Managed Medicaid

Although health plans’ formularies have largely been making it easier for people to access buprenorphine in recent years, new research indicates that coverage barriers and access gaps remain — particularly for a newer, costlier extended-release formulation of the opioid use disorder (OUD) drug.

However, a recent FDA approval could usher in more competition that decreases the price and increases coverage of extended-release buprenorphine, which has major advantages over the immediate-release versions, according to one of the study authors.

The Congressional Budget Office estimated that in 2023, 248 million people who are younger than 65 will have health insurance coverage, with over 57% covered through employment-based health plans. As COVID-era policies expire over the next decade, employment-based coverage will grow to 159 million and remain the largest source of insurance.

The coverage patterns vary significantly by income. People with income less than 150% of the federal poverty level are more likely to be uninsured or covered through Medicaid or the Children’s Health Insurance Program, while those with higher income are predominantly insured through employer-sponsored coverage.

Medicaid redeterminations resumed in recent weeks after years of pandemic-related policies that suspended income verification for the safety net health insurance program, and some states — particularly Florida — seem to be moving faster than others to remove beneficiaries from their rolls, prompting a warning from the Biden administration. Experts say that the pace of redeterminations will vary from state to state — and so will redeterminations’ possible negative effect on health equity, which could intensify if states are cavalier or overaggressive with disenrollments.

“We’re looking closely at the Medicaid renewal numbers released by several states today. Keeping eligible people covered is our #1 priority. States need to do their part to keep people from losing coverage due to red tape,” said CMS Administrator Chiquita Brooks-LaSure on Twitter on June 1. The CMS-controlled Twitter account for Medicaid, while retweeting Brooks-LaSure, said that “we are closely monitoring the Medicaid renewal numbers that states are reporting,” and added that “we will continue to work directly with states to help keep eligible individuals covered.”

The behavioral health workforce isn’t large enough to meet current demand, according to experts, and it is particularly under-resourced for LGBTQ+ patients and people of color, who are not adequately represented in the current workforce despite disproportionate need for treatment. Meanwhile, poor pay and too-high workloads offer little incentive for behavioral health providers to enter insurance networks, driving up costs for patients and stymieing plans’ attempts to comply with mental health parity and network adequacy requirements.

George Washington University (GWU) researchers maintain the only comprehensive database tracking the number of behavioral health providers in the US. They released their first data in 2022 and published an article in Health Affairs that August. According to an April slide deck prepared by GWU researchers Clese Erikson and Randl Dent, Ph.D., there are currently 1.3 million mental health care providers in the U.S. — a figure that includes over 600,000 prescribers of psychotropic drugs and medications for opioid use disorder (MOUD).

The Congressional Budget Office (CBO) garnered headlines recently when it projected that not only will the uninsured rate reach a record low this year, it will creep up again in the next 10 years. In a June 1 webinar hosted by Health Affairs, a CBO official expounded upon how those projections came about, noting that at the behest of Congress, the agency is closely following how coverage shifts affect particular demographics.

In its new projections, CBO said that the uninsured rate among people who are younger than 65 will increase from an unprecedented 8.3% this year to 10.1% in 2033, which would still be below the 12% rate from 2019 before the COVID-19 pandemic. The estimates, which were published in Health Affairs on June 24, show the impact that the expiration of temporary policies put into place during COVID will have on insurance coverage.

After issuing a request for information (RFI) and reviewing feedback from stakeholders, Sen. Bill Cassidy, M.D. (R-La.), is circulating discussion draft legislation to improve coverage for Medicare-Medicaid dual eligibles. While several industry experts agree that the legislation is moving integration in the right direction, they also say certain elements of it may be overly ambitious and raise many questions, such as whether states that have limited the number of Medicaid managed care organizations will inhibit the ability of Medicare Advantage plans to participate in the new model.

Cassidy, who frequently tackles health care issues as a member of several Senate committees, led a bipartisan group of senators in drafting the proposal, which was informed by more than 125 responses to the November RFI. According to a Cassidy aide, the senators will collect feedback through July 1 and hope to formally introduce legislation after Labor Day.

In a new regulation released on May 23, the Biden administration proposed increasing drug price transparency reporting by pharmacy benefit managers and pharmaceutical manufacturers supplying Medicaid — and requiring Medicaid managed care organizations to remove pharmacy benefit administration costs from medical loss ratio (MLR) reporting. Experts say the proposed rule is a marginal but meaningful step forward in prescription drug cost containment, but they add that the proposed rule won’t do as much as bills under serious discussion in Congress to rein in controversial PBM business practices such as spread pricing.

The proposed rule, which CMS says in a fact sheet “implement[s] new statutory authorities included in the Medicaid Services Investment and Accountability Act of 2019,” is meant to improve the Medicaid Drug Rebate Program by “proposing new policies that would assure greater consistency and accuracy of drug information reporting, strengthened data collection, and efficient operation of the MDRP.” Per the fact sheet, notable elements of the regulation include:

Challenges with finding transportation is keeping many U.S. adults from accessing necessary health services, according to a recent report from the Urban Institute. Health policy experts tell AIS Health, a division of MMIT, that providing non-emergency medical transportation (NEMT) can benefit payers by enabling people to make their routine appointments and adhere to medications, which lowers the risk of high-cost hospitalizations.

However, they say that while Medicaid requires NEMT and Medicare Advantage plans are increasingly offering the benefit, NEMT remains uncommon in the commercial, employer-sponsored insurance sector.

Even when NEMT is available, its usage remains low. For instance, a study released earlier this year from the Medical Transportation Access Coalition (MTAC) found that only 4.6% of Medicaid and Children’s Health Insurance Program beneficiaries used NEMT in 2019. The MTAC, which was formed by three leading NEMT brokers and is managed by Faegre Drinker Consulting, analyzed data from 66 million people enrolled in 32 states and Washington, D.C.

More than 1 in 5 adults without access to a vehicle or public transportation missed or skipped a health care visit in the previous year, according to a recent Urban Institute study.

Using June 2022 data from the Urban Institute’s Health Reform Monitoring Survey, the researchers found that overall, about 5% of non-elderly adults reported forgoing medical care due to transportation barriers in the previous year. The experience was more common among Black and Hispanic/Latinx adults, individuals from low-income families, people with disabilities and those using public insurance.

In a new regulation released on May 23, the Biden administration proposed increasing drug price transparency reporting by PBMs and pharmaceutical manufacturers supplying Medicaid — and requiring Medicaid managed care organizations to remove pharmacy benefit administration costs from medical loss ratio (MLR) reporting. Experts say the proposed rule is a marginal but meaningful step forward in prescription drug cost containment, but they add that the proposed rule won’t do as much as bills under serious discussion in Congress to rein in controversial PBM business practices such as spread pricing.

The proposed rule, which CMS says in a fact sheet “implement[s] new statutory authorities included in the Medicaid Services Investment and Accountability Act of 2019,” is meant to improve the Medicaid Drug Rebate Program by “proposing new policies that would assure greater consistency and accuracy of drug information reporting, strengthened data collection, and efficient operation of the MDRP.” Per the fact sheet, notable elements of the regulation include: