While Gov. Chris Christie received widespread praise for seeking to reduce the pain, suffering, and stigma associated with drug addiction in his State of the State address, translating those goals into effective policy could prove a stiff challenge.
Industry experts have raised multiple questions about the scope, cost, and other details of Christie’s proposal to mandate health insurance coverage for up to six months of treatment for substance abuse, including in-patient care. They also warned that, regardless of how the law is crafted, some two-thirds of New Jersey’s residents would remain outside the reach of this reform.
And the state’s powerful physicians lobby opposed the governor’s call for an emergency rule requiring prescribers to provide no more than five days worth of opioid drugs at a time, suggesting that such a limit would do little to curb addiction while decreasing the quality of care for legitimate pain patients.
Christie devoted much of his annual speech to the opiate epidemic plaguing New Jersey, recounting a trio of moving personal stories about addiction and highlighting his efforts over the past few years to stem the flow of opiate painkillers, improve access to treatment, and reduce overdose deaths. Still, some 1,600 residents died of drug overdoses in 2015 and 28,000 sought treatment.
The governor continued to focus on these issues Wednesday, when he joined a group of addicts in a recovery group at the Preferred Behavioral Health clinic in Toms River. Christie thanked them for helping him better understand the issue and pledged to work with leaders from the GOP mega-donor Koch Industries to encourage New Jersey companies to do more to hire former inmates and recovering addicts — another plan he touched on in his speech.
Christie also used the State of the State to announce various regulatory reforms designed to increase treatment options, especially for older teens, and pledge new money for additional beds. Other efforts, including a school curriculum focused on addiction and more sober housing on college campuses, are already enshrined in law, although the programs may not be fully implemented or funded.
But the two major initiatives the governor outlined — the insurance mandate and the rule to limit prescriptions — are likely to present policy and political challenges. The insurance industry and the Medical Society of New Jersey, along with other providers, are among the largest forces in New Jersey’s healthcare sector and two of the most powerful lobbying blocks in Trenton, who often end up on different ends of the same issue.
“Whether your child lives or dies should not be subject to a denial letter from an insurance company. On behalf of our middle class being attacked by the double whammy of the addiction crisis and denied coverage by our insurance industry, I demand we end this today together,” Christie said in his speech Tuesday.
While insurance leaders offered to work with Christie and lawmakers, led by Assemblyman Jon Bramnick, (R-Union), on the mandate, they may be in uncharted territory. Currently, only two states — Massachusetts and New York — require substance-use disorder treatment to be covered and the benefit is capped at 14 days. Requiring coverage for six months, or 180 days, of either outpatient or inpatient care would be extremely costly, experts said, and may not lead to the most effective course of treatment.
Currently, insurance companies in New Jersey must preapprove most nonemergency inpatient services, whether they relate to addiction treatment or other medical care. Decisions involve comparing the care proposed with a standard set of best practices, experts said, and the process can be expedited in urgent situations. No preapproval process is needed for outpatient care.
“Today, New Jersey’s health plans provide coverage for addiction services based on national, evidence-based practices and [we] look forward to having a thoughtful dialogue on current guidelines,” said Ward Sanders, president and CEO of the New Jersey Association of Health Plans, adding that the advocacy organization supported Christie’s plan to limit opiate prescriptions. “We are committed to working with the governor and the Legislature on these important policies.”
Tom Wilson, who heads communications for Horizon Blue Cross Blue Shield, the state’s largest health insurance provider, credited the governor for focusing on “the broad array of factors” that have fueled this crisis. “We are eager to work with Gov. Christie and the Legislature to ensure that those who need and want help ending their addiction have the opportunity to obtain affordable and appropriate treatment,” he said.
Another question is what residents would actually be protected by this reform. The state now has 35 health insurance mandates — requiring a range of cancer screenings, tests for autism and other disabilities, and minimum hospital stays for certain procedures. But since the majority of insurance plans are not governed by state laws like this, the impact of any additional mandate could be limited.
The mandate would apply to roughly 18 percent of state residents who get coverage through the state’s private marketplace, as individuals or through businesses. Another 10 percent — teachers and other public workers covered through the State Health Benefits Plan — are generally included in these mandates, experts said.
Another 20 percent are Medicaid members and, under current federal guidelines, the public plan does not pay for most inpatient addiction treatment. (Christie also pledged to campaign for that to be changed.) If the state chose to include Medicaid in the mandate, it would likely be responsible for the full cost of any claims.
The remaining population — more than 50 percent — is insured through self-funded plans run by large companies or the federal government. These policies are not governed by state insurance laws, including mandates, and while individual companies may choose to include a benefit — like mammograms or prostate cancer screenings — a six-month stay in a rehab facility would be a costly extra, experts noted.
“Who will it cover? How much will it cost? And where will they go?” asked Sen. Joseph Vitale (D-Middlesex), who has led a number of efforts to reduce addiction and will partner with the governor on efforts to increase the availability of sober housing in the community. “There are a lot of unanswered questions.”
Christie’s call to limit opiate prescriptions to a five-day supply is likely to be easier to implement, since the state controls licenses for each doctor, dentist, and other prescriber. But that doesn’t mean it will be simple to accomplish.
Mishael Azam, COO and legislative affairs manager with the Medical Society of New Jersey, said physicians were not on board. She said educating patients on how to securely store and safely dispose of their medicine would do more than limiting supply.
The governor’s proposal was “especially cruel” since the diversion of opiates for illegal use — not abuse by the patient with the prescription — is the source of most addiction, Azam noted, adding that new research also challenges the widely accepted theory that pharmaceuticals are the root of most heroin addiction.
“Unfortunately, statutory medication limits decrease the quality of care and life for pain patients,” Azam said. “The Medical Society of New Jersey opposes such intrusions into the practice of medicine, especially if they do not take into account individual patient circumstances, like medication tolerance or access to insurance, transportation, or alternative treatments.”