“Medicaid will overwhelm the state’s budget unless we begin taking steps now,” said Rep. Kris Steele, a leader in getting the measure passed and chair of a bipartisan task force on Medicaid reforms last year. “This begins the process of reform, and it gives Medicaid recipients more choices and more control.”

Details are scarce, because the waiver application has not yet been submitted. But the law calls for giving vouchers to all beneficiaries who are younger than age 65 and considered “insurable”—which the law defines as meaning that the cost of enrolling that individual in a private plan is equal to or less than the cost to the state of the individual’s remaining in the current Medicaid program. The program would be pilot-tested in two counties, one urban and one rural, and would go statewide by 2013 if found to be effective.

Participants would be allowed to opt out of Medicaid and use their state-allocated Medicaid “premium” to but into an employer-sponsored health plan. The law also expands the state’s current premium assistance plan from employers with 25 or fewer workers, to those with 50 or fewer employees.

The law would increase reimbursement rates to entice more providers into the program; develop a “choice counseling program” for consumers; and institute co-pays of $1 to $3 for beneficiaries with incomes between 133 percent and 185 percent of the federal poverty level (FPL). This last provision will encourage patients to develop responsibility for their care, Steele says.

Sen. Bernest Cain has doubts that the program will work. “I can’t imagine a commercial health plan [taking on the task of enrolling recipients] for the rates we pay in Medicaid,” Cain said. “You’re not going to be able to give vouchers if no plan wants to play…I hate to say it, but I’m being honest with you: I think some of this is smoke and mirrors.”

But Rep. Thad Balkman, a co-sponsor in the House, said Medicaid costs are skyrocketing, and the current plan is a much better alternative to raising taxes or downsizing the Medicaid program. “We had to look for ways to continue or improve the program with existing revenues. We worked hand-in-hand with the OHCA to look for ways to offer a patient empowerment model that would allow patients to be better served, without requiring us to spend more.”

He added he’s confident that commercial plans will step forward. “It’s a new initiative and you’re going to have doubters and questions that have to be answered. I think history will prove that this will be a model for the nation to follow.”

Cain said he was particularly disappointed that the law didn’t do more to offer more long-term care alternatives to the elderly and disabled, such as assisted living and congregate housing—“that’s where you use up all your Medicaid dollars.” Oklahoma’s current Medicaid program pays only for some home-based or nursing home care.

Matthew Gever

Between “The Sopranos,” “Frazier” and the countless neurotic comedians on late night television, one might think that everyone these days is seeing a psychiatrist. That’s not the case in rural communities. Mental health workers, psychiatrists in particular, are in short supply in rural America. “The mental health-care crisis responder for most rural Americans is a law enforcement officer,” said Dennis Mohatt, with the Western Interstate Commission on Higher Education.

To alleviate this shortage, at least one territory and a few states have expanded the scope of practice of psychologists in order to allow them to prescribe medication. There are roughly 179,000 psychologists in the country, according to the Bureau of Labor Statistics, compared to 40,000 psychiatrists.

To qualify for prescription rights, a psychologist must complete 450 hours of classroom instruction, 80 hours of clinical training and 400 hours of supervised treatment involving at least 100 patients. Upon completion, a provisional prescribing certificate is granted for two years, with physician supervision required. Independent prescribing is permitted after two years.

The institute currently has 50 more psychologists who have finished the academic program and are now in supervised treatment settings, many of which are rural. On the whole, “physicians have been open and helpful,” Levine said.

CAJUN COUNTRY ACTS

Louisiana is the only other state that allows psychologists to prescribe. In the Bayou State, a total of 518 psychiatrists serve a population of 4.5 million, which translates to one psychiatrist for every 9,000 residents.

To obtain prescribing rights, a psychologist must earn a master’s degree in clinical psychopharmacology, pass a national proficiency exam and be licensed by the state. No medical supervision is necessary. “We haven’t had one problem yet that I know of,” said Hines. “These guys know more about psychopharmacology than most physicians.”

The legislation would require lengthy education and training for psychologists, and those who complete it would be allowed to practice only in the network of 13 federally funded health clinics that provide care to the poor and uninsured.

Currently, primary-care physicians in community health centers work with psychologists to determine the proper medications for a patient, said bill co-sponsor Sen. Rosalyn Baker. “The goal of the bill is to foster [further] collaboration” between the health professions.

Baker noted that the primary opposition to the bill came from organized medical groups such as the American Medical Association and the American Psychiatric Association. “We have to get out of the notion that it’s one profession against another,” she added.

Christina Kent

Methamphetamine differs from other illicit drugs in many ways—one of them is its relative popularity with women. Roughly half of all people who enter treatment for meth use disorders are women. In contrast, the ratio of those who seek treatment for all substance use disorders is three men to one woman.

Now, as the meth “epidemic” enters its second decade, overall treatment admissions for meth use disorders are rising—and they’re increasing fastest for women, some of whom are pregnant. The phenomenon has resurrected an old debate: what’s the best way to protect the health and wellbeing of an addicted pregnant woman and her child? Law enforcement or treatment? Or both? Meth and other stimulants seriously jeopardize the development of the fetal brain and other organs, and they’re linked to difficulty in sucking and swallowing, as well as hypersensitivity to touch after birth.

Other states are taking the approach of expanding access to treatment and other services for pregnant women.

“My experience has been that most of the women are not doing it (using meth) to hurt their babies, they just don’t know how to get off it,” said bill sponsor Sen. Rosalyn Baker. “We don’t throw people into jail for smoking—even though it’s proven to have adverse health effects such as low birth-weight babies and pre-term births.” The bill sunsets in 2009. “We will have to appropriate more money, but once we get it started, I can’t imagine that we won’t,” Baker said.

Studies have shown that treatment for meth use disorders is as effective as treatment for other substance use disorders. In a sample of women followed for four years, 30 percent remained continuously abstinent from meth for the entire 48 months. However, the percentage of treatment programs that provide special services to pregnant and post-partum women has decreased in the past few years.

Portions of this story were adapted from an upcoming story in NCSL’s State Legislatures Magazine.