Tag: medicaid

Contingency Management: An Effective Framework for Treating Stimulant Use Disorder and Opportunities for State Medicaid Coverage

Between 2003 and 2022, drug overdose deaths in the United States drastically increased by 366%. The major culprit for the increase in narcotic-related mortality were opioids, a class of drugs including heroin, fentanyl, and oxycodone. In recent years, because of more effective treatment options and the availability of opioid overdose-reversal drugs such as Narcan, opioid overdose deaths have started to decline, including a 24% decrease between 2023 and 2024. This decline represents 27,000 fewer overdose deaths.

In recent years, however, stimulant overdose deaths have started to increase even as opioid overdoses flatlined and started to decline. Stimulants chiefly include cocaine and methamphetamine. Cocaine overdose deaths per 100,000 people increased by 661% between 2010 and 2023, while overdose deaths of psychostimulants (which include methamphetamine),increased by 1,325% per 100,000 people between 2008 and 2023. Treatment for individuals with stimulant use disorder is much more limited than for individuals with opioid use disorder. For example, there is no FDA-approved overdose reversal treatment for stimulants, in contrast to Narcan for opioid overdoses. At this time, there are zero FDA-approved pharmaceutical drugs on the market to treat stimulant use disorder.

Currently, one of the most effective treatments for individuals with stimulant use disorder is contingency management. Contingency management is a treatment that uses incentives (frequently financial) to assist people with stimulant use disorder by paying them for remaining abstinent and for adhering to medication or treatment regimens.

While contingency management trials were historically underfunded, these programs are still effective. For example, contingency management programs operated by the Department of Veterans Affairs showed strongly positive results in helping veterans with stimulant use disorder cease substance use and to stay connected to other treatment resources.

While contingency management programs have a robust history of coverage for veterans, they do not for Medicaid members. Medicaid, the joint federal and state public insurance program that predominantly covers low-income and disabled Americans, provides coverage to roughly one-quarter of Americans. However in 2020, Medicaid members constituted 48% of overdose deaths. In 2019,1.7% of Medicaid members had a diagnosis of substance use disorder, representing millions of Americans.

Section 1115 of the Social Security Act allows states to innovate within their state’s Medicaid program, subject to agreement with the federal government and meeting certain budgetary and programmatic requirements. In 2021, the federal Centers for Medicare and Medicaid Services (CMS)approved the first state 1115 Waiver Demonstration with a contingency management program. Currently, CMS has approved five Medicaid contingency management programs in California, Delaware, Hawaii, Montana, and Washington. Two other states, Michigan and Rhode Island, have submitted applications to CMS for authority to implement these programs in their states but are awaiting CMS action.

Programmatically, the five Medicaid contingency management demonstrations differ in scope. For eligible Medicaid members, members can receive contingency management financial incentives for as short as 12 weeks (Montana) to 24 weeks. Delaware extends contingency management services to pregnant and postpartum members with certain types of substance use disorder for as long as 64 weeks. The financial incentives differ from state to state, with members avoiding substance use eligible between $596 and $1,092 in financial incentives over the course of a member’s enrollment in a contingency management program.

While many Medicaid contingency management programs are in their infancy, initial results are available from California’s first-in-the-nation program. The Interim Evaluation Report from California’s 1115 Waiver Demonstration describes an enrollment of 8,500 members across 100 sites. Among members enrolled, there was a higher retention in other drug treatment programs, improved access to care, reduced emergency department visits, and a reduction in overdose deaths. Results were mixed regarding health equity goals and in reducing hospital readmissions among enrolled members.

While more data is needed, early indicators are that Medicaid coverage for contingency management programs will help to reduce overdose deaths and provide more effective treatment for Medicaid members with stimulant use disorder.

HHS Probe Into States’ Medicaid Coverage of Abortion Care: Will Abortion Care Policies Truly be Left up to the States in the Wake of Dobbs?

In 2022, the Supreme Court, in Dobbs v. Jackson Women’s Health Organization overturned Roe v. Wade, holding that abortion care is not a fundamental right under the Constitution. Therefore, access to abortion care is now left up to the states. However, the Trump Administration has also signaled that the current United States Department of Health and Human Services’ (HHS) priorities must protect the right of religious exercise and has expressed a goal to reevaluate programs to ensure enforcement of the Hyde Amendment, which prevents federal funds from being used for elective abortions. The Administration’s statements have created questions about whether future abortion care policies will actually be left to the states. 

On March 19, 2025, HHS’s Office of Civil Rights announced that it plans to investigate thirteen states, including California, Colorado, Illinois, Maine, Minnesota, New York, Maryland, and Massachusetts, for allegedly compelling health care providers to provide abortion care. While the full list of the states under investigation has not been released, the states included are those that mandate state-regulated health insurance plans to cover abortion care. The actions are being taken under the Weldon Amendment that prohibits states from discriminating against health care providers that refuse to cover abortion. The Biden Administration interpreted the amendment not to apply to healthcare sponsors, but this administration believes that interpretation is too limited. While the Trump Administration had previously rescinded civil rights guidance issued by the Biden Administration that largely sought to protect abortion access, this investigation has escalated efforts to limit abortion care. 

Maryland Governor Wes Moore and Massachusetts Governor Maura Healey have publicly responded to the letters they received from HHS and both made clear that their priorities are to continue ensuring access to reproductive health care in their states. While it remains unclear what the outcome of these investigations will be, they indicate a potential threat to states that have decided to continue ensuring access to abortion. Reproductive health care advocates have expressed a concern that this investigation indicates that the Trump Administration does not truly intend to “leave abortion to the states” and that further federal interference with states that have protected abortion access post-Dobbs may be imminent. In addition, concerns have arisen that the investigations do not have weight under law, as they did not arise out of any complaints of the states, and advocates have expressed fear that they have merely arisen to advance the Administration’s political agenda, rather than out of a genuine concern of violation of the law. For citizens, abortion care post-Dobbs has been uncertain, with access largely depending on geography and an increase in travel for abortion access. This investigation indicates the potential that the Trump Administration plans to take action to further limit abortion access, particularly meaning that low-income citizens with less ability to travel may experience further difficulty in access. 

What C.K. v. McDonald Mean for Children’s Mental-Health Access Through Medicaid

In August, it was announced that a landmark settlement agreement, was reached in a New York class action lawsuit against the New York State Department of Health (NYSDOH) and the New York State Office of Mental Health (NYOMH). This settlement follows settlements of similar cases in Michigan and Iowa, showing a movement towards systemic change for youth mental health and children’s advocacy. In C.K. v. McDonald, filed in 2022 by children and disability rights groups on behalf of four children in the U.S. District Court for the Eastern District of New York, the plaintiffs alleged that federal law requires mental health services be made available and provided through a state’s Medicaid program, yet, New York State’s services were “inadequate, inaccessible, and dysfunctional.” The plaintiffs primarily alleged that New York systematically denied Medicaid-enrolled youth access to community-based mental health care, which violated their federal rights and left them at risk of institutionalization and long-term harms. The complaint highlighted that the failure of NYSDOH and NYOMH disproportionately effect youth from low-income households and children of color.

Specifically, the plaintiffs cited a number of federal requirements that New York state was not adhering to, including the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) provision, which requires that Medicaid beneficiaries under 21 receive a number of medical services, including mental health care. The plaintiffs also brought claims under Title II of the Americans with Disabilities Act (ADA), which, under 28 C.F.R. § 35.130, prohibits discrimination or exclusion of qualified individuals from participation in services of a public entity by reason of disability.  The plaintiffs noted that 29 U.S.C. § 794 maintains identical requirements for any program or activity that receives Federal funding. Finally, the plaintiffs cited to Olmstead v. L.C., where the Supreme Court held that the ADA requires states to “provide community-based treatment for persons with mental disabilities.”

 The settlement agreement outlines an 18-month plan of action that the State must implement to improve mental health services for children. The plan establishes that agencies must provide intensive care coordination, in-home behavioral health services, and crisis response planning that does not rely on police. Additionally, the settlement establishes that the State must increase Medicaid reimbursements and institute annual quality audits of these services. The State will also initiate screening and assessment for children who are eligible for services and ensure that an expert is hired in tracking New York’s progress in meeting the agreements of the settlement.

While the settlement is awaiting the court’s final approval, the case outcome demonstrates progression towards improvements in mental health care for the 2.5 million children under 18 who are enrolled in New York’s Medicaid. This step addresses a major gap in care for some of the State’s most vulnerable residents, who so often have to rely on hospitals and residential facilities for care rather than in-home and communal services, which can be extremely distressing and traumatizing. Beyond New York, this case represents  systemic challenges that have been prevalent throughout the country for decades. The New York case, as well as the Michigan and Iowa cases, reinforce a legal precedent that States must be held accountable for providing meaningful, community-based mental health services that are non-discriminatory for Medicaid-eligible and enrolled children. Given the threats to Medicaid funding and massive financial cuts at the Federal level, it is more important than ever that Medicaid funds be spent on proven and effective services.

How the NFIB v. Sebelius Ruling Will Increase the Amount of Uninsured under the ACA

In a March 2012 report, the Congressional Budget Office (CBO) estimated that by 2022, the Patient Protection and Affordable Care Act (ACA) would reduce the number of nonelderly people without health insurance by 33 million, leaving another 27 million still uninsured.  A significant part of that 33 million included the 17 million more people the CBO estimated to qualify for Medicaid by 2022 under the ACA.  They had not previously qualified because the ACA increased the eligible income to those making up to 138% of the Federal Poverty Level.  This increase in eligibility would have been implemented by making all federal Medicaid dollars given to the states contingent on states increasing the pool of eligible individuals.

On June 28th, the Supreme Court ruled in National Federation of Independent Business v. Sebelius, however, that the federal government could not withhold current levels of Medicaid funding to force the Medicaid expansion.  Instead, it could only withhold the additional funds it planned to give out, making the Medicaid expansion optional state-by-state.

Based on the Sebelius ruling, the CBO reworked its estimates in a July 2012 report that concluded, because of the Supreme Court ruling, six million fewer people would qualify for Medicaid than previously estimated. Of those six million, however, an additional three million would qualify for the new exchanges.  Therefore, the net loss of insured people thanks to the Supreme Court ruling was three million.  In updating their numbers, the CBO did not attempt to guess which states would or would not expand their Medicaid program, but attempted to “reflect an assessment of the probabilities of different outcomes…and are, in their judgment, in the middle of the distribution of possible outcomes.”

These figures are being discussed again because of a June 2013 study by HealthAffairs, which did attempt to guess state-by-state who would be expanding their Medicaid programs and its affect on the uninsured.  They note that, after the Supreme Court decision, 14 states had announced their intent to opt-out of the expansion, six were undecided, three were leaning against the expansion, and two were leaning toward the expansion.  They found that if all currently undecided states opted in, 29.8 million people would remain uninsured by 2016 (compared to 26 million people uninsured according to the CBO by the same year).  That number would rise to 31 million if all of the undecided states opted out.  They also note that around 80% of those uninsured would be US citizens, and no matter which way the undecided states go, 4.3 million children and 1 million veterans would likely remain uninsured.

As of a September 17, 2013 a report by the Advisory Board Company found that the number of undecided and not participating states had increased. They found 15 (up from 14) states firm in opting out of expansion, seven (three) leaning against expansion, five (six) undecided or exploring an alternative model, four (two) leaning towards expansion, and overall 20 (25) firmly participating.  Therefore, the percentage of states that could be opting out has increased from 34-46% to 44-54% of states.  This will in turn increase the number of uninsured people.  As the merits of the ACA continue to be debated on Capitol Hill in light of the budget debate, and more states become firm in their plans to opt-in or opt-out of the Medicaid expansion, the number of those who are ultimately uninsured could rise and continue to undermine the goal of universal health care.