State Medicaid Agencies’ Multi-Faceted Response to the Opioid Epidemic

Abstract

Context: Medicaid is the primary payer for substance use disorder (SUD) treatment in the United States. While some policy changes have been well documented, the operational decisions that guide the implementation of these policies have received insufficient attention. The objective of this analysis is to describe the roles that Medicaid programs have taken to address the opioid epidemic and their policy and operational decisions. Methods: We conducted 27 key informant interviews with state agency representatives in 9 states, all of which have been substantially impacted by the opioid epidemic. We focused our interviews on 3 distinct state roles: Regulator, Monitor, and Enforcer; Payer and Contractor; and Collaborator, Evaluator, and Educator. Within those roles, we aimed to synthesize the degree of variation of the policies implemented across these states from 2014-2019, given the breadth of policy levers available to them. Interviews were recorded and transcribed, responses were summarized categorically where possible, and the transcripts were reviewed to identify areas of variation. Findings: We observed substantial convergence in the policies and actions taken by states. All 9 states relaxed or eliminated utilization management policies, such as prior authorization of medications for opioid use disorder, that may be a barrier to access. Most states expanded SUD treatment coverage to align with the American Society of Addiction Medicine continuum of care. As collaborators, Medicaid programs participated in interagency efforts such as opioid task forces, including various levels of data-sharing between agencies. Interviewees discussed ongoing evaluative activities; however, OUD treatment quality measurement remains an area in need of development to support state policymakers.