In Washington, Kentucky governor brags about an opioid policy that worries health experts at home

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Speaking before 13 other governors on Saturday, Kentucky Gov. Matt Bevin (R) talked up a state policy that expands access to drug addiction treatment. But the progress he touted will likely be blunted by forthcoming Medicaid changes in the state, which could make it harder for people with substance use disorder to keep health insurance and, thus, get addiction treatment.

“Couple of things we’ve done in Kentucky,” said Bevin at the biannual governors conference in Washington, D.C., as he went on to list policies like more treatment beds and opioid prescription monitoring systems aimed at curbing an epidemic which kills an average of four Kentucky residents every day.

But in his speech to other governors, Bevin neglected to mention all of Kentucky’s unprecedented changes to Medicaid, which pays for thousands of treatment services annually. The government-run insurance program, Kentucky HEALTH, will soon require people to work 80 hours a month for insurance, pay premiums and copays — and failure to do any of this means being locked out of coverage for six months. In a separate conversation with ThinkProgress, Bevin seemed convinced the changes won’t impede treatment for those addicted to opioids.

The changes imply that people with “chronic” substance use disorder should be exempted from these restrictive policies, but confusion persists among stakeholders. “We don’t know how ‘chronic’ is determined or differs from another [substance use disorder] diagnosis,” said Kentucky Voices for Health’s Emily Beauregard. Local lawmakers just told Priscilla McIntosh, CEO of the Louisville drug treatment center the Morton Center, that a “medically frail” designation from the state should exempt her patients. “It’d be nice to have [more] information very soon so we can all prepare,” she told ThinkProgress.

“So my bottom line is if they cannot afford health care, they can’t access treatment … The untreated disease reality is, we know that, it ends quite badly — often in death.”

Dwale resident Lakin, for one, is especially concerned the new rules will interfere with her drug treatment (paid for by Medicaid), so she, and 14 others, are suing the federal government for even approving Kentucky’s new Medicaid program — an insurance program originally set up for the poor and disabled that now covers 1.4 million people statewide. (Her lawyers asked that ThinkProgress omit her last name for privacy concerns.) The twenty-year-old — who’s recovering from addiction, primarily to methamphetamines — should fall under “medically frail” exemption, but according to her lawyers, this isn’t for certain.

Who is “medically frail”?

The deputy commissioner of the Kentucky Department of Medicaid Services said the state will identify people as “medically-frail” by using a medical diagnosis, health insurance claims, or doctor/enrollee testaments to find these people.

Insurance claims will likely identify those, for example, who went to the emergency room for drug overdosing or went through opiate detox. “But most will likely have to self attest,” said McIntosh. “We think many people will not understand how to initiate or navigate this process.” Here’s an example of the drafted 32-page attestation form for insight into that process:

Only people with HIV, who are “chronically” homeless, or disabled, as recognized through Social Security Income (SSI) will be automatically exempted. The rest, including those who suffer from drug addiction, need to undergo the exemption process.

“We don’t know how long the exemption process will take, but I recall one of the state officials saying 60 days,” McIntosh said. “This, of course, would rely on how quickly the Medicaid member can see a provider and complete the attestation requirements.”

It’s a rigid system because of the medical designation’s history. “Medical frailty is actually a concept in law and regulation,” said health care consultant with Manatt Health, Patricia Boozang, who also advises states on Medicaid expansion designs. It’s intended to be a “protective policy” that tries to safeguard vulnerable communities from losing access to comprehensive coverage. Even so, this designation might miss some people with substance use disorder, she said. “[They] are most at risk of dropping out because they just don’t do what they’re supposed to do.”

Sharon Tankersley, executive director for Lexington’s Voices of Hope, said the state shoulders the responsibility for misunderstanding what it’s supposed to do. To expect people with substance use disorder to “pick up the responsibilities that are implied by this new set of guidelines is pretty naive,” she said.

“I think it definitely will add more work on our clinicians — just with the additional documentation,” said McIntosh of her own addiction treatment facility.

Moreover the requirements fundamentally misunderstand addiction as the rules end up boxing in how diseases and treatments are defined. While medically frailty is obvious during the acute stage of addiction, it’s not so identifiable during a person’s lifelong recovery process, Tankersley said. What the state says qualifies as treatment is especially concerning to Tankersley, as recovery is very personal.

“So my bottom line is if they cannot afford health care, they can’t access treatment … The untreated disease reality is, we know that, it ends quite badly — often in death,” said Tankersley.

Why aren’t officials listening to the stakeholders?

But, despite the uncertainty among many stakeholders and experts nationwide, Bevin is convinced the program will help fight the state’s opioid epidemic. He told ThinkProgress the new rules will enable the state to locate people with substance use disorder.

“It literally will find people like that who are slipping through the cracks and get them help,” Bevin told ThinkProgress on Saturday. “If a person is unable to do one of those things because they have a drug addiction, that’ll be identified as part of the requirement for them and then they’ll be put into a program where they can get help. So right now, these people are getting nothing and this way, they will get something.”

“I think it definitely will add more work on our clinicians — just with the additional documentation,” said McIntosh of her own treatment facility. These restrictive measures — that’ll add to an already arduous process — aren’t tethered to the positive policies proposed by Bevin. In fact, several states sought federal permission to personalize Medicaid for people with substance use disorder and to get federal dollars for treatment beds. Work rules and lock-outs are isolated from that and are intended to improve health by getting people to work. But experts are dubious of this claim as the reverse is likely true: people work because they’re healthy.

Policies for this program, which begins in 2019, are still being developed and stakeholders have not been given definitive answers to their questions just yet. When ThinkProgress reached out to state officials, requesting comment, numerous emails went unanswered.


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