From 2000 to 2014, nearly half a million people in the United States died from drug overdoses. The nation has made significant strides in battling this epidemic, but we need to do more.

Today, International Overdose Awareness Day, is a good time to explore comprehensive strategies to reduce drug addiction, which is one of Community Catalyst’s goals. The aims of this day include remembering those who have died or been permanently injured as a result of drug overdose, and showing that the tragedy of overdose death is preventable. Most national attention has focused on naloxone (brand name Narcan), a lifesaving opioid overdose antidote, which counters the effects of an opioid overdose by allowing the victim to breathe normally. The antidote has been used for several decades by emergency medical personnel, but in recent years, the focus has been getting naloxone into the hands of people who use drugs themselves as well as their friends and families. Studies have shown that providing opioid overdose training and naloxone kits to such nonprofessionals who might witness an opioid overdose can help reduce deaths, and that naloxone distribution to drug users is cost-effective.

Naloxone is an essential step in a larger strategy. But it is under attack.

Overdose Prevention DayElected officials in Maine and Pennsylvania are among those arguing that naloxone perpetuates addiction and encourages people to engage in riskier drug use with no fear of overdose.

But few people who use drugs would knowingly risk death, especially given that naloxone puts opioid users into withdrawal and makes them violently ill. Naloxone does save lives, and is not a crutch for people who have problems with drugs to use in riskier ways. For some, being revived after an overdose is an intervention point for treatment. However, we know it’s not a panacea either. We recommend a multifaceted approach that seeks to prevent and treat addiction, reverse overdoses, and help people access services to lead healthier lives.

An essential component of addressing addiction is starting early, before people transition to problematic use. We promote using  Screening, Brief Intervention, and Referral to Treatment (SBIRT), a public health approach that involves health professionals asking young people a few questions about drug and alcohol use, and providing guidance or referring them to treatment if a problem exists. By providing a space where young people feel comfortable discussing their substance use, trusted adults can abandon the ineffective “Just Say No” paradigm. Instead, they can seize the opportunity to discuss the problems alcohol and drug misuse can cause in a health-centered and compassionate way, and recommend further counseling and treatment. By not waiting until a tragic event occurs, this approach can ultimately prevent overdoses among young people.

Another important step is ensuring that treatment is accessible, evidence-based and good quality. And a third step is supporting approaches that promote support over punishment. People with severe substance use disorders who have experienced an overdose need more community-based supports, ranging from health to social to economic services. This is especially true given that prior overdose is the strongest predictor of future overdoses. Therefore, we promote comprehensive programs for people at risk of arrest or jail because of drug-related behaviors — programs that divert them into health and social services. In these pre-arrest diversion programs, case managers work with participants to understand their multifaceted health problems and develop individualized care plans. This participant-centered approach focuses largely on what individuals believe they need to improve their health, and case managers serve as advocates, coordinating and securing the services they need.

On International Overdose Awareness Day, we want to send a strong message to current and former drug users that they are important members of our communities. At Community Catalyst, whether we are advancing programs and policies that create safe spaces for young people to talk about drug use, or strengthening the continuum of community-based services for people at risk of incarceration, we do so because we think everyone deserves access to quality health care, and that our health system needs to better serve all vulnerable populations.

(Last year, the Robert Wood Johnson Foundation launched a joint initiative with Community Catalyst called the Value Advocacy Project (VAP). The project is supporting consumer health advocacy organizations in six states in their non-lobbying advocacy efforts to pursue local and state policy and health system changes that increase the value of health care by improving health outcomes and lowering health care costs, especially for populations that have disproportionately poor outcomes. Building on the Center for Consumer Engagement in Health Innovation’s recently released Consumer Policy Platform for Health System Transformation, we will be highlighting our state partners working on issues outlined in the policy platform and encouraging them to share how their work can translate to advocates’ efforts across the country.)

New York is in the midst of massive changes to its health care system - within five years, the state expects that 80 percent of residents will receive care under a value-based payment scheme and have access to an Advanced Primary Care practice, modeled on the patient-centered medical home. Value-based payments and advanced primary care are both strategies meant to reduce avoidable hospital use. New York traditionally performs poorly on hospitalization measures - for example, we have some of the worst admissions rates in the country for children and people who have been recently discharged into nursing homes.

New York has two federal funding streams guiding these changes: a.) the State Innovation Model (SIM) Testing grant and b.) the Delivery System Reform Incentive Payment Program (DSRIP), part of an $8 billion Medicaid waiver. Both initiatives are being developed through workgroups, which include some consumer advocates. However, consumers need support and organization to effectively engage in this work. Industry leaders have greater resources to devote to influencing policy than consumers and consumer groups, including money, time and technical expertise. Everyone shares the goal of reducing avoidable hospitalizations. But the strategies developed to achieve it will not succeed if they do not work for consumers. Consumer voices have to be front and center in designing and implementing these strategies. 

Over the next year, Health Care for All New York’s (HCFANY) value advocacy work will focus on educating and organizing consumers according to the following principles (you can see our full set of principles for consumer-friendly health transformation here). 

  • Quality Outcomes. HCFANY will continue to advocate for publicly reported quality measures and for using patient experiences to evaluate delivery reform efforts. Part of this work will include a publication describing how quality measures should be used to measure and reduce disparities – no reform effort should be considered successful unless every community benefits. Without active monitoring, delivery system transformation could even make disparities worse. We are also looking at the opportunities and challenges presented by health transformation for different groups of people – for example, children.   
  • Patient Engagement. Patient engagement should mean providing patients with all of the tools and information they need to advocate for their own care. For example, we’re tracking efforts to improve price transparency and advocating for meaningful care plans for all patients. We’re also developing scorecards that measure how well Performing Provider Systems (part of DSRIP) and Advanced Primary Care practices (happening through SIM) incorporate consumer voices into governance structures and inform consumers about provider incentives.
  • Consumer Leadership. To help create balance between consumers, payers and providers, HCFANY is developing a forum for consumers and advocates who are participating in payment and delivery system reform planning groups. The forum will be a way for the state’s consumer groups to share the burden of this participation and receive technical assistance.
  • Access to Care. Part of our work will focus on consumers’ existing rights and the adaptions that might be needed as the health system changes. New York State already has a managed care and hospital bill of rights, but these were written for the old way of conducting business. We will identify the shortcomings of our existing bill of rights documents, re-assert patients’ rights in new settings and develop a new bill of rights document or set of principles that protects consumers in value-based payment arrangements.

Many of our challenges will overlap with the challenges experienced in other states. Wide-scale use of value-based payments is untested. There may be many benefits for consumers, but there will undoubtedly also be new problems that cannot be fully anticipated. HCFANY is looking forward to sharing what we learn this year with other advocates through publications and conversations, and to learning from them.

Author: Amanda Dunker, Policy Associate, Community Service Society of New York

Even with health care coverage, Medicaid beneficiaries still find themselves facing numerous barriers to accessing the care they need and achieving better health outcomes. One barrier that continues to cause serious access problems is transportation. There are an estimated 3.6 million people in the United States who miss or delay medical care because they don’t have access to transportation.

NEMT 3 Million PeopleIn early August, the Center for Consumer Engagement in Health Innovation (the Center) submitted a comment letter to the Centers for Medicare and Medicaid Services (CMS) regarding Iowa’s request to extend its waiver of Non-Emergency Medical Transportation (NEMT) benefits from its state Medicaid demonstrations (Iowa Wellness Plan and Marketplace Choice Plan). The waiver excludes coverage for NEMT services, a benefit that is standard in non-waiver Medicaid programs.

NEMT provides access to and from medical appointments for consumers who do not have other means of transportation. Reimbursed services can include shared van programs, taxis or public transit. Many in need of NEMT are lower-income beneficiaries, often older adults or people with disabilities. A high proportion of these individuals live with multiple chronic conditions such as end-stage renal disease, cancer or chronic obstructive pulmonary disease. Monitoring and treatment for these conditions require frequent medical appointments and limited transportation options may prevent access to timely, life-sustaining care.

Transportation barriers can have a “domino effect” on health outcomes and cost of care. Missed or delayed appointments can worsen health conditions and end up necessitating expensive ambulance services and costly emergency department visits. This is why NEMT has proven to be highly cost-effective.

For individuals in need of behavioral health services, NEMT is particularly critical. One study found that the largest proportion of adult beneficiaries who use NEMT do so to access mental and behavioral health services. More than 40 percent of NEMT trips in New Jersey and 30 percent of trips in Nevada were used to access mental health or substance use treatment appointments.  

The Center is concerned that several states have sought to exclude NEMT for some of their Medicaid beneficiaries. These actions reveal the need for consumer advocates to ensure that other states do not follow suit. 

This is why the Center submitted comments on Iowa’s waiver request and why we plan to also submit comments opposing Indiana’s similar proposal. We encourage others to do the same. The comment period for Indiana’s NEMT waiver request is open from August 12 - September 11, 2016. 

Submitted by Andrew Jopson, Summer Intern. Andrew is a graduate student at the University of Washington, Seattle.

Louisiana is the leading the way when it comes to being innovative to improve the lives of its citizens.

Our new Governor John Bel Edwards boldly campaigned that he would expand Medicaid in a deeply red state. He appointed a leader who thinks out of the box in Dr. Rebekah Gee, Secretary of the State Department of Health and Hospitals, and kept his promise. 

You may have read that Louisiana is the first state to utilize food stamp data to fast-track Medicaid enrollment. Through a state plan amendment, we were able auto-enroll about 105,000 eligible residents based on their participation in SNAP. Along with linking databases of participants in the Greater New Orleans Community Health Connections Program (which offered limited Primary Care in the four Parishes around New Orleans) and Take Charge Plus (which offered family planning benefits), there were already 233,794 enrollees in the first 30 days of the enrollment period. 

With such great early successes you may be wondering like me, what can they possibly do next? But, this innovative team just keeps on thinking. Their vision of having a healthier more equitable state is just beginning.

Health Care Innovation LouisianaThe Special Projects team is now engaging with the Department of Corrections (DOC) to set up pre–release enrollment for justice-involved individuals into Medicaid. This will allow those men and women released from prison or jail to not only be linked to an insurance plan that can cover their provider visits and medications, but also to receive much-needed care coordination upon release.

Prior to expansion, Medicaid was only available to cover the cost of hospital stays of eligible justice-involved individuals, which was typically limited to persons with disabilities. With Medicaid expansion, the cost of hospital stays for almost all justice involved individuals will now be paid for by Medicaid since eligibility will be based income rather than disability. This is expected to relieve a great financial hardship for the corrections system.  Additionally, for those offenders that DOC indicates have high-need medical issues, the Louisiana Department of Health and its contracted insurance plans are working to ensure those individuals have focused case management prior to their release. This ensures linkages to care and other needs in order to create the best opportunity for successful reentry and to prevent recidivism.

Due to the complexity involved in enrolling and stabilizing this population, the state is taking the project one phase at a time and starting with offenders at the state level in the nine state-run facilities first (approximately 3,500 releases each year). The next phase of the project will involve enrolling state offenders housed within 104 local jails (approximately 15,000 releases each year).  A stakeholder process will be initiated as the state approached phase 2 in order to engage local jails, providers and advocates to make enrollment successful.

We know that many of the individuals who are currently incarcerated have high rates of mental illness and substance use. This population in Louisiana is also disproportionate­ly male, minority and poor. Recidivism can be correlated to the lack of treatment of these behavioral health issues. The leadership Louisiana is providing in the pre – release enrollment project for Medicaid of the incarcerated population is an example of how innovation and creativity can not only decrease costs to systems but save lives.

As a proud Louisiana resident, I look forward to what ground breaking strategies this team will come up with next to ensure we have a healthier more prosperous state. Geaux Louisiana!!!  

Joia Crear Perry, M.D. is CEO of the National Birth Equity Collaborative and a member of Community Catalyst’s Board of Directors.

This month, the first wave of locally-transmitted Zika virus infections in the continental United States in Florida could signal the escalation of a public health crisis with lasting consequences. Early action by the Obama administration improved access to Zika preventives, such as mosquito repellant, for Medicaid beneficiaries. Yet Medicaid’s effectiveness to fight against Zika is hobbled by the refusal of many state governments to close the Medicaid coverage gap. Tens of thousands of those most at risk for Zika in states like Florida, Texas, and Georgia are uninsured because they’re stuck in that gap.

State health advocates have keenly noted the hypocrisy: at the same time that state officials are calling on the federal government to address Zika with emergency aid, these same states cite opposition to federal support as a key reason to resist closing the Medicaid coverage gap—which would make health care accessible for hundreds of thousands of people in need. The result is billions of federal dollars left on the table in non-expansion states – money that would ensure a more comprehensive approach to fighting Zika than relying solely on emergency funds after the situation worsens.

Florida health advocates bristled at the governor’s suggestion that women thinking of becoming pregnant should consult their health care providers about the risk of Zika. Florida CHAIN released a statement  emphasizing the absurdity of this advice for the more than 280,000 uninsured Florida women caught in the coverage gap. The Florida Health Alliance created a Zika fact sheet and this week called on members to contact their legislators about Zika.

Puerto Ricans migrating to the mainland United States are also highly at risk. Puerto Rico recently declared a state of emergency on the island due to Zika. The lack of health care in migrant and immigrant communities has concerning implications for health equity in Florida. This disturbing disparity could be alleviated if Governor Scott and other Florida policymakers took swift action to close the coverage gap this year.

As Texas braces itself to be the next state with local transmissions of Zika, advocates are already calling on state policymakers to close the coverage gap as part of the equation to address Zika. They believe waiting until Zika becomes an emergency to take action is the wrong choice for the roughly 800,000 uninsured Texans in the coverage gap. Increased access to Medicaid among low-income individuals is critical to efforts to detect and prevent the spread of Zika and associated health problems such as microcephaly, which will have long-term effects. Although pregnant women typically have more generous eligibility for Medicaid, women who might not know they are pregnant yet, and the partners of pregnant women – who can spread Zika through sexual transmission – often fall into the coverage gap.

Meanwhile, Louisiana’s newly expanded Medicaid program, Healthy Louisiana, took swift action to prevent Zika by covering mosquito repellant and other preventive services. Louisiana’s decision to close the coverage gap effective July 1, 2016 means that 375,000 Louisianans are newly eligible for Medicaid coverage as Zika heats up in the region. What a contrast!