Medicaid policies hurt access to medications for opioid abuse: GAO

Start adding items to your reading lists:
Save this item to:
This item has been saved to your reading list.

Trine K. Tsouderos HRI Regulatory Center Leader, PwC US January 31, 2020


State and federal Medicaid policies are posing barriers to patient access to medications that help treat opioid abuse or addiction, a new US Government Accountability Office (GAO) report found.

An estimated 38% of the 2 million non-elderly Americans with an opioid use disorder are covered by Medicaid, noted the GAO report, which focused on three medications: buprenorphine, buprenorphine-naloxone, and naltrexone. Methadone was excluded because it is subject to different dispensing rules.

Under federal law, all state Medicaid programs should cover the three pharmaceuticals for opioid misuse in all their forms—oral, implantable and injectable—because their manufacturers participate in the Medicaid Drug Rebate Program. However, 21 states may not offer Medicaid coverage for either implantable buprenorphine, extended-release injectable buprenorphine or both, the GAO found.

Some states require prior authorization before patients can receive medications that assist in opioid abuse therapy. A manufacturer interviewed for the study reported that prior authorization for injectable buprenorphine is particularly burdensome and can take up to 14 days. Such delays can be life-threatening, providers told the GAO.

HRI impact analysis

Preferred Medicaid drug lists sometimes confuse providers who prescribe drugs to treat opioid misuse and, thus, reduce drug access. In some states, managed care plans serving Medicaid enrollees have different preferred therapy lists for such medications and varying dose restrictions for the same drug, and they frequently change these decisions, stakeholders told the GAO.

State Medicaid policies regarding the distribution method for medications used in opioid misuse treatment also can hurt access. Particularly troublesome are requirements that providers purchase the drugs themselves and seek reimbursement after administration. Some providers can’t afford to buy expensive injectables that could go unused, and they want to avoid federal inspections that could result from storing buprenorphine, the report noted.

On the federal front, rules associated with a series of laws expanding the types of providers that can administer and dispense buprenorphine for opioid abuse treatment are limiting their effectiveness. Previously, only federally approved opioid treatment programs could dispense and prescribe the medications. Now physicians, physician assistants and nurse practitioners can get waivers to do so, but they must meet certification, training, experience and state scope-of-license requirements.

States are starting to make progress in removing access barriers to the three drugs studied by the GAO. For example, at least 12 states had passed laws that prohibit prior authorization of drugs that assist with opioid abuse therapy as of September 2019, the report noted.

The 2018 federal SUPPORT Act includes provisions aimed at improving Medicaid coverage for medication-assisted opioid abuse treatment. It requires that state Medicaid programs cover all such drugs with FDA approval from October 2020 through September 2025.

The law also mandates that HHS develop an action plan that among other things must enhance access to medication-assisted therapy. The report is due to Congress by June, according to the Kaiser Family Foundation.

Read our research

Contact us

Trine K. Tsouderos

HRI Regulatory Center Leader, PwC US

Tel: +1 (312) 241 3824

Crystal Yednak

Senior Manager, Health Research Institute, PwC US

Follow us