As the U.S. continues to grapple with the COVID-19 pandemic, it is easy to forget that we are in the midst of another epidemic that has taken the lives of over 800,000 individuals since 1999. The drug overdose epidemic was responsible for 70,630 deaths in 2019 and preliminary data indicates the number of overdose deaths has risen significantly since the start of the COVID-19 emergency, primarily driven by an increase in opioid and stimulant use disorders. Substance use disorders (SUDs) affect people from all walks of life and is increasingly a leading concern among communities of color, LGBTQ+ individuals, and other underserved populations. The condition is particularly prevalent among low-income communities, with 4.6 million Medicaid beneficiaries (over 8% of the total Medicaid population) being treated for SUD in 2019.
Despite the desperate need to connect individuals with SUD to life-saving treatment, including medication-assisted treatment (MAT) with the medications buprenorphine and methadone, the number of people accessing treatment remains incredibly low, at less than 10%. One of the main reasons for this gap in access to treatment is that services are typically unavailable in the communities that need them and, when they are available, individuals often face stigma and discrimination, and worse, a system that still overwhelmingly relies on law enforcement to address issues related to drug use.
The good news is that states have a new opportunity to increase access to SUD services by both meeting people where they are and replacing the role that law enforcement has typically held with more effective public health measures. Section 9813 of the American Rescue Plan Act of 2021 (ARP) allows state Medicaid programs, which cover most individuals with SUD across the country, to provide qualifying community-based mobile behavioral crisis intervention for a five-year period beginning on April 1, 2022. While some states already provide mobile services during mental health or SUD crises, the ARP option will increase the federal matching rate for these services to 85% for the first twelve fiscal quarters of state participation until March 31, 2027. This increased matching rate should incentivize states to incorporate this essential service into the SUD continuum of care currently covered through different Medicaid authorities.
Mobile crisis services under Section 9813 of the ARP are services provided on the scene where the beneficiary is experiencing a crisis related to a mental health or substance use condition, including the person’s home, work, and all other locations, except a hospital or other facility settings. Examples of SUD-related crises are: experiencing symptoms related to relapse, overdose, or any other situation in which the person’s substance use puts them or others in imminent danger. Guidance from the Department of Health and Human Services (HHS) on how states can adopt the Section 9813 option further explains that mobile crisis services should be provided by a team of “professional and paraprofessional staff, crisis intervention specialists, therapists, case managers, and trained peer and family support workers.” In addition, when not on the scene, licensed staff should be on-call for further consultation.
One of the benefits of mobile crisis services is that individuals may receive needed medication on the spot, which is particularly important for beneficiaries experiencing a SUD-related crisis. The HHS guidance mentions that states may want to ensure that clinicians who can prescribe and administer medications are included as part of the crisis teams and encourages states to require teams to carry suboxone (a buprenorphine formulation) and naloxone to treat an opioid use disorder and reverse an opioid-related overdose, respectively. While HHS states that mobile crisis staff should be trained in naloxone administration, this highly effective overdose reversal medication can be administered by laypeople with minimal training. Requiring all mobile crisis teams to carry naloxone represents a simple and efficient way for states to improve mobile crisis services and help save lives experiencing overdoses.
In its guidance, HHS also asks states to require mobile crisis teams to carry fentanyl strips. Fentanyl is a potent synthetic opioid that is involved in an increasing number of overdose deaths. However, individuals are often unaware that the drugs they are consuming contain fentanyl or fentanyl analogues. Fentanyl testing strips are an evidence-based method to identify the presence of fentanyl in pills, powder, or injectable drugs and are used as a strategy to mitigate the effects of unhealthy drug use. Including fentanyl strips as part of mobile crisis services supported through federal matching funds is an important way to emphasize harm reduction and public health measures in response to the SUD crisis.
Mobile crisis interventions for SUDs also ensure beneficiaries receive the services they need in a timely manner and in their communities, as opposed to unnecessary visits to emergency departments and stays in residential institutions. For the past seven years, state Medicaid programs have resorted to using federal waivers to increase federal funding for and availability of inpatient and residential SUD services. Although these levels of care may be necessary for the more extreme circumstances, most individuals with SUD can and should receive more effective treatment in their communities and on an outpatient basis, as long as community-based SUD services, including MAT, are available and well-funded. While HHS’ guidance states that mobile crisis teams should refer beneficiaries to additional treatment as necessary, having this first line of response meet beneficiaries where they are provides individuals with SUD with another avenue to receive free-of-bias services without having to be treated in an institutional setting unnecessarily.
Perhaps the most important result of the new mobile crisis option is that Medicaid beneficiaries with SUD will be able to receive empathy, care, and treatment, when otherwise they could face discrimination, criminalization, and law enforcement intervention. Continuing to emphasize a law enforcement approach to the overdose epidemic has exacerbated the crisis and is counterproductive in helping individuals overcome the challenges presented by SUDs. A move towards compassionate treatment and public health measures is needed to finally put an end to the epidemic, and making mobile crisis services available for Medicaid beneficiaries represents a key step in that direction.
Other NHeLP resources on the Section 9813 mobile crisis option:
Children’s Behavioral Health Mobile Response and Stabilization Services
California Will Expand Coverage of Medicaid Community-Based Mobile Crisis Intervention Services
