States continue to leverage Medicaid Section 1115 Waivers to address opioid crisis

With the end of the COVID-19 public health emergency on May 11, 2023, and the end of Medicaid's continuous enrollment provisions meant to protect coverage during the pandemic, millions are expected to lose Medicaid coverage in the coming months.

Ten states have still not expanded access to Medicaid, according to data released today from the Center for Public Health Law Research at Temple University Beasley School of Law (CPHLR). This denies access to care to approximately 1.9 million people living in Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. North Carolina and South Dakota have both approved expansion, with implementation pending.

"Medicaid funding for low-income adults has been shown to improve access and outcomes for people with substance use disorder," said Jon Larsen, JD, MPP, a Legal Program Manager at the Center for Public Health Law Research at Temple University Beasley School of Law. "We are going through a period of mass disenrollment, and we know that many people who disenroll may not reenroll even if eligible, reducing access to greatly needed care for all impacted."

Medicaid Section 1115 waivers provide one stopgap opportunity for states to support people with substance use disorder by improving access to care for recovery by supporting medication for opioid use disorder (MOUD) treatment during residency at an Institution for Mental Disease (IMD) facilities, coordination of MOUD treatment surrounding release from correctional facilities, and other care coordination.

SUD-specific Section 1115 waivers related to MOUD treatment in IMD facilities have now been approved in 35 states. Only two of the non-expansion states have approved SUD-specific waivers.

"Under Section 1115 waivers states can creatively experiment with requirements to provide flexibility beyond federal requirements for enrollment and benefits—potentially expanding access to needed services that benefit people with opioid use disorder," said Larsen.

Section 1115 waivers have been approved in 11 states to allow for Medicaid payment for mental health treatment services in IMDs.

Nineteen states have approved Section 1115 waivers to address certain social determinants of health (SDOH), including a range of housing, nutrition, employment, and transportation supports. The Biden administration has encouraged Health-Related Social Needs (HRSN) waivers to address health disparities and advance whole-person care, that could ultimately help people with SUD by reducing barriers to care.

Medicaid work requirements are expected to return in Georgia this summer. Other Medicaid work requirement section 1115 waivers may be on the horizon due to the recent Federal Court ruling that vacated the Biden Administration's recission of Georgia's 1115 waiver requiring certain work requirements for Medicaid eligibility.

The dataset published today displays key features of approved state Section 1115 waivers, particularly eligibility and benefit expansions that may increase access to services that benefit people with SUD, as well as expansion of Medicaid under the Affordable Care Act, across all 50 states and the District of Columbia approved as of April 20, 2023.

"Our data build upon valuable existing research by the Kaiser Family Foundation tracking Medicaid 1115 waiver approvals," said Larsen. "Our data capture both Medicaid expansion under the ACA and elements of Section 1115 waivers in the context of addressing the opioid crisis, bringing together details and displaying relevant text from the waivers that are critical to efforts to better understand Medicaid's role in providing access to OUD treatment on a state-by-state basis."

This dataset was built with Indiana University's Hall Center for Law and Health using a scientific legal mapping process called policy surveillance pioneered by CPHLR.