In 2018, the Department of Health and Human Services began inviting state Medicaid reforms to “increase employment and community engagement” among enrollees by requiring work or similar activities as a condition of Medicaid eligibility. As of September 2019, seventeen states have applied for section 1115 Medicaid work requirement waivers, nine of which have been approved (with three currently on hold by federal courts).1 Such programs oblige individuals to complete a specified number of work, job training, job search, or community service hours to maintain Medicaid coverage, with exemptions for pregnant and disabled individuals.
Many work requirement proposals also make exceptions for individuals with substance use disorders (SUD), though this is often conditional on participation in a SUD treatment program.2 Given the high prevalence of SUD within the Medicaid population,3 the availability of SUD treatment may be crucial to maintenance of Medicaid eligibility for individuals in states pursuing work requirements. We sought to quantify the availability of SUD treatment resources in states with and without Medicaid work requirements.
We compared SUD prevalence, all overdose deaths, opioid overdose deaths, and SUD treatment availability across work requirement categories (approved, pending, or no work requirement in the state). Data sources were as follows: work requirement policies (Kaiser Family Foundation,1 National Academy for State Health Policy2); SUD prevalence (National Survey on Drug Use and Health); opioid overdose deaths (CDC WONDER); state population (US Census); SUD treatment facility data, including acceptance of Medicaid payment, offering opioid treatment program, and offering opioid maintenance therapy (OMT) (National Survey of Substance Abuse Treatment Services); number of licensed prescribers with waiver to prescribe buprenorphine for opioid use disorder (Substance Abuse and Mental Health Service Administration [SAMHSA] provider locator). Analyses were conducted at the state level using SAS (version 9.4) in September 2019, with t tests or Wilcoxon tests as appropriate. All data (except work requirement status) pertained to 2017. The study was deemed exempt from approval by the IRB.
Prevalence of SUD was similar across states with and without Medicaid work requirements (Table 1). However, states with approved Medicaid work requirement waivers had a higher burden of both overall and opioid-related overdose deaths, compared with states with pending or no work requirements.
Availability of SUD treatment facilities was similar across work requirement categories, and a majority of facilities accepted Medicaid payment irrespective of work requirement status (Table 2). For opioids, the median proportion of SUD treatment facilities with a formal opioid treatment program or offering OMT was low across all states, though was generally lower among states with work requirements.
Similarly, when scaled by the burden of opioid-related deaths in each state, states with work requirements had lower numbers of treatment facilities offering opioid treatment programs or OMT (Table 2). The median number of clinicians waivered to prescribe buprenorphine was also lower in states with work requirements compared with states without requirements.
We found that states with approved Medicaid work requirements generally have both a higher burden of drug overdose deaths and proportionately fewer treatment resources, compared with states without work requirement waivers. Particularly for opioid use disorder, states with approved or pending work requirements had fewer treatment facilities providing recommended treatments and fewer clinicians waivered to prescribe buprenorphine. Study limitations include limited ability to distinguish between treatment resource availability and true access to care, and known incomplete data on waivered clinicians from SAMHSA.4
Given recent work showing that Medicaid work requirements may disproportionately affect individuals with SUD and other behavioral health disorders,5, 6 states should consider policies that account for the limited availability of SUD treatment to prevent disenrollment and worsening health for individuals with SUD.
The dataset and statistical code used during the current study are available from the corresponding author on request.
Henry J Kaiser Family Foundation. Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State. https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/. Published 2019. Accessed September 19, 2019.
National Academy for State Health Policy. A Snapshot of State Proposals to Implement Medicaid Work Requirements Nationwide. https://nashp.org/state-proposals-for-medicaid-work-and-community-engagement-requirements/. Published 2019. Accessed August 9, 2019.
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Beetham T, Saloner B, Wakeman SE, Gaye M, Barnett ML. Access to office-based buprenorphine treatment in areas with high rates of opioid-related mortality: an audit study. Ann Intern Med. 2019;171(1):1–9. doi:https://doi.org/10.7326/M18-3457
Wen H, Saloner B, Cummings JR. Behavioral and other chronic conditions among adult Medicaid enrollees: implications for work requirements. Health Aff. 2019;38(4):660–667. doi:https://doi.org/10.1377/hlthaff.2018.05059
Tipirneni R, Patel MR, Goold SD, et al. Association of expanded Medicaid coverage with health and job-related outcomes among enrollees with behavioral health disorders. Psychiatr Serv. 2019:appips201900179. doi:https://doi.org/10.1176/appi.ps.201900179
The authors would like to thank Dr. Lewei (Allison) Lin for guidance on usage of the NSSATS and X-waiver databases. No compensation was received for this contribution.
Dr. Tipirneni is supported by a K08 Clinical Scientist Development Award from the National Institute on Aging (1K08AG056591) and by the University of Michigan Grace H. Elta MD Department of Internal Medicine Early Career Endowment Award.
Conflict of Interest
Dr. Tipirneni is on the University of Michigan Institute for Healthcare Policy and Innovation team conducting the evaluation required by the Centers for Medicare and Medicaid Services (CMS) of the Healthy Michigan Plan (HMP) under contract with the Michigan Department of Health and Human Services (MDHHS). The current work was not conducted as part of this evaluation.
The views expressed in this paper are those of the authors and do not represent the official views of CMS or MDHHS. The funders supporting the work of Dr. Tipirneni had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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Christine, P.J., Tipirneni, R. Substance Use Disorder Treatment Availability Among States Considering Medicaid Work Requirements. J GEN INTERN MED 35, 2234–2236 (2020). https://doi.org/10.1007/s11606-019-05623-1