Opioid Bill Contains Victories for Medicaid – as the Administration Undermines Medicaid Access

  

This week the Senate passed a landmark piece of legislation, the SUPPORT for Patients and Communities Act, that aims to curb the nation’s ongoing opioid-use disorder crisis. The legislation includes a critical provision that enables nurse practitioners and physician assistants to prescribe buprenorphine permanently – once they obtain a waiver required by any provider to prescribe medication-assisted treatment (MAT) – and expands MAT prescribing authority for five years to other advanced practice registered nurse (APRN) specialties: certified nurse-midwives, clinical nurse specialists and certified registered nurse anesthetists.

Medicaid Provisions in the SUPPORT for Patients and Communities Act

The bill also includes several critical Medicaid provisions aimed at treating individuals who suffer from an opioid-use disorder and preventing others from developing an opioid-use disorder. Taken together, these provisions will significantly increase access to opioid-use disorder treatment and counseling services for some of the nation’s most vulnerable populations and will decrease the rate of new opioid-use disorders.

These provisions include:

  • A temporary suspension (from Fiscal Year 2020 through FY 2023) of the Medicaid institution for mental disease (IMD) exclusion for short-term stays (less than 30 days per year) and the codification of regulations that allow managed care organizations to receive federal funding for patients who are in an IMD for 15 days or less per month (current law does not allow federal payment for patient stays in IMD facilities with greater than 16 beds);
  • A requirement for states to cover MAT, including methadone and counseling services, for opioid-use disorders from FY 2021 through FY 2025;
  • A provision that allows states to cover care for infants with neonatal abstinence syndrome at a residential pediatric recovery center and an extension of enhanced federal match provided under Medicaid for health home services to treat individuals with substance use disorders;
  • A requirement for state Medicaid programs to not terminate coverage for juvenile inmates under the age of 21 while they are incarcerated and an extension of Medicaid coverage for former foster youths ages 18 to 26 who move states, and;
  • A requirement for states to comply with drug review and use requirements as a condition of receiving federal Medicaid funding and a provision that allows state Medicaid programs access to state prescription drug monitoring programs.

Trump Administration Approval of Medicaid Work Requirements

It is ironic, then, that as the SUPPORT for Patients and Communities Act heads to President Trump’s desk, his administration is actively taking steps that will create barriers for Medicaid beneficiaries to remain covered under the program. CMS Administrator Seema Verma recently defended the administration’s policy of approving Medicaid waivers for demonstration projects that impose work requirements on certain Medicaid populations (i.e., the Medicaid expansion population of low-income, childless adults).

CMS recently faced criticism after 4,300 Arkansans lost Medicaid coverage in September as a result of not meeting the state’s new work requirements; this is the first time in the Medicaid program’s 53-year history that beneficiaries have lost coverage for not meeting work requirements. The administration has approved work requirements for Indiana and New Hampshire, and waivers to impose work requirements are pending in South Dakota, Kansas, Mississippi, Ohio, Maine, Utah and Arizona. Kentucky’s work requirements waiver was struck down in federal court in July, though the administration is currently working with Kentucky to revise implement those requirements nonetheless.

Studies show that work requirements for Medicaid beneficiaries have little to no impact on employment and, as demonstrated in Arkansas, result in coverage losses. According to a December 2017 Kaiser Family Foundation issue brief, roughly 6 in 10 of the 22 million non-disabled adults receiving Medicaid benefits are employed either full- or part-time, while 8 in 10 of these adults live in a working family. Most of these individuals work either for small firms or in low-paying industries which do not offer healthcare coverage and thus rely on Medicaid for such. Further, among those adults who are not working, most report a major barrier to employment such as illness, disability, or care-giving duties. According to the same Kaiser issue brief, Medicaid expansion has not negatively impacted labor market participation; in fact, some research demonstrates that Medicaid coverage supports work.

ANA Commends Congress and Urges Its Members to Vote in the Midterms

ANA applauds Congress for its hard work and dedication in passing the SUPPORT for Patients and Communities Act and for recognizing the role that RNs and APRNs play in patient care for those with an opioid-use disorder.

However, ANA firmly believes in universal access to comprehensive and affordable healthcare services for all Americans. The recent moves by both the Trump administration and state governments fly directly in the face of that goal and represent major steps backward in the effort to ensure that all Americans – especially vulnerable populations such as low-income women and those with pre-existing conditions – have access to all necessary healthcare services. These moves also undermine the progress made in Congress with the SUPPORT for Patients and Communities Act.

Healthcare stands to be a major issue in the upcoming 2018 midterm elections – 22 percent of respondents to a June 2018 NBC News/Wall Street Journal poll named healthcare as the most important factor in deciding their vote. These elections are right around the corner and are an incredibly important opportunity for ANA’s members to make their voices heard when it comes to determining the future of healthcare in this country. When nurses vote, lawmakers in Washington, DC, and in statehouses across the country listen. Visit ANA’s #NursesVote Action Center today and help us make this the most meaningful election for nurses yet.

A bump in the road for APRNs and Patients: The Senate Opioid SUD Legislative Package

  

ANA and other associations representing advanced practice registered nurses (APRNs) have been lobbying for years to make permanent the authority for nurse practitioners (NP) to prescribe medication-assisted treatments (MAT) for opioid-addicted patients and to extend the authority to the other three APRN specialties. The latest Senate package does not include this policy. ANA government affairs staff has been informed there are Senators with “holds” on this package meaning it can’t move forward until there are more negotiations. While we are disappointed the package does not currently include this provision, we still have several more bites at the apple.

The Comprehensive Addiction and Recovery Act of 2016 (Public Law No: 114-198.), commonly referred to as CARA, included a provision that allowed NPs and Physician Assistants (PAs) to take 24 hours of training to prescribe MAT for opioid-addicted patients. (This is referred to as “DATA 2000 waved” or just “DATA waved” authority.) This prescribing authority sunsets in 2021. The reason the prescribing authority is set to expire in 2021 was developed as a budgeting gimmick by Congress to keep the overall projected cost associated with CARA low. This provision was never intended to be a demonstration project – it was because Congress couldn’t find a way to offset the projected cost for permanent prescribing authority.

In June, the U.S. House of Representatives passed the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (H.R. 6), or the “SUPPORT for Patients and Communities Act” for short. Section 3003 of this bill has an agreed upon compromise version of what we have been lobbying for. It permanently extends the MAT prescribing authority for NPs and PAs and allows the other three APRN specialties the authority for five years. It also instructs the Department of Health and Human Services to conduct a study on the efficacy of prescribing MAT, and possible associated narcotics diversion issues, on all providers, including physicians. This would give the opportunity to for us to have data showing how important it is to have more access points for patients and that APRNs are just as qualified to treat opioid substance use disorder as physicians.

While this latest development is disappointing, it’s not over. Both the House and the Senate need to come together to pass identical legislation before any of this is signed into law. We have a large coalition of bipartisan legislators in the House and Senate who all agree that this is good policy. The current disagreement is over how to offset the projected cost estimated by the Congressional Budget Office (CBO). The ANA, along with the other associations representing APRNs, are on top of this issue and will be fighting for the inclusion of Section 3003 into any final package. It’s not over.

Further Reading

The CBO’s scoring rules for determining the cost of legislation are very complicated, convoluted, and don’t always make logical sense. The U.S. Drug Enforcement Agency (DEA) isn’t held to CBO’s scoring rules, and in January 2018, published an economic impact study on CARA. They found that from when the DATA 2000 waiver began through February 21, 2017, there were 33,663 DATA-waived physicians compared to 1,247,716 total physicians. Since February 2017, when NPs could first obtain the DATA 2000 waiver until May 5, 2018, 5,649 NPs have obtained a DATA 2000 waiver compared to 248,000 total NPs. That means proportionately, in less than two years, NPs have received almost as many waivers as physicians received in 17 years (2.3 percent of NPs v. 2.7 percent of physicians).

The DEA estimates that the total economic burden of the opioid epidemic is $75.7 billion, which amounts to $41,000 per patient. They also estimate that the net economic benefit of authorizing NPs and PAs to provide MAT, primarily due to increased labor productivity and decreased healthcare and legal costs, will be $640-729 million dollars over five years. Based on the DEA’s estimate that 5,235 NPs and PAs would obtain the waiver, this amounts to an average costs savings of approximately $122,254-139,255 for every NP or PA obtaining the waiver.

ANA strongly believes that extending the prescribing authority to the other APRN specialties will only further the success of this policy. ANA advocates for all RNs and APRNs to practice to the full extent of their education and practice authority, allowing individualized treatment plans for all patients and increased access to health care services, including MAT.

For additional information or comments, please contact Sam Hewitt, ANA’s senior associate director for federal government relations at Samuel.hewitt@ana.org

Looking at Congress to help fight the opioid epidemic

  

Last week, Senator Claire McCaskill’s (D-Mo) office released a report finding that over the last six years, enough opioids were shipped into the state of Missouri to give every resident 260 pills. While that is a snapshot of just one state, combine that news with the latest report from the Centers for Disease Control and Prevention (CDC) that the number of overdose deaths involving fentanyl and similar drugs nearly doubled between the last half of 2016 and the first half of 2017, and it becomes clear that the opioid crisis is still destroying the lives of individuals, families, and communities in epic proportions.

These reports follow a new CDC alert to public health and health care professionals about the increased availability of illicit synthetic opioids, the second update to the health advisory since October 2015. As the crisis continues to transform, health care providers, government agencies and Congress are also changing their tactics to fight this epidemic.

Over the past few weeks of extensive negotiations, the House of Representatives wrapped up multiple proposed opioid crisis bills into one large package, the SUPPORT for Patients and Communities Act (H.R. 6). This iteration of the bill would grant Nurse Practitioners and Physician Assistants permanent authority to prescribe Medication-Assisted Treatment (MAT) while the other three Advanced Practice Registered Nurse (APRN) professions (Certified Nurse-Midwives, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists) would have authorization for five years. The SUPPORT for Patients and Communities Act would also require a study of the efficacy of providing MAT by all providers, including physicians. H.R. 6 will now move to the Senate where there has been concern over the CBO estimated cost of $395 million over a 10-year period. Given the important role that treatment has in solving this epidemic, ANA does not believe this cost should impede the passing of this bill and increase access to life saving treatment to those suffering from substance use disorders.

Medication-Assisted Treatment has been shown to be the most effective form of treatment for opioid use disorders. The National Institute on Drug Abuse states that combined with behavioral therapy, effective MAT programs for opioid addiction decrease overdose deaths resulting in cost savings, reduce transmissions of HIV and hepatitis C related to IV drug use, and mitigate associated criminal activity. Along with APRNs providing MAT services, all nurses with their roles as direct care givers, care coordinators, educators, and patient advocates play a pivotal role in solving this crisis by helping patients and their families understand the risks and benefits of pain treatment options.

ANA will continue to work with Congress, federal agencies, and our partners in the Nursing Community to fight to expand the nurse’s role in solving the opioid crisis. We urge everyone to now call their Senators in support of Senate bill S.2317 (Addiction Treatment Access Improvement Act of 2018) and ensure that they include it in any opioid package that is passed.