In the September 2024 Issue of the Quarterly

This issue of the Quarterly features several articles related to state health policy for behavioral and mental health, including policy recommendations for sustainable growth of the behavioral health workforce, state-level opioid review programs and their impacts, the legal landscape surrounding opioid treatment agreements, and the impacts of Medicaid institutions for mental disease exclusion waivers on the availability of substance abuse treatment facilities. In addition, the issue contains original scholarship on state approaches to Medicaid maternity care contracting as well as state Medicaid experience with value-based payment arrangements for medical products. Readers also will find interesting articles on state-level education quality and its effects on cognitive function, paid leave mandates and care for older parents, the missed opportunity of the VALID Act for regulating laboratory tests, the use of artificial intelligence algorithms to reduce bias and improve population health, and a proposal to expand the Quintuple Aim to include preservation of the environment as another element for improved population health.

The demand for behavioral health services in the United States has far outpaced supply and was exacerbated by the coronavirus pandemic, leading to a severe shortage of licensed providers and limited access to care for individuals in need of treatment. In “Policy Recommendations for Coordinated and Sustainable Growth of the Behavioral Health Workforce,” Briana Last and Erika Crable summarize evidence demonstrating that the long standing challenges of low wages, high workloads, and training gaps continue to impede behavioral health workforce development and retention. The authors argue that current efforts focused primarily on increasing nonspecialist providers are unlikely to address the causes of the behavioral health provider shortage and may even exacerbate them. Instead, they propose federal and state policies to sustain behavioral health workforce growth to meet demand while supporting fair wages, labor protections, and rigorous training.

Health care providers, managers, and policymakers around the world have long subscribed to the Triple Aim of better health for the population, better experiences of care and outcomes for individuals, and lower per capita costs. In recent years, this paradigm has been expanded to include the additional aims of preventing clinician burnout and assuring health equity. In “For a Hexagonal Aim as Driver of Change for Health Care and Health Insurance Systems,” Pierre-Henri Bréchat and colleagues propose a further expansion to include a sixth aim of preserving and improving the health of the environment to create the best health possible. They assert that, as environmental changes continue to impact the structure of society, a “hexagonal aim” might provide ethical guiderails to foster sustainable and improved population health.

Recent reports about the dangers of faulty laboratory tests, especially laboratory developed tests (LDTs), including the spectacular collapse of Theranos owing to fraudulent claims about its blood tests, have fueled public concern about their safety and led to calls for regulatory reform. The Verifying Accurate Leading-edge IVCT [In Vitro Clinical Test] Development (VALID) Act would have helped ensure laboratory test safety and validity through an expansion of Food and Drug Administration (FDA) oversight. However, Congress did not pass the VALID Act, forcing the FDA to finalize regulatory reform on its own. In “Regulating Laboratory Tests: The Missed Opportunity of the VALID Act,” Caroline Horrow and Aaron Kesselheim discuss the rationale for changes to FDA oversight of LDTs and the potential impact of some key proposals pursued by Congress and the FDA, first in the VALID Act and then in recently finalized regulatory changes.

As the United States health care system struggles to achieve the Quintuple Aim (better health, better care, lower costs, reduced clinician burnout, and greater equity), many providers and payers are looking increasingly to machine learning (ML) and artificial intelligence (AI) for help. However, these tools by themselves are unlikely to resolve the challenges facing the health care system. In “Targeting ML and AI Algorithms in Health Care to Reduce Bias and Improve Population Health,” Thelma Hurd, Fay Cobb-Payton, and Darryl Hood call upon AI developers, end users, the public, providers, and policymakers to work collaboratively to adopt a national AI health strategy that realizes the Quintuple Aim, minimizes race-based medicine, prioritizes transparency, equity, and algorithmic vigilance, and integrates patient and community voices throughout all aspects of AI development and deployment.

Workers’ compensation agencies in Washington State and Ohio have implemented opioid review programs (ORPs) to curb unsafe prescribing. Although evidence suggests that such programs reduce unsafe prescribing, pharmaceutical companies and patient advocates have raised concerns about negative impacts that also could result. In “Impacts of State-Level Opioid Review Programs on Injured Workers and Their Health Care Providers: A Qualitative Study in Washington and Ohio,” Tasleem Padamsee and colleagues explored whether three core sets of problems have occurred: (1) unmanaged pain or reduced function among patients, (2) anger or resistance to ORPs from patients or providers, and (3) damage to patient–provider relationships or clinical autonomy. Using in-depth semi-structured interviews with providers and patients in both states, the authors found generally positive consequences of opioid regulations, with providers reporting more limited prescribing and more focused pain control, and patients reporting satisfactory pain control and recovery along with collaborative relationships with providers. Overall, the feared negative impacts did not come to pass for either patients or providers, and opioid controls seem to have been favorably perceived.

Opioid treatment agreements (OTAs) between clinicians and patients describe the risks of opioids and specify requirements that patients must meet to receive their medication. Although it is unclear whether OTAs effectively mitigate opioids’ risks, professional organizations recommend that they be implemented, and jurisdictions increasingly are requiring them. In “The Legal Landscape for Opioid Treatment Agreements,” Larisa Svirsky and colleagues surveyed the laws and regulations of all 50 states and the District of Columbia to identify which jurisdictions require the use of OTAs, the circumstances in which OTA use is mandatory, and the terms that OTAs must include, if any. The authors also surveyed criminal and civil judicial decisions in which OTAs were discussed as evidence on which a court relied to make its decision regarding litigation outcomes. The authors found that OTA use is entwined with legal obligations in various ways, with a slight majority (27) of states now requiring OTAs, and the requirements for OTA use generally triggered, at least in part, by long-term prescribing. Otherwise, there is substantial variation and flexibility within OTA requirements and OTA use can inform courts’ reasoning in lawsuits involving patients or clinicians. The authors urge clinicians and health care institutions to identify ways for OTAs to enhance clinician–patient relationships and patient care within the bounds of relevant legal requirements and risks.

Access to integrated care for those with co-occurring mental health (MH) and substance use disorders (SUDs) has been limited because of an exclusion in Medicaid on paying for SUD care for those in institutions for mental disease (IMDs). However, the federal government in 2015 began to encourage states to pursue waivers of this exclusion, and by the end of 2020, 28 states had done so. In “The Impact of Medicaid Institutions for Mental Diseases Exclusion Waivers on the Availability of Substance Abuse Treatment Services and the Varying Effect by Ownership Type,” Yimin Ge, John Romley, and Rosalie Liccardo Pacula used data from the National Survey of Substance Abuse Treatment Services to examine the effect of state IMD SUD waivers on the percentage of facilities offering co-occurring MH and SUD treatment, overall and for residential facilities specifically. They found that the adoption of a waiver increased the odds of a state’s residential treatment facility offering co-occurring MH and SUD treatment a year or more later, with increased odds of offering co-occurring treatment in private for-profit SUD facilities. They conclude that Medicaid IMD waivers are at least somewhat effective in impacting the population targeted by the policy.

Medicaid agencies principally provide maternity care through contracts with managed care organizations. However, limited research has documented the extent to which states use these agreements to set binding expectations for access, quality, and equity across the maternal health continuum and how states approach the task of maternal health contracting. In “The Spectrum of State Approaches to Medicaid Maternity Care Contracting,” Caitlin Murphy and colleagues (1) reviewed the literature to identify maternal health “best practices” for people with elevated health and social needs, (2) reviewed the managed care contracts in use across 40 states and the District of Columbia to determine the extent to which they incorporate best practices, and (3) conducted interviews with four state Medicaid agencies to better understand how states approach maternal health when developing their contracts. Their analysis of the literature identified nearly 60 “best practices,” but the contracts themselves reflected a fragmented and incomplete approach to the maternal health continuum. The authors recommend that a major step forward would be the development of a “best practices tool” to help state Medicaid agencies translate evidence into comprehensive, clear contracting expectations.

To date, uptake of value-based payment (VBP) arrangements for medical products has been concentrated primarily among private payers. Interest among Medicaid programs has been growing, but their experiences and approaches to VBP arrangements for medical products are not well understood. In “Experiences and Interest in VBP Arrangements for Medical Products among Medicaid Agencies: An Exploratory Analysis,” Beena Bhuiyan Khan and colleagues used a mixed-methods approach involving a survey and semi-structured interviews to gain an understanding of state experiences with VBP arrangements for medical products. The authors report that states collectively identified several significant challenges to VBP arrangements, including the time, expertise, and resources required to design and implement them. To overcome these challenges, they outline a range of strategies to assist states to pursue VBP arrangements for medical products, including more direct engagement from the Centers for Medicare and Medicaid Services, state-to-state peer learning and collaboration, data infrastructure and sharing, and additional research to inform VBP arrangement approaches.

The federal Family and Medical Leave Act passed by Congress in 1993 provides a nonuniversal, unpaid work benefit. Over the past two decades, several states have adopted the Paid Family Leave policy (PFL) and Paid Sick Leave policy (PSL). In view of the critical role that family caregivers play in providing long-term care in the United States, Kanika Arora and Douglas Wolf analyzed longitudinal data from the Health and Retirement Study (1998 – 2020) to examine the effect of the PFL and PSL policies on care provision to older parents. In “Paid Leave Mandates and Care for Older Parents,” they found that PSL adoption led to an increase in care provision, with some of the strongest effects among women and unpartnered adult children. PFL adoption, by itself, was not associated with care provision to parents except when PFL also offered job protection. Overall, the authors contend that paid family leave, when combined with job protection, could support potential family caregivers.

Although educational attainment is consistently associated with better cognitive function among older adults, little is known about how education quality is related to cognitive function. In “State-Level Education Quality and Trajectories of Cognitive Function by Race and Educational Attainment,” Katrina Walsemann and colleagues used prospective data on cognitive function from the Health and Retirement Study linked to historical data on state investment in public schools to examine whether growing up in states with higher-quality education systems may protect against poor cognitive function, particularly among Black adults and adults who completed fewer years of school. The sample was restricted to non-Hispanic White and Black adults born between 1914 and 1959. The authors found that residence in states with higher resourced education systems during childhood was associated with better cognitive function, particularly among those who completed less than 12 years of schooling, regardless of race. For non-Hispanic White adults, higher-resourced state education systems were associated with higher scores of total cognitive function and episodic memory. For Black adults, the relationship between state education resources and cognitive function varied by age, with positive associations in midlife and generally null or negative associations at the oldest ages. The findings suggest that Federal and state investment in public schools may provide students with opportunities to develop important cognitive resources during schooling that translate into better cognitive function in later life, especially among marginalized populations.

In closing, we invite readers to visit the Quarterly’s website for timely opinion pieces on important policy issues (https://www.milbank.org/quarterly/the-milbankquarterly-opinions/). Recent contributions include:

• Sara Rosenbaum and Marybeth Musumeci on federal court decisions that have delayed the implementation of new rules protecting health care for transgender people issued under Section 1557 of the Affordable Care Act;
• Harold Pollack and Eshan Dosani on the need for greater resources to be devoted to criminal justice research;
• David Rosner and Gerald Markowitz on inequality, disease, and death in American history; and

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