe naive dream that if we start talking about substance use disorder writ large, that's gonna broaden the net of people who can come in, because very few people actually either intentionally or unintentionally only use one drug, right? Either it's mixed in, or they're intentionally using one, so we need an

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Kima Taylor: Substance use system, and we also then need to have, folks coming together and saying, what are the data outputs we want to see? And so what that means is

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Kima Taylor: One, when we talk about benefit packages, we need to talk about medications for substance use disorders. I'm under the impression

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Kima Taylor: maybe not this administration, but FDA is coming out with more, right? We have to pack into… when I say they may cut benefit packages and you want to fight against it, don't go and say, I just want buprenorphine, methadone. Say, we want to have

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Kima Taylor: Medications for Substance Use Disorder Services. We want to make sure the full aspects of counseling are available for people with behavioral… I would say behavioral health, because I think mental health should be in there, too. Behavioral health services, right? But making it broader in a way

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Kima Taylor: that you are not narrowing it, one, to people who just have access to insurance, that are for the whole, making sure it's full group. And the last piece I'll say, and I think this is going to become particularly important, not just in rural settings, but other settings, but really thinking about those telehealth

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Kima Taylor: reimbursements and making sure they stay in place. Because you're not going to have access to buprenorphine if you don't have provider… if, you know, because of these cuts, there's no more rural hospital or provider scenario.

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Kima Taylor: Which we haven't got into, but unfortunately is real. So how does telehealth play into having, and how do we reinforce the current telehealth regs that we have that will allow for access to medications

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Kima Taylor: for Substance Use Disorder, regardless of where you live, and it also can expand access to culturing logistically effective services when that happens. And so it's like thinking, how do people get care?

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Kima Taylor: And educating, and again, we said no one group can do everything. Silvana's drowning, right? So when the health folks go in and are… and, you know, the other health advocates who are primary care advocates, maybe, maybe their primary care association are like, we're gonna go in and preserve the benefits that currently exist. It's like, this is what we need for substance use services. And if… and if you have questions while you're in there, like, text me, here's my text number. Like, being available in these particular times

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Kima Taylor: to make sure our community is being served. And then the last and most important is you have to collect the data to see if it's effective.

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Kima Taylor: You have to make sure you are serving everyone to the left and to the right. And if you're not serving them, it doesn't mean you cut the money, which is what we always seem to do. It's you sit people down and say, how are we going to do it better? It's like one of those rapid cycles, right? It's like we are completely missing

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Kima Taylor: Black women who are unhoused. All right, we need to think of who we need to partner with so we can do it better. Don't cut the money for everyone. That makes no sense.

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Kima Taylor: And so that data piece is tricky in this day and age, as we said, but we really do need it. And I think that's a place where.

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Kima Taylor: if we could have, I don't know if there's any out there, but private funders who can allow for people to have a little more privacy to take over where government is not doing some of this data collection, to not only assess for now, but for the future for what we want to see.

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Anne Dwyer: Thank you, Kima. You know, addressing those inequities, I think, is… needs to continue to be a fundamental part of the conversation, even as we all kind of face these broader threats.

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Anne Dwyer: Before I jump to the Q&A, and I would, you know, as part of that, given the questions, we'd love to kind of unpack, with you all a little bit more. I know we've kind of talked generally, but kind of

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Anne Dwyer: how the financing pressures of the changes under HR1 will impact individuals on the ground. But before we jump into that, I would just love to get ahead of one thing that sometimes pops up, and this is for you, Kay.

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Anne Dwyer: So sometimes we see folks be like, well, we have these pots of money, right? We have this Rural Health Transformation Fund that was $50 billion in H.R. 1. We have the opioid settlement money, we have these now EPSCT settlements. You know, most recent, we have now some of these social media settlements.

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Anne Dwyer: Can you just… and look, these pots of money are important. We should make sure that they're supporting the people that need to be supported, and they're going to the right places and right causes.

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Anne Dwyer: at the same time, I think when you're just relying on, kind of, pots of money, it can be some potentially,

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Anne Dwyer: create some trouble down the road. Can you talk a little bit about why maybe that thinking of relying… that thinking those programs will make up for the cuts is kind of flawed thinking?

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Kay Johnson: Yes, absolutely. Well, first of all, even something like the Rural Health Transformation, while it sounds like a lot of money, it's about a tenth of what many may lose in terms of Medicaid-insured individuals coming into services. The second is that it sort of gives you that… it puts you back in the zero-sum game.

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Kay Johnson: there's this much money, and a whole bunch of people are going to fight for it, and programs are going to have to write grant applications, and if you live in this community, you might get it. If you live in that community, that might not be a priority community for your state. And the state politics enters into all of that, so what does your legislature and your administrative agency think

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Kay Johnson: are the risky communities, or the important communities, or the communities where they need legislators to vote for other things. So, it's very different than having an entitlement

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Kay Johnson: with health coverage for a broad array of benefits that includes behavioral health parity. It's a completely different ballgame. I think the other is really looking at how there's giving with the right hand and taking with the left. I just did the wrong hands, but maybe that looked right on screen. Giving with the right hand and taking with the left.

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Kay Johnson: Because, I mean, if you think of it, you know, so giving the little bit of rural health money because, frankly, they needed some votes from rural members of Congress who were putting pressure on rural, because the rural hospitals were putting pressure on the members of Congress.

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Kay Johnson: But, again, that doesn't create an equal distribution, but then, okay, so how many kinds of CDC grants are not getting out the door?

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Kay Johnson: How many kinds of HRSA grants are not getting out the door?

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Kay Johnson: where's the Head Start money gonna go? You know, where's the, you know, community health centers, FQHCs lost their big boost in funding. Their money's all gonna be suppressed, so grant funding is…

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Kay Johnson: Notoriously unreliable, it comes and goes, it's subject to politics, and it is never, ever a good substitute for individual coverage entitlement.

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Kay Johnson: It is a very good tool for creating infrastructure, for doing evaluations, for building capacity in the workforce, so it's not a substitute, it's an and or.

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Anne Dwyer: Thanks so much. With that, I think we'll move to, as I mentioned, some of the Q&A. So, I think two around the same themes. I'd love to touch on the first one, and then ask Silvana for kind of her thoughts on the second question. But the first question is really around looking at HR1,

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Anne Dwyer: you know, the reality is, it's, you know, over $900 billion in cuts to federal Medicaid support to states over the next 10 years, and that's just on the federal side. We know it's a state-federal program with the match that was mentioned.

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Anne Dwyer: You know, RAND has done a report kind of looking at the impact on different states. Medicaid expansion states are going to see some of the largest cuts.

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Anne Dwyer: States that, rely on different financing mechanisms that were impacted by H.R. 1 are going to see some of the biggest cuts. But would love for, you know, Kay and Kima for you to opine just

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Anne Dwyer: what are the types of policy choices that states are going to be left with in terms of trying to manage, some of these cuts? And maybe, Kima, I'll kick it to you first.

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Kima Taylor: Yeah, it's gonna be… bloody. First, I would like to say… bias, but please save the postpartum money. And I think, like, right, anything that was ever possibly optional

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Kima Taylor: is going to be under target. So, and I don't mean just in healthcare, I mean K-12 education is being cut, and I am a K-12 advocate, because I have kids in school, and we are vicious.

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Kima Taylor: Right? It's a warm, fuzzy… and so… and, like, K-12 education, you can see right now, healthcare, often you're healthy until you're not, so people see it a little differently. They're gonna have to decide, does the money go here or there? When I have my healthcare pot, which aspects of Medicaid, which are those wraparound services? Oh, Medicaid started covering doulas. Are we still going to do that?

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Kima Taylor: And this is really important when they say, are we still going to cover them? They may say they're covering them, but only give them $2, and you're not still really covering them, right? I think it's important to look at those provider payments, because if you effectively are too low, you are not going to have any providers.

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Kima Taylor: And so it looks like a pretty facade, but people are still at risk. But then there's SNAP funding. There's all of these different… and nobody wants to raise taxes.

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Kima Taylor: So there's gonna be all of these different shifts.

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Kima Taylor: That are often based on the last person that administrator or policymaker talked to. I do want to just flag, before going to Kay, a lot of times we focus on the legislature. I think this is one of those places where you look at what the state administration is doing, what all those officials are doing that you don't really pay attention to, because they break

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Kima Taylor: power for making these changes, great tower for MCO contracting for all these people, and those are really big leverage points that we could be, influencing. Fantastic day.

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Kay Johnson: So, we have several really great slides that we've been using around this. We didn't happen to use any today, but it's this tearing down. So, if it's…

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Kay Johnson: 10 or 11 people… million people losing Medicaid, and another 10 or 11 million people losing their Affordable Care Act marketplace coverage.

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Kay Johnson: And then we've got, you know, millions of people losing their SNAP, and another 2 million kids losing their school lunch or their other nutrition subsidies. And then the child tax credits aren't coming back, and then we've got all these families with immigrant parents, or with immigration concerns, who are losing public benefits, who are losing

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Kay Johnson: Medicaid, even though lawfully present, and so on. So, you know, that's the direct cost, that's the direct thing. And then there's that indirect cost of just even if we talk about cutting the trillion dollars out of Medicaid, it's going to be the state and local context, and again, as Kima said, that takes you right into education funding there, and right in direct conflict with it, and and those other programs. So we've got the

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Kay Johnson: all of them, we've got the appropriated programs, as I said, you know, CUS and Head Starts, no more funding

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Kay Johnson: for community health centers, cuts in family planning and education, and so on. And this trickle-down effect, you know, the potential for more… more maternal deaths, more vaccine-preventable diseases, more substance use and mental health concerns, more families going unhoused, and unfed.

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Kay Johnson: You know, it's just all really, as I say, rolling downhill. The choices that states have to make are in some ways impossible and untenable for this amount of money.

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Kay Johnson: And there's a question about this, and I think it's… it's really important to say it isn't just that the feds are taking money, they're…

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Kay Johnson: causing people to be disenrolled, to become uninsured, in two massive pieces of the program, the marketplace and Medicaid.

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Kay Johnson: And then the states are left with making those choices. So whether, as Kima says, they cut benefits, they cut eligibility, 1 in 5 kids is in an optional category, the postpartum women, a lot of the pregnant women are in an optional category. Or then they decide, oh, you know, these other people, well, they don't need any dental care. These people, they don't need any SCT.

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Kay Johnson: It's just the opportunities for states

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Kay Johnson: are all bad, I guess. They're not really opportunities, the dilemmas and challenges before them of what the decisions that they have to make. Or maybe they pay the providers less, and we just lose access generally there. I don't know, it's a… that's, like, kind of my usual speech about that question.

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Anne Dwyer: Yeah, and you know, one impact to your point, Kay, about, you know, there's impacts in Medicaid coverage and marketplace coverage. You know, one commenter in the Q&A kind of talks about the intersection with

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Anne Dwyer: Increased medical bills, collections, bankruptcy, and whether someone's gonna, you know, go and seek health coverage, even when they need it, if they're afraid of, you know, the financial impact.

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Anne Dwyer: Silvana, I would love, kind of, your input here. I mean, you know, have you… how have you seen, whether it's your patients or other clinics you work with, and their patients, how…

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Anne Dwyer: how have their behaviors changed or not changed based on their… whether or not they have coverage and their ability to pay? And sometimes this is an education thing where, you know, maybe they even have access to services even without coverage, but they just assume they don't because they don't have coverage, right? And so there's that dynamic as well, but would love for you to kind of weigh in on your experience there.

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Silvana Mazzella: Well, I think, I think, you know.

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Silvana Mazzella: We are right now not seeing, you know, the big onslaught, but every day, every month, we have people who…

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Silvana Mazzella: It could be they switched MCO, right? We helped them switch for a different benefit, and unfortunately, that benefit now doesn't take place for X weeks. They've already filled a medication, right? So…

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Silvana Mazzella: Again, you know, I think the…

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Silvana Mazzella: what smaller clinics, smaller substance use treatment facilities, mental health agencies, CBOs end up doing is filling in the gap there, right? Doing additional work, with pharmacies and additional advocacy. And so.

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Silvana Mazzella: you know, you take what happens with a small number of people every month in one facility, and you multiply it by a hundred. And…

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Silvana Mazzella: And that is for… for… Patients, constituents lucky enough to have those additional services, whether they're funded or not?

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Silvana Mazzella: So I think that's… that's what we can expect. I think the other, thing on the heels of the previous discussion

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Silvana Mazzella: is not only the impact to states, but the impact to cities, right? So we've talked about the impact to individuals themselves, to those serving individuals, and what states, the bad and worse choices that we'll have to make

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Silvana Mazzella: But we have multiple cities that stand to see lots of people lose their roles.

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Silvana Mazzella: And they are going to have to, and are already making really tough choices and moving money around to try to figure out how to mitigate

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Silvana Mazzella: damage, and I think we're going to see,

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Silvana Mazzella: Lots of people enter more safety net programs that will be faced with, what do I do now? Do I still provide care?

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Silvana Mazzella: How creative and innovative can I get?

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Silvana Mazzella: Or do I not provide care? And a lot of people will not seek care, right? So some people will seek care in droves at safety net providers, and others will not seek care. Others will not…

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Silvana Mazzella: Go to a medical facility or an emergency room when they are sick.

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Silvana Mazzella: Because they don't know what's going to happen, with their benefits.

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Silvana Mazzella: people will not seek substance use treatment because they won't know what will happen, or they've been told they're going to lose benefits if they don't have that advocacy piece, right? I think the backdrop to this, just to echo the previous discussion on education.

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Silvana Mazzella: Is that there's so much information out there, and yet not enough very specific information that we can, you know, easily package without doing a lot of work to help people stay on.

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Anne Dwyer: That's great, and you know, I know we're reaching the end of our time together. I'm gonna ask you all one last question. It's gonna be for advocates and policymakers.

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Anne Dwyer: who want to do something concrete in the next 6 months, what's one action item you give them? I'm going to go to you, Kay and then Kima and Silvana in a minute, but before I do that, just want to remind folks, we will be posting the recording of this webinar on our Medicaid Connections webpage, along with resources that we mentioned in the chat. So, if you want links to those, again, you can search… go back to that page, and that should be up, I think, by the end

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Anne Dwyer: of the week. So with that, Kay, one thing in the action that advocates or policymakers could take in the next six months.

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Kay Johnson: I want to go back to something Silvana just said, and we've all touched on in this, and that is doing real education about what this means. If you're in a position to do it at the individual level, or at the community organization level, do it there. If you're in a position to educate your state policy makers, do it there. If you're in a position, and all of us should be.

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Kay Johnson: to influence what members of Congress think, do it there. But in some way, learn enough of the basics, and there's plenty of basics for us, and be a translator, be the advocate, be the educator. If every one of us does that.

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Kay Johnson: Some things can be saved.

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Anne Dwyer: Kima.

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Kima Taylor: So, I was gonna say what Kay said, but I'm gonna add on to it and say, and really hook onto that translator, be the educator and translator, but also learn about the other person. So, if you're working with people who do housing work.

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Kima Taylor: Understand where they're coming from, and start building those bonds, because you can do this piece for 6 months, but you could build a movement that can last for a couple of years, and really help support

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Kima Taylor: we often talk about clients, but it's us, right? It's us, our loved ones, the people we love, our communities, our families. And so build those relationships. Find the Silvana where you are, and start building.

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Anne Dwyer: I love highlighting that bright spot, right? Using this as an opportunity to build those relationships and those coalitions, and then using them into the future. All right, last Silvana.

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Silvana Mazzella: I would say you don't have to reinvent the wheel. As was said before, there are lots of documents out there. Some of them are very area-specific, but find some documents, find people.

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Silvana Mazzella: law… health law advocates and others, housing advocates, HIV advocates who have taken this information and packaged it in a way that's understandable.

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Silvana Mazzella: And, this is so overwhelming. We can't do everything but maybe pick 3 things you as an individual, or 3 things your agency, clinic, etc. can do. We're going to give one-on-one and hand it out education. We're going to help people.

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Silvana Mazzella: look up their benefits to see what their eligibility is. We're going to… whatever that other thing is, but… but…

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Silvana Mazzella: Some small, concrete steps, because there are just so many to do.

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Anne Dwyer: Well, this has been an incredible discussion. Thank you so much all for your insights and contributions, and for our audience for your engagement. We look forward to seeing you, next month for our next webinar. Have a great day, everyone.

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Kima Taylor: Bye, guys!