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Silverman AF, Westlake MA, Hinds OM, Harris SJ, Abraham AJ, Grogan CM, Andrews CM. Substance use disorder treatment carve outs in Medicaid managed care. J Subst Use Addict Treat 2024; 161:209357. [PMID: 38554998 PMCID: PMC11090713 DOI: 10.1016/j.josat.2024.209357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 02/19/2024] [Accepted: 03/18/2024] [Indexed: 04/02/2024]
Abstract
INTRODUCTION Medicaid managed care organizations (MCO) play a major role in addressing the nation's epidemic of drug overdose and mortality by administering substance use disorder (SUD) treatment benefits for over 50 million Americans. While it is known that some Medicaid MCO plans delegate responsibility for managing SUD treatment benefits to an outside "carve out" entity, the extent and structure of such carve out arrangements are unknown. This is an important gap in knowledge, given that carve outs have been linked to reductions in rates of SUD treatment receipt in several studies. To address this gap, we examined carve out arrangements used by Medicaid MCO plans to administer SUD treatment benefits in ten states. METHODS Data for this study was gleaned using a purposive sampling approach through content analysis of publicly available benefits information (e.g., member handbooks, provider manuals, prescription drug formularies) from 70 comprehensive Medicaid MCO plans in 10 selected states (FL, GA, IL, MD, MI, NH, OH, PA, UT, and WV) active in 2018. Each Medicaid MCO plan's documents were reviewed and coded to indicate whether a range of SUD treatment services (e.g., inpatient treatment, outpatient treatment, residential treatment) and medications were carved out, and if so, to what type of entity (e.g., behavioral health organization). RESULTS A large majority of Medicaid MCO plans carved out at least some (28.6 %) or all (40.0 %) SUD treatment services, with nearly all plans carving out some (77.1 %) or all (14.3 %) medications, mainly due to the carving out of methadone treatment. Medicaid MCO plans most commonly carved out SUD treatment services to behavioral health organizations, while most medications were carved out to state Medicaid fee-for-service plans. CONCLUSIONS Carve out arrangements for SUD treatment vary dramatically across states, across plans, and even within plans. Given that some studies have linked carve out arrangements to reductions in treatment access, their widespread use among Medicaid MCO plans is cause for further consideration by policymakers and other key interest groups. Moreover, reliance on such complex arrangements for administering care may create challenges for enrollees who seek to learn about and access plan benefits.
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Affiliation(s)
- Allie F Silverman
- Heller School for Social Policy and Management, Brandeis University, Schneider Building, 415 South Street, Waltham, MA 02453, United States of America.
| | - Melissa A Westlake
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC 29208, United States of America
| | - Olivia M Hinds
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC 29208, United States of America
| | - Samantha J Harris
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD 21205, United States of America
| | - Amanda J Abraham
- School of Public and International Affairs, University of Georgia, Candler Hall, 202 Herty Drive, Athens, GA 30602, United States of America
| | - Colleen M Grogan
- Center for Health Administration Studies, Crown School of Social Work, Policy, and Practice, 969 East 60th Street, Chicago, IL 60637, United States of America
| | - Christina M Andrews
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC 29208, United States of America
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Lewis CD, Andrews C, Abraham AJ, Westlake M, Taxman FS, Grogan CM. State Medicaid Initiatives Targeting Substance Use Disorder in Criminal Legal Settings, 2021. Am J Public Health 2024; 114:527-530. [PMID: 38513172 PMCID: PMC11008297 DOI: 10.2105/ajph.2024.307604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Objectives. To document state Medicaid pre- and postrelease initiatives for individuals in the criminal legal system with substance use disorder (SUD). Methods. An Internet-based survey was sent in 2021 to Medicaid directors in all 50 US states and the District of Columbia to determine whether they were pursuing initiatives for persons with SUD across 3 criminal legal settings: jails, prisons, and community corrections. A 90% response rate was obtained. Results. In 2021, the majority of states did not report any targeted Medicaid initiatives for persons with SUD residing in criminal legal settings. Eighteen states and the District of Columbia adopted at least 1 Medicaid initiative for persons with SUD across the 3 criminal legal settings. The most commonly adopted initiatives were in the areas of medication for opioid use disorder treatment and Medicaid enrollment. Out of 24 possible initiatives for each state (8 initiatives across 3 criminal legal settings), the 2 most commonly adopted were (1) provision of medication treatment of opioid use disorder before release from criminal legal settings (16 states) and (2) facilitation of Medicaid enrollment through suspension rather than termination of Medicaid enrollment upon entry to a criminal legal setting (14 states). Initiatives pertaining to Medicaid SUD care coordination were adopted by the fewest (9) states. Conclusions. In 2021, states' involvement in Medicaid SUD initiatives for criminal legal populations remained low. Increased adoption of Medicaid SUD initiatives across criminal legal settings is needed, especially knowing the high rate of overdose mortality among this group. (Am J Public Health. 2024;114(5):527-530. https://doi.org/10.2105/AJPH.2024.307604).
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Affiliation(s)
- Cashell D Lewis
- Cashell D. Lewis is with Crown Family School of Social Work, Policy, and Practice, University of Chicago, IL. Christina Andrews and Melissa Westlake are with the Department of Health Services Policy and Management at Arnold School of Public Health, University of South Carolina, Columbia. Amanda J. Abraham is with the Department of Public Administration and Policy in the School of Public and International Affairs, University of Georgia, Athens. Faye S. Taxman is with the Schar School of Policy and Government and Center for Advancing Correctional Excellence!, George Mason University, Fairfax, VA. Colleen M. Grogan is with Crown Family School of Social Work, Policy, and Practice and the Center for Health Administration Studies, University of Chicago
| | - Christina Andrews
- Cashell D. Lewis is with Crown Family School of Social Work, Policy, and Practice, University of Chicago, IL. Christina Andrews and Melissa Westlake are with the Department of Health Services Policy and Management at Arnold School of Public Health, University of South Carolina, Columbia. Amanda J. Abraham is with the Department of Public Administration and Policy in the School of Public and International Affairs, University of Georgia, Athens. Faye S. Taxman is with the Schar School of Policy and Government and Center for Advancing Correctional Excellence!, George Mason University, Fairfax, VA. Colleen M. Grogan is with Crown Family School of Social Work, Policy, and Practice and the Center for Health Administration Studies, University of Chicago
| | - Amanda J Abraham
- Cashell D. Lewis is with Crown Family School of Social Work, Policy, and Practice, University of Chicago, IL. Christina Andrews and Melissa Westlake are with the Department of Health Services Policy and Management at Arnold School of Public Health, University of South Carolina, Columbia. Amanda J. Abraham is with the Department of Public Administration and Policy in the School of Public and International Affairs, University of Georgia, Athens. Faye S. Taxman is with the Schar School of Policy and Government and Center for Advancing Correctional Excellence!, George Mason University, Fairfax, VA. Colleen M. Grogan is with Crown Family School of Social Work, Policy, and Practice and the Center for Health Administration Studies, University of Chicago
| | - Melissa Westlake
- Cashell D. Lewis is with Crown Family School of Social Work, Policy, and Practice, University of Chicago, IL. Christina Andrews and Melissa Westlake are with the Department of Health Services Policy and Management at Arnold School of Public Health, University of South Carolina, Columbia. Amanda J. Abraham is with the Department of Public Administration and Policy in the School of Public and International Affairs, University of Georgia, Athens. Faye S. Taxman is with the Schar School of Policy and Government and Center for Advancing Correctional Excellence!, George Mason University, Fairfax, VA. Colleen M. Grogan is with Crown Family School of Social Work, Policy, and Practice and the Center for Health Administration Studies, University of Chicago
| | - Faye S Taxman
- Cashell D. Lewis is with Crown Family School of Social Work, Policy, and Practice, University of Chicago, IL. Christina Andrews and Melissa Westlake are with the Department of Health Services Policy and Management at Arnold School of Public Health, University of South Carolina, Columbia. Amanda J. Abraham is with the Department of Public Administration and Policy in the School of Public and International Affairs, University of Georgia, Athens. Faye S. Taxman is with the Schar School of Policy and Government and Center for Advancing Correctional Excellence!, George Mason University, Fairfax, VA. Colleen M. Grogan is with Crown Family School of Social Work, Policy, and Practice and the Center for Health Administration Studies, University of Chicago
| | - Colleen M Grogan
- Cashell D. Lewis is with Crown Family School of Social Work, Policy, and Practice, University of Chicago, IL. Christina Andrews and Melissa Westlake are with the Department of Health Services Policy and Management at Arnold School of Public Health, University of South Carolina, Columbia. Amanda J. Abraham is with the Department of Public Administration and Policy in the School of Public and International Affairs, University of Georgia, Athens. Faye S. Taxman is with the Schar School of Policy and Government and Center for Advancing Correctional Excellence!, George Mason University, Fairfax, VA. Colleen M. Grogan is with Crown Family School of Social Work, Policy, and Practice and the Center for Health Administration Studies, University of Chicago
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Estrada MAG, Abraham AJ, Andrews CM, Grogan CM. Statewide efforts to address the opioid epidemic: Results from a national survey of single state agencies. J Subst Use Addict Treat 2024; 160:209309. [PMID: 38336265 PMCID: PMC11060908 DOI: 10.1016/j.josat.2024.209309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/11/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Single State Agencies (SSAs) are at the forefront of efforts to address the nation's opioid epidemic, responsible for allocating billions of dollars in federal, state, and local funds to ensure service quality, promote best practices, and expand access to care. Federal expenditures to SSAs have more than tripled since the early years of the epidemic, yet, it is unclear what initiatives SSAs have undertaken to address the crisis and how they are financing these efforts. METHODS This study used data from an internet-based survey of SSAs, conducted by the University of Chicago Survey Lab from January to December 2021 (response rate of 94 %). The survey included a set of 14 items identifying statewide efforts to address the opioid epidemic and six funding sources. We calculated the percentage of SSAs that supported each statewide effort and the percentage of SSAs reporting use of each source of funding across the 14 statewide efforts. RESULTS Treatment of opioid-related overdose figured most prominently among statewide efforts, with all SSAs providing funding for naloxone distribution and all but one SSA supporting naloxone training. Recovery support services, Project ECHO, and Hub and Spoke models were supported by the vast majority of SSAs. Statewide efforts related to expanding access to medications for opioid use disorder (MOUD) received somewhat less support, with 45 % of SSAs supporting mobile methadone/MOUD clinics/programs and 70 % supporting buprenorphine in emergency departments. A relatively low proportion of SSAs (54 %) provided support for syringe services programs. State Opioid Response (SOR) funds were the most common funding source reported by SSAs (57 % of SSAs), followed by block grant funds (19 %) and other state funding (15 %). CONCLUSION Results highlight a range of SSA efforts to address the nation's opioid epidemic. Limited adoption of efforts to expand access to MOUD and harm reduction services may represent missed opportunities. The uncertainty over reauthorization of the SOR grant post-2025 also raises concerns over sustainability of funding for many of these statewide initiatives.
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Affiliation(s)
- Miguel Antonio G Estrada
- Department of Public Administration and Policy, School of Public and International Affairs, University of Georgia, Athens, GA, USA.
| | - Amanda J Abraham
- Department of Public Administration and Policy, School of Public and International Affairs, University of Georgia, Athens, GA, USA
| | - Christina M Andrews
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Colleen M Grogan
- Crown Family School of Social Work, Policy, and Practice, University of Chicago, Chicago, IL, USA
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Bruch JD, Roy V, Grogan CM. The Financialization of Health in the United States. N Engl J Med 2024; 390:178-182. [PMID: 38197821 DOI: 10.1056/nejmms2308188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Affiliation(s)
- Joseph Dov Bruch
- From the Department of Public Health Sciences (J.D.B.) and the Crown Family School of Social Work, Policy, and Practice (C.M.G.), University of Chicago, Chicago; and the Yale National Clinician Scholars Program, Yale University, New Haven, CT (V.R.)
| | - Victor Roy
- From the Department of Public Health Sciences (J.D.B.) and the Crown Family School of Social Work, Policy, and Practice (C.M.G.), University of Chicago, Chicago; and the Yale National Clinician Scholars Program, Yale University, New Haven, CT (V.R.)
| | - Colleen M Grogan
- From the Department of Public Health Sciences (J.D.B.) and the Crown Family School of Social Work, Policy, and Practice (C.M.G.), University of Chicago, Chicago; and the Yale National Clinician Scholars Program, Yale University, New Haven, CT (V.R.)
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Andrews CM, Westlake MA, Abraham AJ, Grogan CM, Harris SJ, Jehan S. Medicaid Managed Care Prior Authorization For Buprenorphine Tied To State Partisanship And Health Plan Profit Status, 2018. Health Aff (Millwood) 2024; 43:55-63. [PMID: 38190595 DOI: 10.1377/hlthaff.2023.00288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Buprenorphine is among the most effective drugs for treating opioid use disorder, yet only a quarter of Americans who need it receive it. Requiring prior authorization has been identified as an important barrier to buprenorphine access. However, the practice remains widespread in Medicaid-the largest insurer of Americans with opioid use disorder. In this study, we examined how prior authorization for buprenorphine is related to plan structure and state political environment, using data on all 266 comprehensive Medicaid managed care plans active in 2018. We found substantial variation in prior authorization use across states, with all plans requiring prior authorization in eleven states and no plans requiring it in thirteen other states. We found that for-profit plans and those located in Republican states were more likely to impose prior authorization policies. Our findings suggest that managed care plans' decisions regarding use of prior authorization may be shaped by internal pressures to control costs, as well as by differing partisan stances regarding the need to prevent criminal diversion of buprenorphine.
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Affiliation(s)
- Christina M Andrews
- Christina M. Andrews , University of South Carolina, Columbia, South Carolina
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Shoulders A, Andrews CM, Westlake MA, Abraham AJ, Grogan CM. Changes in Medicaid Fee-for-Service Benefit Design for Substance Use Disorder Treatment During the Opioid Crisis, 2014 to 2021. JAMA Health Forum 2023; 4:e232502. [PMID: 37566428 PMCID: PMC10422193 DOI: 10.1001/jamahealthforum.2023.2502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/12/2023] [Indexed: 08/12/2023] Open
Abstract
Importance Medicaid is the largest payer of substance use disorder treatment in the US and plays a key role in responding to the opioid epidemic. However, as recently as 2017, many state Medicaid programs still did not cover the full continuum of clinically recommended care. Objective To determine whether state Medicaid fee-for-service (FFS) programs have expanded coverage and loosened restrictions on access to substance use disorder treatment in recent years. Design, Setting, and Participants In 2014, 2017, and 2021, a survey on coverage for substance use disorder treatment was conducted among state Medicaid programs and the District of Columbia with FFS programs. This survey was completed by Medicaid program directors or knowledgeable staff. Data analysis was performed in 2022. Main Outcomes and Measures The following were calculated for a variety of substance use disorder treatment services (individual and group outpatient, intensive outpatient, short-term and long-term residential, recovery support, inpatient treatment and detoxification, and outpatient detoxification) and medications (methadone, oral and injectable naltrexone, and buprenorphine): (1) the percentage of Medicaid FFS programs covering these services and medications and (2) the percentage of Medicaid FFS programs using utilization management policies, such as copayments, prior authorizations, and annual maximums. Results This study had response rates of 92% in 2014 and 2017 (47 of 51 states) and 90% in 2021 (46 of 51 states). For the 2021 wave, data are reported for the 38 non-managed care organization plan-only states. Between 2017 and 2021, coverage of individual and group outpatient treatment increased to 100% of states, and use of annual maximums for medications decreased to 3% or less (n ≤ 1). However, important gaps in coverage persisted, particularly for more intensive services: 10% of Medicaid FFS programs (n = 4) did not cover intensive outpatient treatment, 13% (n = 5) did not cover short-term residential care, and 33% (n = 13) did not cover long-term residential care. Use of utilization controls, such as copays, prior authorizations, and annual maximums, decreased but continued to be widespread. Conclusions and Relevance In this survey study of state Medicaid FFS programs, increases in coverage and decreases in use of utilization management policies over time were observed for substance use disorder treatment and medications. However, these findings suggest that some states still lag behind and impose barriers to treatment. Future research should work to identify the long-term ramifications of these barriers for patients.
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Affiliation(s)
- Angela Shoulders
- Department of Economics, Darla Moore School of Business, University of South Carolina, Columbia
| | - Christina M. Andrews
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia
| | - Melissa A. Westlake
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia
| | - Amanda J. Abraham
- Department of Public Administration and Policy, School of Public and International Affairs, University of Georgia, Athens
| | - Colleen M. Grogan
- Center for Health Administration Studies, Crown School of Social Work, Policy, and Practice, The University of Chicago, Chicago, Illinois
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Andrews CM, Hinds OM, Lozano-Rojas F, Besmann WL, Abraham AJ, Grogan CM, Silverman AF. State Funding For Substance Use Disorder Treatment Declined In The Wake Of Medicaid Expansion. Health Aff (Millwood) 2023; 42:981-990. [PMID: 37406236 DOI: 10.1377/hlthaff.2022.01568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
The US continues to grapple with an escalating epidemic of opioid-related overdose and mortality. State funds, which are the second-largest source of public funding for substance use disorder (SUD) treatment and prevention, play a critically important role in responding to this crisis. Despite their importance, little is known about how these funds are allocated and how they have changed over time, particularly within the context of Medicaid expansion. In this study we assessed trends in state funds during the period 2010-19, using difference-in-differences regression and event history models. Our findings reveal dramatic variation in state funding across states, from a low of $0.61 per capita in Arizona to a high of $51.11 per capita in Wyoming in 2019. Moreover, state funding declined during the period after Medicaid expansion by an average of $9.95 million in expansion states (relative to nonexpansion states), especially in states that expanded eligibility under Republican-controlled legislatures, where it declined by an average of $15.94 million. Medicaid substitution strategies, which, in effect, shift some of the financial burden for financing SUD treatment from the state to the federal level, may erode resources for broader system-level efforts that are urgently needed in the midst of the opioid epidemic.
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Affiliation(s)
- Christina M Andrews
- Christina M. Andrews , University of South Carolina, Columbia, South Carolina
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Harris SJ, Abraham AJ, Lozano-Rojas F, Negaro S, Andrews CM, Grogan CM. Allocation of federal funding to address the opioid crisis in the criminal-legal system. J Subst Use Addict Treat 2023; 150:209064. [PMID: 37156423 DOI: 10.1016/j.josat.2023.209064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/03/2023] [Accepted: 05/01/2023] [Indexed: 05/10/2023]
Abstract
INTRODUCTION The opioid crisis remains a chief public health concern in the United States, and justice-involved populations are among the most vulnerable to opioid related harms. This study aimed to identify all discretionary federal funding allocated to states, cities, and counties targeting the opioid crisis for justice-involved populations in fiscal year (FY) 2019. We then aimed to assess the extent to which federal funding was allocated to states with the highest need. METHODS We collected data from publicly available government databases (N = 22) to identify federal funding targeting opioids in criminal justice-involved populations. Descriptive analyses examined the extent to which funding allocated per person in the justice-involved population was associated with funding need, proxied by a composite measure of opioid mortality and drug-related arrests. We created a generosity measure and dissimilarity index to assess the degree to which funding matched need across states. RESULTS More than 590 million dollars were allocated across 517 grants by 10 federal agencies in FY 2019. About half of states received less than $100.00 dollars per capita in the state corrections population. Funding generosity ranged from 0 % to 504.2 %, with more than half of states (52.9 %, n = 27) receiving fewer dollars per opioid problem than the US average. Further, a dissimilarity index indicated that about 34.2 % of funding (~$202.3 million) would have to be reallocated to distribute funding more evenly across states. CONCLUSIONS Results suggest that additional efforts are needed to more equitably distribute funds to meet the needs of states with more severe opioid problems.
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Affiliation(s)
- Samantha J Harris
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, 306 Hampton House, 624 N Broadway, Baltimore, MD 21205, USA.
| | - Amanda J Abraham
- University of Georgia School of Public and International Affairs, Department of Public Administration and Policy, 280F Baldwin Hall, Athens, GA 30602, USA.
| | - Felipe Lozano-Rojas
- University of Georgia School of Public and International Affairs, Department of Public Administration and Policy, 203B Baldwin Hall, Athens, GA 30602, USA.
| | - Sophia Negaro
- University of South Carolina Arnold School of Public Health, Department of Health Service Policy and Management, 915 Greene Street, Columbia, SC 29208, USA.
| | - Christina M Andrews
- University of South Carolina Arnold School of Public Health, Department of Health Service Policy and Management, 344 Discovery Building, 915 Greene Street, Columbia, SC 29208, USA.
| | - Colleen M Grogan
- University of Chicago Crown Family School of Social Work, Policy, and Practice, 969 E. 60th Street, Chicago, IL 60637, USA.
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Crable EL, Grogan CM, Purtle J, Roesch SC, Aarons GA. Correction: Tailoring dissemination strategies to increase evidence-informed policymaking for opioid use disorder treatment: study protocol. Implement Sci Commun 2023; 4:28. [PMID: 36932418 PMCID: PMC10021924 DOI: 10.1186/s43058-023-00406-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Affiliation(s)
- Erika L Crable
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA. .,Child and Adolescent Services Research Center, San Diego, CA, USA. .,University of California, San Diego Altman Clinical and Translational Research Institute Dissemination and Implementation Science Center, La Jolla, CA, USA.
| | - Colleen M Grogan
- Crown Family School of Social Work, Policy, and Practice, The University of Chicago, Chicago, IL, USA
| | - Jonathan Purtle
- Department of Public Health Policy and Management, New York University School of Global Public Health, New York City, NY, USA.,Global Center for Implementation Science, New York University School of Global Public Health, New York City, NY, USA
| | - Scott C Roesch
- Child and Adolescent Services Research Center, San Diego, CA, USA.,Department of Psychology, San Diego State University, San Diego, CA, USA
| | - Gregory A Aarons
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA.,Child and Adolescent Services Research Center, San Diego, CA, USA.,University of California, San Diego Altman Clinical and Translational Research Institute Dissemination and Implementation Science Center, La Jolla, CA, USA
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Crable EL, Grogan CM, Purtle J, Roesch SC, Aarons GA. Tailoring dissemination strategies to increase evidence-informed policymaking for opioid use disorder treatment: study protocol. Implement Sci Commun 2023; 4:16. [PMID: 36797794 PMCID: PMC9936679 DOI: 10.1186/s43058-023-00396-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/30/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Policy is a powerful tool for systematically altering healthcare access and quality, but the research to policy gap impedes translating evidence-based practices into public policy and limits widespread improvements in service and population health outcomes. The US opioid epidemic disproportionately impacts Medicaid members who rely on publicly funded benefits to access evidence-based treatment including medications for opioid use disorder (MOUD). A myriad of misaligned policies and evidence-use behaviors by policymakers across federal agencies, state Medicaid agencies, and managed care organizations limit coverage of and access to MOUD for Medicaid members. Dissemination strategies that improve policymakers' use of current evidence are critical to improving MOUD benefits and reducing health disparities. However, no research describes key determinants of Medicaid policymakers' evidence use behaviors or preferences, and few studies have examined data-driven approaches to developing dissemination strategies to enhance evidence-informed policymaking. This study aims to identify determinants and intermediaries that influence policymakers' evidence use behaviors, then develop and test data-driven tailored dissemination strategies that promote MOUD coverage in benefit arrays. METHODS Guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework, we will conduct a national survey of state Medicaid agency and managed care organization policymakers to identify determinants and intermediaries that influence how they seek, receive, and use research in their decision-making processes. We will use latent class methods to empirically identify subgroups of agencies with distinct evidence use behaviors. A 10-step dissemination strategy development and specification process will be used to tailor strategies to significant predictors identified for each latent class. Tailored dissemination strategies will be deployed to each class of policymakers and assessed for their acceptability, appropriateness, and feasibility for delivering evidence about MOUD benefit design. DISCUSSION This study will illuminate key determinants and intermediaries that influence policymakers' evidence use behaviors when designing benefits for MOUD. This study will produce a critically needed set of data-driven, tailored policy dissemination strategies. Study results will inform a subsequent multi-site trial measuring the effectiveness of tailored dissemination strategies on MOUD benefit design and implementation. Lessons from dissemination strategy development will inform future research about policymakers' evidence use preferences and offer a replicable process for tailoring dissemination strategies.
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Affiliation(s)
- Erika L Crable
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA. .,Child and Adolescent Services Research Center, San Diego, CA, USA. .,University of California, San Diego Altman Clinical and Translational Research Institute Dissemination and Implementation Science Center, La Jolla, CA, USA.
| | - Colleen M Grogan
- Crown Family School of Social Work, Policy, and Practice, The University of Chicago, Chicago, IL, USA
| | - Jonathan Purtle
- Department of Public Health Policy and Management, New York University School of Global Public Health, New York City, NY, USA.,Global Center for Implementation Science, New York University School of Global Public Health, New York City, NY, USA
| | - Scott C Roesch
- Child and Adolescent Services Research Center, San Diego, CA, USA.,Department of Psychology, San Diego State University, San Diego, CA, USA
| | - Gregory A Aarons
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA.,Child and Adolescent Services Research Center, San Diego, CA, USA.,University of California, San Diego Altman Clinical and Translational Research Institute Dissemination and Implementation Science Center, La Jolla, CA, USA
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Abraham AJ, Andrews CM, Harris SJ, Westlake MM, Grogan CM. Coverage and Prior Authorization Policies for Medications for Opioid Use Disorder in Medicaid Managed Care. JAMA Health Forum 2022; 3:e224001. [PMID: 36331441 PMCID: PMC10157383 DOI: 10.1001/jamahealthforum.2022.4001] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Importance Medicaid is a key policy lever to improve opioid use disorder treatment, covering approximately 40% of Americans with opioid use disorder. Although approximately 70% of Medicaid beneficiaries are enrolled in comprehensive managed care organization (MCO) plans, little is known about coverage and prior authorization (PA) policies for medications for opioid use disorder (MOUD) in these plans. Objective To compare coverage and PA policies for buprenorphine, methadone, and injectable naltrexone across Medicaid MCO plans and fee-for-service (FFS) programs and across states. Design, Setting, and Participants This cross-sectional study analyzed MOUD data from 266 Medicaid MCO plans and FFS programs in 38 states and the District of Columbia in 2018. Main Outcomes and Measures For each medication, the percentages of MCO plans and FFS programs that covered the medication without PA, covered the medication with PA, and did not cover the medication were calculated, as were the percentages of MCO, FFS, and all (MCO and FFS) beneficiaries who were covered with no PA, covered with PA, and not covered. In addition, MCO plan coverage and PA policies were mapped by state. Analyses were conducted from January 1 through May 31, 2022. Results Coverage and PA policies were compared for MOUD in 266 MCO plans and 39 FFS programs, representing approximately 70 million Medicaid beneficiaries. Overall, FFS programs had more generous MOUD coverage than MCO plans. However, a higher percentage of FFS programs imposed PA for the 3 medications (47.0%) than did MCOs (35.9%). Furthermore, although most Medicaid beneficiaries were enrolled in a plan that covered MOUD, 53.2% of all MCO- and FFS-enrolled beneficiaries were subject to PA. Results also showed wide state variation in MCO plan coverage and PA policies for MOUD and the percentage of Medicaid beneficiaries subject to PA. Conclusions and Relevance This cross-sectional study found variation in MOUD coverage and PA policies across Medicaid MCO plans and FFS programs and across states. Thus, Medicaid beneficiaries' access to MOUD may be heavily influenced by their state of residency and the Medicaid plan in which they are enrolled. Left unaddressed, PA policies are likely to remain a barrier to MOUD access in the nation's Medicaid programs.
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Affiliation(s)
- Amanda J Abraham
- Department of Public Administration and Policy, University of Georgia School of Public and International Affairs, Athens
| | - Christina M Andrews
- Arnold School of Public Health, Health Services Policy and Management Department, University of South Carolina, Columbia
| | - Samantha J Harris
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Melissa M Westlake
- Arnold School of Public Health, Health Services Policy and Management Department, University of South Carolina, Columbia
| | - Colleen M Grogan
- Crown Family School of Social Work, Policy, and Practice, The University of Chicago, Illinois
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Kofler N, Grogan CM. Giving Voice to the Voiceless in Environmental Gene Editing. Hastings Cent Rep 2021; 51 Suppl 2:S66-S73. [PMID: 34905241 DOI: 10.1002/hast.1322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Participatory deliberation, whereby diverse experts and publics collectively engage in decision-making, can ensure a more informed and just decision by centering historically marginalized perspectives and engaging a spectrum of value systems. Broad and diverse participation is crucial for the equitable distribution of risks and benefits resulting from complex and uncertain decisions such as environmental gene editing. From an ethical position that gives intrinsic value to the nonhuman and recognizes the interconnectedness of species across generations, we argue that deliberation over environmental gene editing must include the voice of nature and the voice of future generations. Inclusion of these key participant groups can encourage reflection on the human relationship with nature and help safeguard intergenerational equity of decisions reached. By drawing from the legal rights of nature movement, the Boardman River Dams Project, and methods for representative participation, we offer strategies for inclusion of nonhuman nature and future generations in deliberative processes about environmental gene editing and other crucial decisions about our shared environments.
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Grogan CM, Lin YA, Gusmano MK. Unsanitized and Unfair: How COVID-19 Bailout Funds Refuel Inequity in the US Health Care System. J Health Polit Policy Law 2021; 46:785-809. [PMID: 33765137 DOI: 10.1215/03616878-9155977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
CONTEXT The CARES Act of 2020 allocated provider relief funds to hospitals and other providers. We investigate whether these funds were distributed in a way that responded fairly to COVID-19-related medical and financial need. The US health care system is bifurcated into the "haves" and "have nots." The health care safety net hospitals, which were already financially weak, cared for the bulk of COVID-19 cases. In contrast, the "have" hospitals suffered financially because their most profitable procedures are elective and were postponed during the COVID-19 outbreak. METHODS To obtain relief fund data for each hospital in the United States, we started with data from the HHS website. We use the RAND Hospital Data tool to analyze how fund distributions are associated with hospital characteristics. FINDINGS Our analysis reveals that the "have" hospitals with the most days of cash on hand received more funding per bed than hospitals with fewer than 50 days of cash on hand (the "have nots"). CONCLUSIONS Despite extreme racial inequities, which COVID-19 exposed early in the pandemic, the federal government rewards those hospitals that cater to the most privileged in the United States, leaving hospitals that predominantly serve low-income people of color with less.
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Affiliation(s)
- Colleen M Grogan
- Colleen M. Grogan is with the Crown Family School of Social Work, Policy, and Practice, University of Chicago, Chicago, IL. Yu-An Lin is with the Department of Social Work, National Taipei University, New Taipei City, Taiwan. Michael K. Gusmano is with the Department of Health Behavior, Society and Policy, Rutgers University School of Public Health, Piscataway Township, NJ, and The Hastings Center, Garrison, NY
| | - Yu-An Lin
- Colleen M. Grogan is with the Crown Family School of Social Work, Policy, and Practice, University of Chicago, Chicago, IL. Yu-An Lin is with the Department of Social Work, National Taipei University, New Taipei City, Taiwan. Michael K. Gusmano is with the Department of Health Behavior, Society and Policy, Rutgers University School of Public Health, Piscataway Township, NJ, and The Hastings Center, Garrison, NY
| | - Michael K Gusmano
- Colleen M. Grogan is with the Crown Family School of Social Work, Policy, and Practice, University of Chicago, Chicago, IL. Yu-An Lin is with the Department of Social Work, National Taipei University, New Taipei City, Taiwan. Michael K. Gusmano is with the Department of Health Behavior, Society and Policy, Rutgers University School of Public Health, Piscataway Township, NJ, and The Hastings Center, Garrison, NY
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Park SE, Mosley JE, Grogan CM, Pollack HA, Humphreys K, D'Aunno T, Friedmann PD. Patient-centered care's relationship with substance use disorder treatment utilization. J Subst Abuse Treat 2020; 118:108125. [PMID: 32972650 PMCID: PMC7528396 DOI: 10.1016/j.jsat.2020.108125] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/29/2020] [Accepted: 08/25/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Calls for more patient-centered care are growing in the substance use disorder (SUD) treatment field. However, evidence is sparse regarding whether patient-centered care improves access to, or utilization of, effective treatment services. METHODS Using nationally representative survey data from SUD treatment clinics in the United States, we examine the association between patient-centered clinical care and the utilization of six services: methadone, buprenorphine, behavioral treatment, routine medical care, HIV testing, and suicide prevention counseling. We measured clinics' practice of and emphasis on patient-centered care with two variables: (1) whether the clinic regularly invites patients into clinical decision-making processes, and (2) whether supervisors believe in patient-centered healthcare and shared decision-making practices within their clinics. RESULTS In 2017, only 23% of SUD treatment clinics regularly invited patients into care decision-making meetings when their cases were discussed. A composite variable captured clinical supervisors' own experience with and expectations for patient-clinician interaction within their clinics (Cronbach's alpha = 0.79). Results from regression models that controlled for several organizational and environmental factors show that patient-centered care was independently associated with greater utilization of four of six evidence-based services. CONCLUSIONS A minority of SUD clinics practice patient-centered healthcare in the United States. Given the connection to evidence-based services, increasing participatory mechanisms in SUD treatment service provision can facilitate patients' access to appropriate and evidence-based services.
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Affiliation(s)
| | | | | | | | - Keith Humphreys
- Veterans Affairs and Stanford University Medical Centers, USA
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Grogan CM. Medicaid's Post-ACA Paradoxes. J Health Polit Policy Law 2020; 45:617-632. [PMID: 32186342 DOI: 10.1215/03616878-8255541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Medicaid's experience one decade after the passage of the Affordable Care Act represents extreme divergence across the American states in health care access and utilization, policy designs that either expand or restrict eligibility, and delivery model reforms. The past decade has also witnessed a growing ideological divide about the very purpose and intent of the Medicaid program and its place within the US health care system. While liberal-leaning states have actively embraced the program and used it to expand health coverage to working adults and families as an effort to improve health and prevent poverty and the insecurity and instability that comes with high medical costs (evictions, bankruptcy), conservative states have actively rejected this expanded idea of Medicaid and argued instead that the program should revert back to its "original" purpose and be used only for the "truly" needy. This article highlights several paradoxes within Medicaid that have led to this growing bifurcation, and it concludes by shedding light on important targets for future reform.
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Grogan CM, Bersamira CS, Singer PM, Smith BT, Pollack HA, Andrews CM, Abraham AJ. Are Policy Strategies for Addressing the Opioid Epidemic Partisan? A View from the States. J Health Polit Policy Law 2020; 45:277-309. [PMID: 31808787 DOI: 10.1215/03616878-8004886] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
CONTEXT In contrast to the Affordable Care Act, some have suggested the opioid epidemic represents an area of bipartisanship. This raises an important question: to what extent are Democrat-led and Republican-led states different or similar in their policy responses to the opioid epidemic? METHODS Three main methodological approaches were used to assess state-level policy responses to the opioid epidemic: a legislative analysis across all 50 states, an online survey of 50 state Medicaid agencies, and in-depth case studies with policy stakeholders in five states. FINDINGS Conservative states pursue hidden and targeted Medicaid expansions, and a number of legislative initiatives, to address the opioid crisis. However, the total fiscal commitment among these Republican-led states pales in comparison to states that adopt the ACA Medicaid expansion. Because the state legislative initiatives do not provide treatment, these states spend substantially less than states with Democratic control. CONCLUSIONS Rather than persistently working to retrench all programs, conservatives have relied on policy designs that emphasize devolution, fragmentation, and inequality to both expand and retrench benefits. This strategy, which allocates benefits differentially to different social groups and obfuscates responsibility, allows conservatives to avoid political blame typically associated with retrenchment.
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Abstract
OBJECTIVE Substance use disorder treatment professionals are paying increased attention to implementing patient-centered care. Understanding environmental and organizational factors associated with clinicians' efforts to engage patients in clinical decision-making processes is essential for bringing patient-centered care to the addictions field. This study examined factors associated with patient-centered care practices in substance use disorder treatment. METHODS Data were from the 2017 National Drug Abuse Treatment System Survey, a nationally representative survey of U.S substance use disorder treatment clinics (outpatient nonopioid treatment programs, outpatient opioid treatment programs, inpatient clinics, and residential clinics). Multivariate regression analyses examined whether clinics invited patients into clinical decision-making processes and whether clinical supervisors supported and believed in patient-centered care practices. RESULTS Of the 657 substance use disorder clinics included in the analysis, about 23% invited patients to participate in clinical decision-making processes. Clinicians were more likely to engage patients in decision-making processes when working in residential clinics (compared with outpatient nonopioid treatment programs) or in clinics serving a smaller proportion of patients with alcohol or opioid use disorder. Clinical supervisors were more likely to value patient-centered care practices if the organization's administrative director perceived less regional competition or relied on professional information sources to understand developments in the substance use disorder treatment field. Clinicians' tendency to engage patients in decision-making processes was positively associated with clinical supervisors' emphasis on patient-centered care. CONCLUSIONS A minority of U.S. substance use disorder clinics invited patients into clinical decision-making processes. Therefore, patient-centered care may be unavailable to certain vulnerable patient groups.
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Affiliation(s)
- Sunggeun Ethan Park
- School of Social Work, University of Michigan, Ann Arbor (Park); School of Social Service Administration, University of Chicago, Chicago (Grogan, Mosley, Pollack); Health Services Research & Development, U.S. Department of Veterans Affairs Medical Center, Palo Alto, California, and Department of Psychiatry, Stanford University Medical Center, Stanford, California (Humphreys); Department of Medicine, University of Massachusetts--Baystate, and Office of Research, Baystate Health, Springfield, Massachusetts (Friedmann)
| | - Colleen M Grogan
- School of Social Work, University of Michigan, Ann Arbor (Park); School of Social Service Administration, University of Chicago, Chicago (Grogan, Mosley, Pollack); Health Services Research & Development, U.S. Department of Veterans Affairs Medical Center, Palo Alto, California, and Department of Psychiatry, Stanford University Medical Center, Stanford, California (Humphreys); Department of Medicine, University of Massachusetts--Baystate, and Office of Research, Baystate Health, Springfield, Massachusetts (Friedmann)
| | - Jennifer E Mosley
- School of Social Work, University of Michigan, Ann Arbor (Park); School of Social Service Administration, University of Chicago, Chicago (Grogan, Mosley, Pollack); Health Services Research & Development, U.S. Department of Veterans Affairs Medical Center, Palo Alto, California, and Department of Psychiatry, Stanford University Medical Center, Stanford, California (Humphreys); Department of Medicine, University of Massachusetts--Baystate, and Office of Research, Baystate Health, Springfield, Massachusetts (Friedmann)
| | - Keith Humphreys
- School of Social Work, University of Michigan, Ann Arbor (Park); School of Social Service Administration, University of Chicago, Chicago (Grogan, Mosley, Pollack); Health Services Research & Development, U.S. Department of Veterans Affairs Medical Center, Palo Alto, California, and Department of Psychiatry, Stanford University Medical Center, Stanford, California (Humphreys); Department of Medicine, University of Massachusetts--Baystate, and Office of Research, Baystate Health, Springfield, Massachusetts (Friedmann)
| | - Harold A Pollack
- School of Social Work, University of Michigan, Ann Arbor (Park); School of Social Service Administration, University of Chicago, Chicago (Grogan, Mosley, Pollack); Health Services Research & Development, U.S. Department of Veterans Affairs Medical Center, Palo Alto, California, and Department of Psychiatry, Stanford University Medical Center, Stanford, California (Humphreys); Department of Medicine, University of Massachusetts--Baystate, and Office of Research, Baystate Health, Springfield, Massachusetts (Friedmann)
| | - Peter D Friedmann
- School of Social Work, University of Michigan, Ann Arbor (Park); School of Social Service Administration, University of Chicago, Chicago (Grogan, Mosley, Pollack); Health Services Research & Development, U.S. Department of Veterans Affairs Medical Center, Palo Alto, California, and Department of Psychiatry, Stanford University Medical Center, Stanford, California (Humphreys); Department of Medicine, University of Massachusetts--Baystate, and Office of Research, Baystate Health, Springfield, Massachusetts (Friedmann)
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Abstract
In 2018, the Trump Administration took the unprecedented step of allowing states to impose work requirements as a condition of Medicaid eligibility. States can apply for a demonstration waiver to require Medicaid beneficiaries aged 19-64 who do not meet exemption criteria (e.g., disability, caring for a sick relative) to participate in "community engagement" activities, which include employment, volunteering, and enrollment in a qualifying education or job training program. Debate thus far has focused primarily around the important issue of whether such requirements are legal. Less attention has focused on another serious concern - namely, that work requirements could exacerbate the nation's most urgent public health crisis: the opioid epidemic. Many enrollees with opioid use disorder who are unable to meet states' community engagement criteria will not qualify for an exemption from the work requirements, and risk being dropped from Medicaid enrollment. Refusing health insurance to individuals who are unable to meet work requirements could result in significant losses in coverage among a highly vulnerable population. Implementing new barriers to Medicaid coverage will hinder the effectiveness of massive state and federal investments in improving access to evidence-based addiction treatment.
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Affiliation(s)
| | - Keith Humphreys
- Senior Research Career Scientist, Center for Innovation to Implementation, U.S. Department of Veterans Affairs, Stanford University School of Medicine, Menlo Park, CA, USA
| | - Colleen M Grogan
- School of Social Service Administration, University of Chicago, Chicago, IL, USA
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Andrews CM, Grogan CM, Smith BT, Abraham AJ, Pollack HA, Humphreys K, Westlake MA, Friedmann PD. Medicaid Benefits For Addiction Treatment Expanded After Implementation Of The Affordable Care Act. Health Aff (Millwood) 2019; 37:1216-1222. [PMID: 30080460 DOI: 10.1377/hlthaff.2018.0272] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Affordable Care Act (ACA) established a minimum standard of insurance benefits for addiction treatment and expanded federal parity regulations to selected Medicaid benefit plans, which required state Medicaid programs to make changes to their addiction treatment benefits. We surveyed Medicaid programs in all fifty states and the District of Columbia regarding their addiction treatment benefits and utilization controls in standard and alternative benefit plans in 2014 and 2017, when plans were subject to ACA parity requirements. The number of state plans that provided benefits for residential treatment and opioid use disorder medications increased substantially. States imposing annual service limits on outpatient addiction treatment decreased by over 50 percent. Fewer states required preauthorization for services, with the largest reductions for medications treating opioid use disorder. The ACA may have prompted state Medicaid programs to expand addiction treatment benefits and reduce utilization controls in alternative benefit plans. This trend was also observed among standard Medicaid plans not subject to ACA parity laws, which suggests a potential spillover effect.
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Affiliation(s)
- Christina M Andrews
- Christina M. Andrews ( ) is an assistant professor in the College of Social Work, University of South Carolina, in Columbia
| | - Colleen M Grogan
- Colleen M. Grogan is a professor in the School of Social Service Administration, University of Chicago, in Illinois
| | - Bikki Tran Smith
- Bikki Tran Smith is a PhD student in the School of Social Service Administration, University of Chicago
| | - Amanda J Abraham
- Amanda J. Abraham is an assistant professor in the School of Public and International Affairs, University of Georgia, in Athens
| | - Harold A Pollack
- Harold A. Pollack is the Helen Ross Professor in the School of Social Service Administration, University of Chicago
| | - Keith Humphreys
- Keith Humphreys is a professor of psychiatry and behavioral sciences in the Department of Psychiatry, Stanford School of Medicine, and a senior research career scientist at the Veterans Affairs Palo Alto Health Care System, both in California
| | - Melissa A Westlake
- Melissa A. Westlake is a PhD student in College of Social Work, University of South Carolina
| | - Peter D Friedmann
- Peter D. Friedmann is chief research officer for academic affairs at Baystate Health, in Springfield, Massachusetts
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Abraham AJ, Smith BT, Andrews CM, Bersamira CS, Grogan CM, Pollack HA, Friedmann PD. Changes in State Technical Assistance Priorities and Block Grant Funds for Addiction After ACA Implementation. Am J Public Health 2019; 109:885-891. [PMID: 30998407 DOI: 10.2105/ajph.2019.305052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To assess states' provision of technical assistance and allocation of block grants for treatment, prevention, and outreach after the expansion of health insurance coverage for addiction treatment in the United States under the Affordable Care Act (ACA). Methods. We used 2 waves of survey data collected from Single State Agencies in 2014 and 2017 as part of the National Drug Abuse Treatment System Survey. Results. The percentage of states providing technical assistance for cross-sector collaboration and workforce development increased. States also shifted funds from outpatient to residential treatment services. However, resources for opioid use disorder medications changed little. Subanalyses indicated that technical assistance priorities and allocation of funds for treatment services differed between Medicaid expansion and nonexpansion states. Public Health Implications. The ACA's infusion of new public and private funds enabled states to reallocate funds to residential services, which are not as likely to be covered by health insurance. The limited allocation of block grant funds for effective opioid medications is concerning in light of the opioid crisis, especially in states that did not implement the ACA's Medicaid expansion.
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Affiliation(s)
- Amanda J Abraham
- Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Bikki Tran Smith, Colleen M. Grogan, and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Clifford S. Bersamira is with the Myron B. Thompson School of Social Work, University of Hawai'i at Mānoa, Honolulu. Peter D. Friedmann is with the University of Massachusetts Medical School Baystate, Springfield
| | - Bikki Tran Smith
- Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Bikki Tran Smith, Colleen M. Grogan, and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Clifford S. Bersamira is with the Myron B. Thompson School of Social Work, University of Hawai'i at Mānoa, Honolulu. Peter D. Friedmann is with the University of Massachusetts Medical School Baystate, Springfield
| | - Christina M Andrews
- Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Bikki Tran Smith, Colleen M. Grogan, and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Clifford S. Bersamira is with the Myron B. Thompson School of Social Work, University of Hawai'i at Mānoa, Honolulu. Peter D. Friedmann is with the University of Massachusetts Medical School Baystate, Springfield
| | - Clifford S Bersamira
- Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Bikki Tran Smith, Colleen M. Grogan, and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Clifford S. Bersamira is with the Myron B. Thompson School of Social Work, University of Hawai'i at Mānoa, Honolulu. Peter D. Friedmann is with the University of Massachusetts Medical School Baystate, Springfield
| | - Colleen M Grogan
- Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Bikki Tran Smith, Colleen M. Grogan, and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Clifford S. Bersamira is with the Myron B. Thompson School of Social Work, University of Hawai'i at Mānoa, Honolulu. Peter D. Friedmann is with the University of Massachusetts Medical School Baystate, Springfield
| | - Harold A Pollack
- Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Bikki Tran Smith, Colleen M. Grogan, and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Clifford S. Bersamira is with the Myron B. Thompson School of Social Work, University of Hawai'i at Mānoa, Honolulu. Peter D. Friedmann is with the University of Massachusetts Medical School Baystate, Springfield
| | - Peter D Friedmann
- Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Bikki Tran Smith, Colleen M. Grogan, and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Clifford S. Bersamira is with the Myron B. Thompson School of Social Work, University of Hawai'i at Mānoa, Honolulu. Peter D. Friedmann is with the University of Massachusetts Medical School Baystate, Springfield
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Andrews CM, Abraham AJ, Grogan CM, Westlake MA, Pollack HA, Friedmann PD. Impact of Medicaid Restrictions on Availability of Buprenorphine in Addiction Treatment Programs. Am J Public Health 2019; 109:434-436. [PMID: 30676789 PMCID: PMC6366513 DOI: 10.2105/ajph.2018.304856] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To examine how utilization restrictions on state Medicaid benefits for buprenorphine are related to addiction treatment programs' decision to offer the drug. METHODS We used data from 2 waves of the National Drug Abuse Treatment System Survey conducted in 2014 and 2017 in the United States to assess the relationship of utilization restrictions to buprenorphine availability. RESULTS The proportion of programs offering buprenorphine was 43.2% in states that did not impose any utilization restrictions, 25.5% in states that imposed only annual limits, 17.3% in states that imposed only prior authorization, and 12.8% in states that imposed both. Programs in states requiring prior authorization from Medicaid had substantially lower odds of offering buprenorphine (odds ratio = 0.50; 95% confidence interval = 0.29, 0.87). CONCLUSIONS Medicaid prior authorization was linked to lower odds of buprenorphine provision among addiction treatment programs. Public Health Implications. State Medicaid prior authorization requirements are linked to reduced odds of buprenorphine provision among addiction treatment programs and may discourage prescribing.
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Affiliation(s)
- Christina M Andrews
- Christina M. Andrews and Melissa A. Westlake are with the College of Social Work, University of South Carolina, Columbia. Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Colleen M. Grogan and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Peter D. Friedmann is with Baystate Medical Center, Springfield, MA, and the University of Massachusetts, Baystate Campus, Springfield
| | - Amanda J Abraham
- Christina M. Andrews and Melissa A. Westlake are with the College of Social Work, University of South Carolina, Columbia. Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Colleen M. Grogan and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Peter D. Friedmann is with Baystate Medical Center, Springfield, MA, and the University of Massachusetts, Baystate Campus, Springfield
| | - Colleen M Grogan
- Christina M. Andrews and Melissa A. Westlake are with the College of Social Work, University of South Carolina, Columbia. Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Colleen M. Grogan and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Peter D. Friedmann is with Baystate Medical Center, Springfield, MA, and the University of Massachusetts, Baystate Campus, Springfield
| | - Melissa A Westlake
- Christina M. Andrews and Melissa A. Westlake are with the College of Social Work, University of South Carolina, Columbia. Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Colleen M. Grogan and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Peter D. Friedmann is with Baystate Medical Center, Springfield, MA, and the University of Massachusetts, Baystate Campus, Springfield
| | - Harold A Pollack
- Christina M. Andrews and Melissa A. Westlake are with the College of Social Work, University of South Carolina, Columbia. Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Colleen M. Grogan and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Peter D. Friedmann is with Baystate Medical Center, Springfield, MA, and the University of Massachusetts, Baystate Campus, Springfield
| | - Peter D Friedmann
- Christina M. Andrews and Melissa A. Westlake are with the College of Social Work, University of South Carolina, Columbia. Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Colleen M. Grogan and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Peter D. Friedmann is with Baystate Medical Center, Springfield, MA, and the University of Massachusetts, Baystate Campus, Springfield
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Affiliation(s)
- Daniel M. Fox
- Daniel M. Fox is with the Milbank Memorial Fund, New York, NY. Colleen M. Grogan is with the School of Social Service Administration, University of Chicago, Chicago, IL
| | - Colleen M. Grogan
- Daniel M. Fox is with the Milbank Memorial Fund, New York, NY. Colleen M. Grogan is with the School of Social Service Administration, University of Chicago, Chicago, IL
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Affiliation(s)
- Colleen M. Grogan
- School of Social Service Administration, University of Chicago, Chicago, Illinois, USA
| | - Sunggeun (Ethan) Park
- School of Social Service Administration, University of Chicago, Chicago, Illinois, USA
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Abraham AJ, Andrews CM, Grogan CM, Pollack HA, D'Aunno T, Humphreys K, Friedmann PD. State-Targeted Funding and Technical Assistance to Increase Access to Medication Treatment for Opioid Use Disorder. Psychiatr Serv 2018; 69:448-455. [PMID: 29241428 PMCID: PMC6703818 DOI: 10.1176/appi.ps.201700196] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE As the United States grapples with an opioid epidemic, expanding access to effective treatment for opioid use disorder is a major public health priority. Identifying effective policy tools that can be used to expand access to care is critically important. This article examines the relationship between state-targeted funding and technical assistance and adoption of three medications for treating opioid use disorder: oral naltrexone, injectable naltrexone, and buprenorphine. METHODS This study draws from the 2013-2014 wave of the National Drug Abuse Treatment System Survey, a nationally representative, longitudinal study of substance use disorder treatment programs. The sample includes data from 695 treatment programs (85.5% response rate) and representatives from single-state agencies in 49 states and Washington, D.C. (98% response rate). Logistic regression was used to examine the relationships of single-state agency targeted funding and technical assistance to availability of opioid use disorder medications among treatment programs. RESULTS State-targeted funding was associated with increased program-level adoption of oral naltrexone (adjusted odds ratio [AOR]=3.14, 95% confidence interval [CI]=1.49-6.60, p=.004) and buprenorphine (AOR=2.47, 95% CI=1.31-4.67, p=.006). Buprenorphine adoption was also correlated with state technical assistance to support medication provision (AOR=1.18, 95% CI=1.00-1.39, p=.049). CONCLUSIONS State-targeted funding for medications may be a viable policy lever for increasing access to opioid use disorder medications. Given the historically low rates of opioid use disorder medication adoption in treatment programs, single-state agency targeted funding is a potentially important tool to reduce mortality and morbidity associated with opioid disorders and misuse.
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Affiliation(s)
- Amanda J Abraham
- Dr. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Dr. Andrews is with the College of Social Work, University of South Carolina, Columbia. Dr. Grogan and Dr. Pollack are with the School of Social Service Administration, University of Chicago, Chicago. Dr. D'Aunno is with the Wagner Graduate School of Public Service, New York University, New York. Dr. Humphreys is with the School of Medicine, Stanford University, Palo Alto, California. Dr. Friedmann is with the Department of Medicine, University of Massachusetts-Baystate and Baystate State Health System, Springfield, Massachusetts
| | - Christina M Andrews
- Dr. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Dr. Andrews is with the College of Social Work, University of South Carolina, Columbia. Dr. Grogan and Dr. Pollack are with the School of Social Service Administration, University of Chicago, Chicago. Dr. D'Aunno is with the Wagner Graduate School of Public Service, New York University, New York. Dr. Humphreys is with the School of Medicine, Stanford University, Palo Alto, California. Dr. Friedmann is with the Department of Medicine, University of Massachusetts-Baystate and Baystate State Health System, Springfield, Massachusetts
| | - Colleen M Grogan
- Dr. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Dr. Andrews is with the College of Social Work, University of South Carolina, Columbia. Dr. Grogan and Dr. Pollack are with the School of Social Service Administration, University of Chicago, Chicago. Dr. D'Aunno is with the Wagner Graduate School of Public Service, New York University, New York. Dr. Humphreys is with the School of Medicine, Stanford University, Palo Alto, California. Dr. Friedmann is with the Department of Medicine, University of Massachusetts-Baystate and Baystate State Health System, Springfield, Massachusetts
| | - Harold A Pollack
- Dr. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Dr. Andrews is with the College of Social Work, University of South Carolina, Columbia. Dr. Grogan and Dr. Pollack are with the School of Social Service Administration, University of Chicago, Chicago. Dr. D'Aunno is with the Wagner Graduate School of Public Service, New York University, New York. Dr. Humphreys is with the School of Medicine, Stanford University, Palo Alto, California. Dr. Friedmann is with the Department of Medicine, University of Massachusetts-Baystate and Baystate State Health System, Springfield, Massachusetts
| | - Thomas D'Aunno
- Dr. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Dr. Andrews is with the College of Social Work, University of South Carolina, Columbia. Dr. Grogan and Dr. Pollack are with the School of Social Service Administration, University of Chicago, Chicago. Dr. D'Aunno is with the Wagner Graduate School of Public Service, New York University, New York. Dr. Humphreys is with the School of Medicine, Stanford University, Palo Alto, California. Dr. Friedmann is with the Department of Medicine, University of Massachusetts-Baystate and Baystate State Health System, Springfield, Massachusetts
| | - Keith Humphreys
- Dr. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Dr. Andrews is with the College of Social Work, University of South Carolina, Columbia. Dr. Grogan and Dr. Pollack are with the School of Social Service Administration, University of Chicago, Chicago. Dr. D'Aunno is with the Wagner Graduate School of Public Service, New York University, New York. Dr. Humphreys is with the School of Medicine, Stanford University, Palo Alto, California. Dr. Friedmann is with the Department of Medicine, University of Massachusetts-Baystate and Baystate State Health System, Springfield, Massachusetts
| | - Peter D Friedmann
- Dr. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Dr. Andrews is with the College of Social Work, University of South Carolina, Columbia. Dr. Grogan and Dr. Pollack are with the School of Social Service Administration, University of Chicago, Chicago. Dr. D'Aunno is with the Wagner Graduate School of Public Service, New York University, New York. Dr. Humphreys is with the School of Medicine, Stanford University, Palo Alto, California. Dr. Friedmann is with the Department of Medicine, University of Massachusetts-Baystate and Baystate State Health System, Springfield, Massachusetts
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Grogan CM, Andrews C, Abraham A, Humphreys K, Pollack HA, Smith BT, Friedmann PD. Survey Highlights Differences In Medicaid Coverage For Substance Use Treatment And Opioid Use Disorder Medications. Health Aff (Millwood) 2018; 35:2289-2296. [PMID: 27920318 DOI: 10.1377/hlthaff.2016.0623] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Affordable Care Act requires state Medicaid programs to cover substance use disorder treatment for their Medicaid expansion population but allows states to decide which individual services are reimbursable. To examine how states have defined substance use disorder benefit packages, we used data from 2013-14 that we collected as part of an ongoing nationwide survey of state Medicaid programs. Our findings highlight important state-level differences in coverage for substance use disorder treatment and opioid use disorder medications across the United States. Many states did not cover all levels of care required for effective substance use disorder treatment or medications required for effective opioid use disorder treatment as defined by American Society of Addiction Medicine criteria, which could result in lack of access to needed services for low-income populations.
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Affiliation(s)
- Colleen M Grogan
- Colleen M. Grogan is a professor at the School of Social Service Administration, University of Chicago, in Illinois
| | - Christina Andrews
- Christina Andrews is an assistant professor at the College of Social Work, University of South Carolina, in Columbia
| | - Amanda Abraham
- Amanda Abraham is an assistant professor in the Department of Public Administration and Policy at the University of Georgia, in Athens
| | - Keith Humphreys
- Keith Humphreys is a professor of psychiatry and behavioral sciences in the Department of Psychiatry at the Stanford School of Medicine, in California
| | - Harold A Pollack
- Harold A. Pollack is the Helen Ross Professor at the School of Social Service Administration, University of Chicago
| | - Bikki Tran Smith
- Bikki Tran Smith is a doctoral student at the School of Social Service Administration, University of Chicago
| | - Peter D Friedmann
- Peter D. Friedmann is chief research officer at Baystate Health, in Springfield, Massachusetts
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Abraham AJ, Andrews CM, Grogan CM, D'Aunno T, Humphreys KN, Pollack HA, Friedmann PD. The Affordable Care Act Transformation of Substance Use Disorder Treatment. Am J Public Health 2018; 107:31-32. [PMID: 27925819 DOI: 10.2105/ajph.2016.303558] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Amanda J Abraham
- Amanda J. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Colleen M. Grogan and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Thomas D'Aunno is with the Robert F. Wagner Graduate School of Public Service and College of Global Public Health, New York University, New York, NY. Keith N. Humphreys is with the Veterans Affairs Palo Alto Health Care System, Livermore, CA.Peter D. Friedmann is with the University of Massachusetts Medical School - Baytstate and Baystate Health, Springfield
| | - Christina M Andrews
- Amanda J. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Colleen M. Grogan and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Thomas D'Aunno is with the Robert F. Wagner Graduate School of Public Service and College of Global Public Health, New York University, New York, NY. Keith N. Humphreys is with the Veterans Affairs Palo Alto Health Care System, Livermore, CA.Peter D. Friedmann is with the University of Massachusetts Medical School - Baytstate and Baystate Health, Springfield
| | - Colleen M Grogan
- Amanda J. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Colleen M. Grogan and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Thomas D'Aunno is with the Robert F. Wagner Graduate School of Public Service and College of Global Public Health, New York University, New York, NY. Keith N. Humphreys is with the Veterans Affairs Palo Alto Health Care System, Livermore, CA.Peter D. Friedmann is with the University of Massachusetts Medical School - Baytstate and Baystate Health, Springfield
| | - Thomas D'Aunno
- Amanda J. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Colleen M. Grogan and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Thomas D'Aunno is with the Robert F. Wagner Graduate School of Public Service and College of Global Public Health, New York University, New York, NY. Keith N. Humphreys is with the Veterans Affairs Palo Alto Health Care System, Livermore, CA.Peter D. Friedmann is with the University of Massachusetts Medical School - Baytstate and Baystate Health, Springfield
| | - Keith N Humphreys
- Amanda J. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Colleen M. Grogan and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Thomas D'Aunno is with the Robert F. Wagner Graduate School of Public Service and College of Global Public Health, New York University, New York, NY. Keith N. Humphreys is with the Veterans Affairs Palo Alto Health Care System, Livermore, CA.Peter D. Friedmann is with the University of Massachusetts Medical School - Baytstate and Baystate Health, Springfield
| | - Harold A Pollack
- Amanda J. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Colleen M. Grogan and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Thomas D'Aunno is with the Robert F. Wagner Graduate School of Public Service and College of Global Public Health, New York University, New York, NY. Keith N. Humphreys is with the Veterans Affairs Palo Alto Health Care System, Livermore, CA.Peter D. Friedmann is with the University of Massachusetts Medical School - Baytstate and Baystate Health, Springfield
| | - Peter D Friedmann
- Amanda J. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Colleen M. Grogan and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Thomas D'Aunno is with the Robert F. Wagner Graduate School of Public Service and College of Global Public Health, New York University, New York, NY. Keith N. Humphreys is with the Veterans Affairs Palo Alto Health Care System, Livermore, CA.Peter D. Friedmann is with the University of Massachusetts Medical School - Baytstate and Baystate Health, Springfield
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Tran Smith B, Seaton K, Andrews C, Grogan CM, Abraham A, Pollack H, Friedmann P, Humphreys K. Benefit requirements for substance use disorder treatment in state health insurance exchanges. Am J Drug Alcohol Abuse 2017; 44:426-430. [PMID: 29261341 DOI: 10.1080/00952990.2017.1411934] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Established in 2014, state health insurance exchanges have greatly expanded substance use disorder (SUD) treatment coverage in the United States as qualified health plans (QHPs) within the exchanges are required to conform to parity provisions laid out by the Affordable Care Act and the Mental Health Parity and Addiction Equity Act (MHPAEA). Coverage improvements, however, have not been even as states have wide discretion over how they meet these regulations. OBJECTIVE How states regulate SUD treatment benefits offered by QHPs has implications for the accessibility and quality of care. In this study, we assessed the extent to which state insurance departments regulate the types of SUD services and medications plans must provide, as well as their use of utilization controls. METHODS Data were collected as part of the National Drug Abuse Treatment System Survey, a nationally-representative, longitudinal study of substance use disorder treatment. Data were obtained from state Departments of Insurance via a 15-minute internet-based survey. RESULTS States varied widely in regulations on QHPs' administration of SUD treatment benefits. Some states required plans to cover all 11 SUD treatment services and medications we assessed in the study, whereas others did not require plans to cover anything at all. Nearly all states allowed the plans to employ utilization controls, but reported little guidance regarding how they should be used. CONCLUSION Although some states have taken full advantage of the health insurance exchanges to increase access to SUD treatment, others seem to have done the bare minimum required by the ACA. By not requiring coverage for the entire SUD continuum of care, states are hindering client access to appropriate types of care necessary for recovery.
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Affiliation(s)
- Bikki Tran Smith
- a School of Social Service Administration , University of Chicago , Chicago , IL , USA
| | - Kathleen Seaton
- b Department of Psychiatry , School of Medicine, Stanford University , Stanford , CA , USA
| | - Christina Andrews
- c College of Social Work , University of South Carolina , Columbia , SC , USA
| | - Colleen M Grogan
- a School of Social Service Administration , University of Chicago , Chicago , IL , USA
| | - Amanda Abraham
- d Department of Medicine , Division of General Internal Medicine, University of Massachusetts-Baystate , Springfield , MA
| | - Harold Pollack
- a School of Social Service Administration , University of Chicago , Chicago , IL , USA
| | - Peter Friedmann
- e University of Massachusetts , Medical School , Springfield , MA , USA
| | - Keith Humphreys
- b Department of Psychiatry , School of Medicine, Stanford University , Stanford , CA , USA
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Grogan CM, Park SE. The Politics of Medicaid: Most Americans Are Connected to the Program, Support Its Expansion, and Do Not View It as Stigmatizing. Milbank Q 2017; 95:749-782. [PMID: 29226447 DOI: 10.1111/1468-0009.12298] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Policy Points: More than half of Americans are connected to the Medicaid program-either through their own coverage or that of a family member or close friend-and are significantly more likely to view Medicaid as important and to support increases in spending, even among conservatives. This finding helps explain why Affordable Care Act repeal efforts faced (and will continue to face) strong public backlash. Policymakers should be aware that although renaming programs within Medicaid may have increased enrollment take-up, this destigmatization effort might have also increased program confusion and reduced support for Medicaid even among enrollees who say the program is important to them. CONTEXT Since the 1980s, Medicaid enrollment has expanded so dramatically that by 2015 two-thirds of Americans had some connection to the program in which either they themselves, a family member, or a close friend is currently or was previously enrolled. METHODS Utilizing a nationally representative survey-the Kaiser Family Foundation Poll: Medicare and Medicaid at 50 (n = 1,849)-and employing ordinal and logistic regression analyses, our study examines 3 questions: (1) are individuals with a connection to Medicaid more likely to view the program as important, (2) are they more likely to support an increase in Medicaid spending, and (3) are they more likely to support adoption of the Medicaid expansion offered under the Affordable Care Act? For each of these questions we examine whether partisanship and views of stigma also impact support for Medicaid and, if so, whether these factors overwhelm the impact of connection to the program. FINDINGS Controlling for the strong effect of partisanship, people with any connection to the Medicaid program are more likely to view the program as important than those with no connection. However, when it comes to increasing spending or expanding the program, the type of connection to the program matters. In particular, adults with current and previous Medicaid coverage and those with a family member or close friend with Medicaid coverage are more likely to support increases in spending and the Medicaid expansion; but, those connected to Medicaid only through coverage of a child are no more likely to support Medicaid than those with no connection. CONCLUSIONS Future research should probe more deeply into whether people with different types of connection to Medicaid view the program differently, and, if so, how and why. Moreover, future research should also explore whether state-level attempts to destigmatize Medicaid by renaming the program also serves to reduce knowledge and support for Medicaid.
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Affiliation(s)
- Colleen M Grogan
- School of Social Service Administration, The University of Chicago
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Abstract
This special issue of the Journal is devoted to understanding the many roads that lead toward achieving health equity. The eleven articles in the issue portray an America that is struggling with the clash between its historical ideal of pursuing equality for all and its ambivalence toward achieving equity in all social domains, especially health. Organized in five sections, the issue contains articles that examine and analyze: the role of civil rights law and the courts in shaping health equity; the political discourse that has framed our understanding of health equity; health policies that affect health equity, such as the Medicaid program, as well as related strategies that might help to improve equity, such as the use of mobile technologies to empower individuals; immigration policies and practices that impact health equity in marginalized populations; and commentaries in the final section that explore how the Affordable Care Act has addressed health equity, how repeal of the law would jeopardize equity gains, and how the political discourse and culture of the Trump administration could adversely affect health equity.
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Abstract
This commentary reviews the many different ways the Affordable Care Act (ACA) explicitly and implicitly attempted to improve health equity, and then assesses how the Republican proposal to repeal and replace the ACA (the proposed American Health Care Act) would impact efforts to improve health equity. Although the American health care system still had a long way to go to achieve health equity, it may be argued that the ACA was a major step forward in creating new programs and regulations that had the potential to improve health equity. In stark contrast, Trumpcare makes no mention of health equity as a goal and-if passed-would result in an increase in health inequity. It would shamefully represent the first time in modern US history that a major federal health reform bill would actually move us further away from creating more equal access to health care coverage and toward reduced health equity.
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Affiliation(s)
| | - Colleen M. Grogan
- Daniel M. Fox is with the Milbank Memorial Fund, New York, NY. Colleen M. Grogan is with the School of Social Service Administration at the University of Chicago, Chicago, IL
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Abstract
This study considers five important questions related to the role of race in state-level public support for the Medicaid expansion: (1) whether public support for the Medicaid expansion varies across the American states; (2) whether public support is positively related to state adoption; (3) whether this support is racialized; (4) whether, if racialized, there is evidence of more state responsiveness to white support than to nonwhite (black and/or Latino) support; and (5) does the size of the nonwhite population matter more when white support is relatively low? Our findings suggest that while public support for the Medicaid expansion is high at the state level, especially in comparison to public support for the ACA, there are important variations across the states. Although overall public support is positively related to state adoption, we find that public support for the Medicaid expansion is racialized in two ways. First, there are large differences in support levels by race; and second, state adoption decisions are positively related to white opinion and do not respond to nonwhite support levels. Most importantly, there is evidence that when the size of the black population increases and white support levels are relatively low, the state is significantly less likely to expand the Medicaid program. Our discussion highlights the democratic deficits and racial bias at the state level around this important coverage policy.
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Grogan CM. Editor's Note. J Health Polit Policy Law 2017; 42:419-423. [PMID: 28213394 DOI: 10.1215/03616878-3802915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Abstract
Seven states have used Section 1115 waivers to expand Medicaid as part of the Affordable Care Act (ACA). While each state pursued a unique plan, there are similarities in the types of changes each state desired to make. Equally important to how a state modified their Medicaid programs is how a state talked about Medicaid and reform. We investigate whether the rhetoric that emerged in waiver states is unique, analyze whether the rhetoric is associated with particular waiver reforms, and consider the implications of our findings for the future of Medicaid policy making. We find that proponents in waiver states have convinced a conservative legislature that their reform is sufficiently innovative that they are not doing a Medicaid expansion, and not building on the traditional Medicaid program. Particularly striking is that none of these reforms are entirely new to the Medicaid program. While not new, the way in which waiver states have been allowed to implement many of the reforms is new and has become stricter. We find an emerging consensus utilized by conservative policy makers in framing the Medicaid expansion. Expansion efforts by conservative policy makers in other states have subsequently pushed this framing far to the right.
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Grogan CM. The Politics of Framing Policy Solutions and Whether Policies Address Problems. J Health Polit Policy Law 2017; 42:1-3. [PMID: 28073855 DOI: 10.1215/03616878-3702758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Abstract
Over the past fifty years Medicaid has taken divergent paths in financing mental health and addiction treatment. In mental health, Medicaid became the dominant source of funding and had a profound impact on the organization and delivery of services. But it played a much more modest role in addiction treatment. This is poised to change, as the Affordable Care Act is expected to dramatically expand Medicaid's role in financing addiction services. In this article we consider the different paths these two treatment systems have taken since 1965 and identify strategic lessons that the addiction treatment system might take from mental health's experience under Medicaid. These lessons include leveraging optional coverage categories to tailor Medicaid to the unique needs of the addiction treatment system, providing incentives to addiction treatment programs to create and deliver high-quality alternatives to inpatient treatment, and using targeted Medicaid licensure standards to increase the quality of addiction services.
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Affiliation(s)
- Christina Andrews
- Christina Andrews is an assistant professor in the College of Social Work, University of South Carolina, in Columbia
| | - Colleen M Grogan
- Colleen M. Grogan is a professor in the School of Social Service Administration, University of Chicago, in Illinois
| | - Marianne Brennan
- Marianne Brennan is a doctoral student in the School of Social Service Administration, University of Chicago
| | - Harold A Pollack
- Harold A. Pollack is a professor in the School of Social Service Administration, University of Chicago
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Affiliation(s)
- Daniel M Fox
- Daniel M. Fox is president emeritus of the Milbank Memorial Fund, New York, NY. Colleen M. Grogan is with the School of Social Service Administration, University of Chicago, Chicago, IL
| | - Colleen M Grogan
- Daniel M. Fox is president emeritus of the Milbank Memorial Fund, New York, NY. Colleen M. Grogan is with the School of Social Service Administration, University of Chicago, Chicago, IL
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Grogan CM. Editor's Note. J Health Polit Policy Law 2016; 41:155-156. [PMID: 27559547 DOI: 10.1215/03616878-3476081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Grogan CM. Editor’s Note. J Health Polit Policy Law 2015; 40:1113-1114. [PMID: 27265905 DOI: 10.1215/03616878-3424438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Grogan CM. A Conceptual Advance--Two Faces of Neoliberalism. J Health Polit Policy Law 2015; 40:939-940. [PMID: 26958675 DOI: 10.1215/03616878-3161150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Abstract
This introductory essay to JHPPL's special issue on accountable care organizations (ACOs) presents the broader themes addressed in the issue, including (1) a central tension between cooperation versus competition in health care markets with regard to how to bring about improved quality, lower costs, and better access; (2) US regulatory policy - whether it will be able to achieve the appropriate balance in health care markets under which ACOs could realize expected outcomes; and (3) ACO realities - whether ACOs will be able to overcome or further embed existing inequities in US health care markets.
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Grogan CM. Introduction. J Health Polit Policy Law 2015; 40:575-576. [PMID: 25700375 DOI: 10.1215/03616878-2890415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Grogan CM. Editor’s Note. J Health Polit Policy Law 2015; 40:445-446. [PMID: 26258185 DOI: 10.1215/03616878-2888367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Andrews C, Abraham A, Grogan CM, Pollack HA, Bersamira C, Humphreys K, Friedmann P. Despite Resources From The ACA, Most States Do Little To Help Addiction Treatment Programs Implement Health Care Reform. Health Aff (Millwood) 2015; 34:828-35. [PMID: 25941285 PMCID: PMC4706741 DOI: 10.1377/hlthaff.2014.1330] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Affordable Care Act (ACA) dramatically expands health insurance for addiction treatment and provides unprecedented opportunities for service growth and delivery model reform. Yet most addiction treatment programs lack the staffing and technological capabilities to respond successfully to ACA-driven system change. In light of these challenges, we conducted a national survey to examine how Single State Agencies for addiction treatment--the state governmental organizations charged with overseeing addiction treatment programs--are helping programs respond to new requirements under the ACA. We found that most Single State Agencies provide little assistance to addiction treatment programs. Most agencies are helping programs develop collaborations with other health service programs. However, fewer than half reported providing help in modernizing systems to support insurance participation, and only one in three provided assistance with enrollment outreach. In the absence of technical assistance, it is unlikely that addiction treatment programs will fully realize the ACA's promise to improve access to and quality of addiction treatment.
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Affiliation(s)
- Christina Andrews
- Christina Andrews is an assistant professor of social work at the University of South Carolina, in Columbia
| | - Amanda Abraham
- Amanda Abraham is an assistant professor of health policy and management at the University of Georgia, in Athens
| | - Colleen M Grogan
- Colleen M. Grogan is a professor of health policy at the University of Chicago, in Illinois
| | - Harold A Pollack
- Harold A. Pollock is an associate professor of health policy at the University of Chicago
| | - Clifford Bersamira
- Clifford Bersamira is a doctoral student in social work at the University of Chicago
| | - Keith Humphreys
- Keith Humphreys is a professor of psychiatry and behavioral sciences at the Veterans Affairs and Stanford University Medical Centers, both in Stanford, California
| | - Peter Friedmann
- Peter Friedmann is a professor of medicine at the Providence Veteran Affairs Medical Center, the Rhode Island Hospital, and the Alpert Medical School of Brown University, all in Providence, Rhode Island
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Grogan CM. Editor's note. J Health Polit Policy Law 2015; 40:277-279. [PMID: 26191565 DOI: 10.1215/03616878-2882207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Grogan CM. Editor’s note. J Health Polit Policy Law 2015; 40:1-2. [PMID: 25905119 DOI: 10.1215/03616878-2864135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Grogan CM. The Role of the Private Sphere in US Healthcare Entitlements: Increased Spending, Weakened Public Mobilization, and Reduced Equity. ACTA ACUST UNITED AC 2015. [DOI: 10.1515/for-2015-0007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractThe private sphere has always been an important component in US healthcare entitlements. Since the ACA further embeds the role of private actors, how private actors make claims on the state, and how the state reacts to these claims, becomes even more important, because such claims significantly shape US healthcare entitlements. The extent and increase of private benefits and contracting with private health plans is explicated for each healthcare entitlement program. The politics of how private inclusion shapes healthcare entitlements is examined with three main implications: it (1) creates a dominant discourse of health care deficits and spending crises; (2) submerges the role of government and may diminish mobilization for claiming entitlements; and (3) reduces equity in the distribution of costs and benefits. I conclude by highlighting that there are simple policy designs to address these problems, but the political dynamics of private inclusion will likely work against such policy logics.
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Grogan CM. The United States has struggled with how to adequately provide health care for its poor and middle class for a long time. J Health Polit Policy Law 2014; 39:1131-1134. [PMID: 25756174 DOI: 10.1215/03616878-2822598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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