State lawmakers agreed yesterday to advance key items of Gov. Chris Christie’s agenda to address New Jersey’s opioid epidemic. Yet many of them remain concerned about the cost of these proposals, the capacity of the treatment system to absorb new patients, and the possibility that the changes envisioned could leave some patients without the help they need.
Legislation to codify two of Christie’s policy priorities was approved with broad support by both the Senate health committee and the Assembly panel Monday, with few changes from the draft version first circulated just days ago among the sponsors and legislative leadership.
The measure (A3/S3) would ensure that millions of Garden State residents had immediate access to long-term treatment for addiction issues, without interference from their health insurance company; it would also limit initial opioid prescriptions to five days only in cases of acute pain and require physicians to explain to patients the potential for becoming addicted. As of Monday night, the legislation had yet to be posted for public review on the Legislature’s website.
While they chose to support or stay neutral at Monday’s hearings, critical stakeholders also continue to struggle with some aspects of the proposal. Insurance companies, represented by the New Jersey Association of Health Plans, are worried about the potential costs of long-term inpatient treatment with limited controls. The New Jersey Business and Industry Association is concerned about the impact of these additional expenses on premiums and what that will mean to its members.
The legislation does not address cost of insurance mandate
The draft legislation would apply to plans that cover government workers and teachers — whose healthcare is funded by taxpayers — as well as to those who buy coverage on the New Jersey market, about 30 percent of insured residents. But it does not address the potential cost of the insurance mandate, which would require health plans to provide up to 28 days of treatment without any review by insurance company officials, and as much as six months of care if required by a physician with minimal financial oversight.
“Health Plans can cover anything that the Legislature passes but you should be aware that there will be a significant cost to the State Health Benefits Program and the coverage mandate will significantly increase premiums for all policy holders who buy insurance in the commercial marketplace,” AHP President Ward Sanders wrote in his testimony.
The AHP and the business association asked legislative leaders to send the bill to the budget committee in both the Assembly and Senate for a full financial review. But staff for Assembly Speaker Vincent Prieto (D-Hudson) and Senate President Steve Sweeney (D-Gloucester) — both sponsors of the bill — said Monday the legislation would instead go straight to a floor vote.
In his January 10 State of the State address, Christie focused extensively on New Jersey’s ongoing addiction crisis and charged legislative leaders with passing a law to address two policy goals within a month — the insurance mandate and prescription limits. Since then, the work of crafting a bill has fallen to nonpartisan legislative staff and the offices of other sponsors: health committee chair Sen. Joe Vitale (D-Middlesex), Senate Minority Leader Tom Kean Jr. (R-Union), physician and Assemblyman health committee chair Herb Conaway (D-Burlington), and Assembly Minority Leader Jon Bramnick (R-Union.)
Opioid and heroin use has become a growing focus for the governor in recent years and, despite numerous efforts to reduce overdose deaths and connect addicts with better treatment, the death rate continues to rise. New Jersey lost 1,600 residents to the disease in 2015 alone, a 22 percent annual increase.
Christie’s proposals more difficult to implement than he has suggested?
Christie has enjoyed broad support for his commitment to addressing addiction as a disease, not a moral failing, but experts suggest his latest proposals may be more difficult to implement and less beneficial than he has suggested. The mandate requiring long-term insurance for addiction treatment would apply to less than 30 percent of Garden State insurance policies since most are regulated by federal, not state, law and its success depends on the availability of treatment beds.
“These beds are not available,” Sen. Robert Singer (R-Ocean), warned fellow members of the Senate health committee.
New Jersey currently licenses fewer than 3,000 inpatient beds, plus 315 outpatient programs. In 2015, some 28,000 residents sought treatment, while many thousands more were turned away. Waiting lists for low-cost facilities can stretch up to eight weeks, experts said.
“We’ve got to understand what we’re doing so there’s not chaos,” Singer added. He urged colleagues to consider adding language to the bill to expedite the regulatory approval process the state uses to approve new beds, something Vitale is seeking to address through a separate bill introduced late last year and approved by a Senate committee earlier this month.
‘Easier to open a gentleman’s club in this state’ than to expand drug treatment programs
Tom Allen, an addiction specialist who leads Core Health, a treatment facility in South Amboy, agreed bed access was “a chronic issue.” He joked that current state regulations and local zoning laws make it almost “easier to open a gentleman’s club in this state” than to expand drug treatment programs.
But Robert Budsock, president and CEO of Integrity House, which runs both inpatient and outpatient substance abuse programs, said his program dedicates 390 of its 420 beds to those without the ability to pay. These beds are rarely free, he said, recalling how Integrity House had to scramble to find a spot to accommodate four poor people who walked in last week desperate for treatment.
“If those four individuals had a rich insurance package, I could have had them in treatment within two hours,” Budsock said. “The biggest bed shortage we have is beds for poor people.”
Experts agree that category includes the nearly 2 million New Jersey residents now covered by Medicaid, or FamilyCare, which encompasses extensive outpatient and counseling services, but very limited inpatient services. The insurance mandate in Christie’s legislation — which he framed in his annual speech as relief for middle-class families — would not apply to these patients, something that worried several Assembly members. (Those covered by self-insured plans not subject to state law — nearly half of the policies issued statewide — would also be outside its reach.)
“I have grave concerns that we’re not actually reaching far enough,” said Assemblywoman Pamela Lampitt (D-Camden),” that we’re going to be creating cracks in our own system and not catching those individuals” on Medicaid or without insurance who also need help. Lampitt also worried about the likely impact on premium prices, but voted to support the proposal all the same.
But Jessica Knowles, a substance abuse counselor at Humble Beginnings Recovery Centers, in Cherry Hill, said the legislation could still be a tremendous help to many families. Knowles said she often encounters patients who are “working people and are paying for private insurance [but] have their hopes let down when they find out substance abuse isn’t covered for them or their children.”
Patients sent home from detox programs when insurance company refused to pay
Knowles also described patients being sent home from weeklong detox programs after only a few days, when their insurance company refused to pay. “And these are people who are willing [to enter treatment] and have made the call to get help,” she said.
According to the AHP’s testimony, a mix of federal and state laws already mandate extensive coverage for addiction treatment, including inpatient care. But these laws also allow insurance-company physicians to review these treatment plans to assess both medical necessity and cost implications. The group also pointed to several studies that suggest inpatient treatment —which is far more expensive than outpatient care — is not always the best option, something a number of treatment providers echoed in testimony Monday.
The legislation also seeks to reduce the supply of highly addictive opiates by limiting the initial prescription for acute pain to a five-day supply; doctors can now provide up to 30 days’ worth of pills for injuries, like a broken arm, or after surgeries that result in temporary discomfort. The restrictions would not apply to patients with chronic pain related to cancer or other conditions, or to those in hospice.
Testifying before the Assembly committee Monday, Prieto noted that studies show four out of five heroin addicts became hooked first on prescription pills. “That’s something we have to curtail,” he said, calling the epidemic “one of the greatest challenges we have at this time in the state.”
Governor’s plan to limit first prescriptions to five-day supply blasted as ‘cruel’
While physicians and pain patients first blasted Christie’s proposal for limiting first prescriptions as “cruel” and “punishment” to those who are suffering, some — including Dr. Lewis Wetstein, of Freehold, with the American College of Surgeons — agreed not to oppose the measure Monday. Several urged the committee members to consider amending the law to allow for a seven-day supply, instead of five, especially for those who endure major surgery and might get caught on a weekend scrambling to get a renewal.
“There has to be a different way to address this other than making patients suffer,” Wetstein said, explaining that he performs cardiac surgery that involves cracking ribs and prying open a patient’s chest — a process that causes significant pain and suffering, even when the operation is a success. These patients usually need at least ten days to two weeks of pain medicine, he said.
The bill permits physicians to issue another prescription after four days, if they assess the patient and determine more medicine is needed. The doctor would also be required to discuss the dangers of addiction with the patient, or their parent or guardians if treating a minor; offer less addictive options; check the state’s electronic database to ensure the patient isn’t obtaining pills from another physician; and record their conversation with the patient in the person’s medical chart.
Vitale, who has worked for years to combat addiction and reduce the harm associated with drug use, stressed that it will take time to combat the full impact of drug abuse in New Jersey. “It will be a while before we see the light at the end of the tunnel,” he said. “We can continue to treat people the best we can, but if we don’t address the demand side we will continue to deal with this for generations.”