Association for Public Policy Analysis & Management

Background and Purpose: The Affordable Care Act (ACA) has produced dramatic changes in the organization, funding, and accessibility of substance use disorder (SUD) treatment. Concurrently, the national opioid epidemic has presented a significant challenge and pressing policy priority for states when considering the accessibility of treatment. As part of the National Drug Abuse Treatment System Survey (NDATSS) project to better understand the implications of the ACA and political and policymaking factors that influence state-level decision-making and actions regarding SUD service delivery reforms, we developed case studies of eight states through a series of in-depth qualitative interviews.

Methods: California, Colorado, Florida, Georgia, Kentucky, Ohio, New Hampshire, and New York were selected for inclusion based upon variation in: (1) Medicaid expansion versus non-expansion; (2) state-based versus federally-facilitated insurance exchange; and (3) high salience of SUD issues, as measured by media attention. A total of 83 audio-recorded telephone interviews were conducted with approximately 10 stakeholders from each state involved in the implementation of state-level reforms including administrators from Single State Agencies for SUD Services, Medicaid, and Health Insurance Exchanges; regional and county behavioral health authorities; SUD treatment providers; treatment and recovery advocacy groups; and Medicaid Managed Care and Qualified Health Plan representatives. Using a modified grounded theory approach, all interview transcripts were first coded using an a priori-based scheme. Transcripts were then co-coded to establish consensus. Finally, emergent themes were identified and analyzed with respect to state policies and delivery model factors.

Results: The opioid epidemic is a top priority across states and states have taken several approaches to SUD addressing treatment accessibility. However, political factors play a significant role in how states address the epidemic. Predominantly Democrat-controlled states have adopted ACA reforms and Medicaid waiver opportunities to increase access to SUD treatment to address the opioid epidemic. In contrast, Republican-controlled states such as Florida and Georgia have political leadership who have rejected the ACA but have implemented other state-level policy reforms. New Hampshire, a battleground state, was particularly heavy-hit by the epidemic and bipartisan support for Medicaid expansion and the development of a robust SUD treatment benefit would likely not have been possible without such grave problems. We detail the similarities and differences in state approaches toward reform given these political factors. Additionally, we explore an emerging policymaking concerns related to the growing need for buprenorphine prescribers across states attracting previously negligent “pill mill” prescribers.

Conclusions and Implications: Understanding how states are implementing SUD service delivery reforms provides important contextual information about the nature of health reform at the ground level and helps us to think about the motivations – such as the opioid epidemic – and understandings of those responsible for policy planning and implementation.