Medicaid Expansion: Behavioral Health Treatment Use in Selected States in 2014
Published: 2017-06-22T00:00:00

Fast Facts:
Behavioral health conditions disproportionately affect low-income people. Some states expanded Medicaid to cover low-income adults, as authorized by the Affordable Care Act, so we examined how many people in this expansion group received behavioral health treatment.
In four states—Iowa, New York, Washington, and West Virginia—we found that in 2014:
Up to 1 in 3 Medicaid expansion enrollees received behavioral health treatment.
Psychotherapy visits and antidepressant medications were most commonly used.
In 3 states, enrollment in Medicaid likely increased access to this treatment (most enrollees in the 4th state already had access to it).

Highlights:
section_title: Why GAO Did This Study
paragraphs: Behavioral health conditions disproportionately affect low-income populations. Treatment can improve individuals' symptoms and help avoid negative outcomes. The expansion of Medicaid to cover low-income adults in some states—authorized by PPACA—may have increased the demand for such treatment. However, little is known about the extent to which Medicaid expansion enrollees experienced behavioral health conditions or utilized treatment during the first year of expansion in 2014.
GAO was asked to provide information about the utilization of behavioral health treatment among Medicaid expansion enrollees during the first year of expansion in 2014. For selected states in 2014, this report describes (1) the population of Medicaid expansion enrollees with behavioral health diagnoses, and (2) the use of behavioral health treatment among Medicaid expansion enrollees.
GAO selected four expansion states—Iowa, New York, Washington, and West Virginia—based on, among other criteria, availability and reliability of Medicaid enrollment and utilization data. GAO analyzed Medicaid data on behavioral health diagnoses and treatment use for expansion enrollees for 2014, the most recent year available. GAO also reviewed documents and interviewed Medicaid officials from all selected states to understand how data were recorded, and how treatment for expansion enrollees compared with what was available prior to expansion. The Department of Health and Human Services provided technical comments on a draft of this report, which GAO incorporated as appropriate.
section_title: What GAO Found
paragraphs: In four selected states, from 17 to 25 percent of enrollees who were covered by state expansions of Medicaid—authorized by the Patient Protection and Affordable Care Act (PPACA)—had diagnosed behavioral health conditions (mental health and substance use conditions) in 2014. Mental health conditions were more common than substance use conditions; from 11 to 20 percent of expansion enrollees were diagnosed with a mental health condition, compared with 6 to 8 percent diagnosed with a substance use condition. The most common mental health condition category was mood disorders, such as depression. For substance use, substance-related conditions (e.g., addiction to drugs like opioids) were more prevalent than alcohol-related conditions.
From 20 to 34 percent of expansion enrollees in the four selected states received behavioral health treatment in 2014, which includes outpatient services such as psychotherapy or prescription drugs. Treatment rates exceeded rates of diagnosed conditions, in part, because prescription drugs are not recorded with diagnosis codes. Thus, enrollees who only used behavioral health prescription drugs—and no outpatient services—were not counted in the diagnosis totals.
The two most commonly used behavioral health service categories were psychotherapy services (visits with a provider aimed at reducing and managing symptoms) and diagnostic services, such as diagnostic evaluations.
Antidepressants were the most commonly used behavioral health prescription drug category; over two-thirds of expansion enrollees who used a behavioral health drug took an antidepressant.
Officials in three of the four selected states said that expansion enrollees likely had greater access to behavioral health treatment after enrolling in Medicaid. Officials from Iowa, Washington, and West Virginia reported that, compared to being uninsured, expansion enrollees could more easily access treatment, such as community-based mental health services and behavioral health prescription drugs. Officials in New York said expansion enrollees experienced less of a change, because most of its enrollees were previously eligible for Medicaid.

section_title: Letter
paragraphs: Research has shown that low-income individuals disproportionately  experience behavioral health conditions. Such conditions include those  related to mental health, such as depression, and to substance use, such  as alcohol use disorder. In particular, research has shown that individuals  enrolled in Medicaid—a joint federal-state program that finances health  care coverage for certain low-income and medically needy individuals— experience a higher rate of behavioral health conditions than those with  private insurance. Access to behavioral health treatment—including both  behavioral health services and prescription drugs—is important because  of the consequences of untreated conditions, which may include  worsening health, increased medical costs, and negative effects on  employment and workplace performance.
As of January 1, 2014, states have the option to expand eligibility for the  Medicaid program—as allowed by the Patient Protection and Affordable  Care Act (PPACA)—to certain adults with incomes up to 138 percent of  the federal poverty level (FPL). PPACA requires states that choose to  expand Medicaid to provide enrollees with benefit plans that include  behavioral health treatment, and therefore Medicaid programs in these  states may have experienced increased demand for behavioral health  treatment. However, little is known about the extent to which expansion  enrollees had diagnosed behavioral health conditions, or what types of  behavioral health services and related prescription drugs enrollees  received during the first year of Medicaid expansion in 2014.
Given the importance of access to treatment for individuals with  behavioral health conditions, and the likely increased demand on  Medicaid programs in expansion states, you asked us to provide  information about the utilization of behavioral health treatment among  Medicaid expansion enrollees during the first year of expansion in 2014.  This report describes  1.  the population of Medicaid expansion enrollees with behavioral health  diagnoses in selected states in 2014, and  2.  the use of behavioral health treatment among Medicaid expansion  enrollees in selected states in 2014.
To describe the population of Medicaid expansion enrollees with  behavioral health diagnoses in selected states in 2014, we selected four  states (Iowa, New York, Washington, and West Virginia) that met the  following criteria: (1) were among the 25 states that chose to expand  Medicaid as allowed under PPACA as of January 1, 2014; (2) had  enrollment and utilization data for expansion enrollees in the Medicaid  Statistical Information System (MSIS) for all of calendar year 2014 that  were sufficiently reliable for the purpose of our reporting objectives; and  (3) had available information and documentation on Medicaid behavioral  health benefits, and how enrollment, service utilization, and prescription  drug data were recorded for expansion enrollees in MSIS. Our selected  states were the only four states that met these criteria as of January  2016, and they are not representative of all states and their Medicaid  programs. In addition, a number of state-specific factors—such as  differences in population health status and provider supply—could  contribute to variation across our selected states, but attributing this  variation to such factors was beyond the scope of this study. For each  state, we analyzed enrollment and service utilization data to (1) identify all  expansion enrollees (both newly and not newly eligible), (2) determine the  extent to which they had diagnosed behavioral health conditions, and (3)  describe characteristics of enrollees with these conditions. We considered  an enrollee to have a diagnosed behavioral health condition if that  enrollee received any outpatient services with a recorded diagnosis code  for a behavioral health condition in 2014. Among the substance-related  conditions, we also identified opioid abuse and dependence as a unique  category, and we selected these codes based on prior research on opioid  use in Medicaid. Because we measured behavioral health conditions  based on outpatient service utilization data, our estimates do not include  individuals with conditions who did not use outpatient services during  2014—such as individuals who used no services or who only used  inpatient services—or those who used only behavioral health prescription  drugs. For the group of enrollees with a behavioral health condition, we  used enrollment data to describe their characteristics; specifically, we  examined age, gender, and geographic (i.e., urban vs. rural) location.
To describe the use of behavioral health treatment among Medicaid  expansion enrollees in selected states in 2014, we used enrollment,  service utilization, and prescription drug data for the same four selected  states. We defined behavioral health treatment as the receipt of  behavioral health services, behavioral health prescription drugs, or both.  We defined behavioral health services as outpatient screening,  assessment, diagnostic, treatment, rehabilitation, and habilitation services  used primarily or exclusively to evaluate and address the needs of  individuals with behavioral health conditions. To identify behavioral health  services, we reviewed the following for each state: (1) Medicaid provider  manuals and other coverage documentation that contained the procedure  codes and descriptions for covered services, and (2) a list of all services  that were provided to expansion enrollees in calendar year 2014 that  were recorded with a primary diagnosis of a behavioral health condition.  We selected codes from these two sources that we determined to be  behavioral-health specific based on their descriptions. Consequently,  lists of services are different for each state based on their coverage and  utilization of services in 2014. We also analyzed behavioral health  service use by category; for this analysis, we divided the top 25 most- used behavioral health services by state into categories, such as  diagnostic services and psychotherapy services, based on their  descriptions. We excluded all inpatient and laboratory services from our  analysis. In addition, because our analysis was limited to Medicaid  service utilization data, our results do not reflect the use of behavioral  health services not paid for by Medicaid, such as state- or grant-funded  services.
To more fully examine service utilization patterns among expansion  enrollees, we also examined evaluation and management services— more general medical visits with a physician or other medical provider— because some individuals may have received behavioral health treatment  during these visits, including services provided by a psychiatrist. We  limited our analysis of evaluation and management services to those  visits recorded with a primary diagnosis of a behavioral health condition.  However, because of the uncertainty of the extent to which behavioral  health treatment was provided as part of evaluation and management  services, we do not count them as behavioral health services, or include  them in our overall definition of behavioral health treatment.
We also examined outpatient emergency room visits—for any condition,  not just a behavioral health condition—among expansion enrollees with  and without a behavioral health diagnosis. Emergency room visits were of  interest, because prior research has suggested that individuals who have  a behavioral health condition may access emergency care more  frequently than those without such conditions.
To examine behavioral health prescription drug use, we examined  Medicaid data for prescription drugs provided to expansion enrollees in  2014. We defined behavioral health prescription drugs as Food and Drug  Administration (FDA)-approved drugs used, on- or off-label, to treat adults  with behavioral health conditions in the United States as of 2014. To  identify these drugs, we worked with a contractor, QuintilesIMS, who  developed a list of behavioral health drugs based on information on how  drugs are classified by therapeutic use, survey data on prescribing  patterns, and expert clinical opinion. We categorized the list of drugs into  12 categories, such as antidepressants, based on our prior work and  consultation with QuintilesIMS. See appendix I for the list of behavioral  health prescription drugs we included in our analysis.
We conducted interviews with officials from our selected states to discuss  behavioral health benefits for Medicaid expansion enrollees; how  enrollment, service utilization, and prescription drug data were recorded  in MSIS; officials’ perspectives on the results of our analysis; and whether  Medicaid expansion affected the availability of behavioral health  treatment for expansion enrollees, relative to what was available for low- income, uninsured adults prior to the first year of expansion in 2014. We  also interviewed a physician group specializing in addiction medicine and  consulted with clinical experts from QuintilesIMS for additional  perspectives on our results.
We assessed the reliability of MSIS data by interviewing knowledgeable  federal and state officials; reviewing related documentation, such as  studies that assessed the completeness and quality of Medicaid data;  comparing the results of our analysis to published figures from the  Centers for Medicare & Medicaid Services (CMS), which oversees  Medicaid at the federal level; and testing the data for logical errors. Based  on this work, we determined that the data were sufficiently reliable for the  purposes of our reporting objectives. For further details on our scope and  methodology, including our data reliability assessment, see appendix II.
We conducted our performance audit from November 2015 through June  2017 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: Behavioral Health Conditions
paragraphs: Behavioral health conditions—including those related to mental health  and substance use—affect a substantial number of adults in the United  States. The Substance Abuse and Mental Health Services Administration  (SAMHSA) estimated that in 2015 about 43 million adults (18 percent)  had a mental health condition—including about 10 million adults (4  percent) with a serious mental illness—and about 20 million (8 percent)  had a substance use condition. Examples of common mental health  conditions include anxiety disorders, such as phobias and post-traumatic  stress disorder, and mood disorders, such as depression and bipolar  disorder. Examples of common substance use conditions include alcohol  use disorder and opioid use disorder. There is substantial overlap  between individuals with mental health and substance use conditions;  about 8 million adults had both types of conditions, also referred to as co- occurring conditions. Individuals with behavioral health conditions also  experience higher rates of physical health conditions. Low-income  individuals, such as those enrolled in Medicaid, are at greater risk for  developing behavioral health conditions. In 2015, a greater percentage of  individuals covered by Medicaid experienced mental health conditions  and co-occurring conditions than individuals with private insurance.
section_title: Behavioral Health Treatment
paragraphs: Treatment for behavioral health conditions can help individuals reduce  their symptoms, improve their ability to function, and avoid the potential  consequences of untreated conditions, such as worsening health,  reduced educational attainment, loss of employment, and involvement  with the justice system. Treatment for behavioral health conditions can  include behavioral health services, prescription drugs, or a combination of  both. Behavioral health services include diagnostic services, which  involve the collection and evaluation of information to determine the  nature and extent of behavioral health problems, and psychosocial  therapies, such as psychotherapy. Psychotherapy—also referred to as  counseling or “talk therapy”—typically involves regular visits with a  provider focused on helping individuals understand, reduce, and manage  their symptoms. Prescription drugs may also be used to treat both mental  health and substance use conditions. SAMHSA estimated that in 2015,  more adults used a mental health medication (12 percent) than received  outpatient mental health treatment (7 percent). A common type of drug  used to treat mental health conditions is antidepressants, which treat  depression as well as other conditions, such as anxiety. For certain  substance use conditions, individuals may receive medication-assisted  treatment (MAT), which involves the use of medications in conjunction  with behavioral health services, such as psychotherapy. According to  SAMHSA, the use of medications like methadone, buprenorphine, and  naltrexone for individuals with opioid use disorders can help them  more fully engage in their recovery.
One potential barrier to accessing treatment is a shortage of qualified  behavioral health professionals, particularly in rural areas. According to  the Health Resources and Services Administration, there were more than  4,500 mental health professional shortage areas in the United States as  of April 2017, containing about a third of the American population (about  109 million people). Over half of these shortage areas were in rural or  partially rural locations. We previously reported that states were taking a  number of steps to address behavioral health workforce shortages, such  as providing Medicaid reimbursement for telehealth services. Telehealth  services allow a patient in a rural location to interact with a medical  provider through interactive video conferencing. Research has suggested  that telehealth services are particularly effective for specialties such as  mental health that involve mostly verbal interaction rather than physical  examination.
section_title: Medicaid
paragraphs: CMS and states jointly fund and administer the Medicaid program, and  states have flexibility within broad federal parameters for designing and  implementing their Medicaid programs. For example, state Medicaid  programs must cover certain mandatory populations and benefits, but  states may choose to also cover other optional populations and benefits.  Traditionally, Medicaid did not require states to include behavioral health  services in their Medicaid programs; however, all state Medicaid  programs provided some behavioral health services. Likewise, states  were not required to include coverage for prescription drugs in their  Medicaid programs, but all states did. Under PPACA, most expansion  enrollees must be covered under an alternative benefit plan, which must  cover 10 essential health benefits categories. Mental health and  substance use services, including behavioral health treatment, and  prescription drugs are 2 of the 10 essential health benefits categories.  Medicaid is the largest source of funding for behavioral health treatment  in the nation, with spending estimated at about $53 billion for 2014.
Prior to 2014—when states had the option to expand Medicaid to all  adults up to 138 percent of the FPL—states had varying levels of  coverage available for low-income, uninsured adults. For example, the  four states we selected had the following coverage available.
Iowa had coverage available for low-income adults up to 200 percent  of the FPL under a Medicaid waiver, but coverage did not include  behavioral health treatment.
New York provided Medicaid benefits to low-income, childless adults  up to 100 percent of the FPL. Enrollees with incomes up to about 78  percent of the FPL were served through traditional Medicaid.  Enrollees above this income level and up to 100 percent of the FPL  were covered under New York’s Family Health Plus program, which  was implemented in 2001 through a Medicaid waiver.
Washington expanded Medicaid as of January 3, 2011, as part of  PPACA’s early expansion option. Although the state covered  enrollees up to 138 percent of the FPL, enrollment was limited to  around 41,000 individuals who were previously enrolled in Basic  Health, a state-funded health coverage program for adults up to 200  percent of the FPL with capped enrollment.
West Virginia did not have Medicaid coverage for low-income,  childless adults prior to its Medicaid expansion in 2014.
As a result, the extent to which expansion enrollees were newly eligible  for Medicaid coverage in 2014 varied among our selected states. For  example, while most Medicaid expansion enrollees in New York were  previously eligible for coverage under the state’s pre-PPACA Medicaid  program, all expansion enrollees in West Virginia were newly eligible. See  figure 1 for information on the size of each state’s Medicaid expansion  population, the percent who were newly eligible, as well as other state  characteristics.
States that expanded Medicaid could choose different delivery systems to  provide benefits to expansion enrollees, such as fee-for-service or  managed care. Under a fee-for-service model, states pay providers for  each covered service for which the providers bill the state. Under a  managed care model, states contract with managed care organizations to  provide or arrange for medical services, and prospectively pay the plans a  fixed monthly fee per enrollee. States that provide Medicaid benefits  through managed care may contract with separate companies to manage  medical and behavioral health benefits, often referred to as “carving out”  behavioral health benefits. See table 1 for information on Medicaid  coverage of physical and behavioral health benefits for expansion  enrollees in our selected states for 2014.
section_title: Funding for Behavioral Health Treatment
paragraphs: Although Medicaid is the largest source of funding for behavioral health  treatment in the nation, states have historically also had a large role in  funding behavioral health services through programs other than Medicaid,  especially for low-income, uninsured adults. In addition, states may use  SAMHSA-administered mental health and substance use block grants to  design and support a variety of treatments for individuals with behavioral  health conditions. As we previously reported, some states that did not  expand Medicaid provided behavioral health treatment to priority  populations to focus care on adults with the most serious conditions and  used waitlists for those with more modest behavioral health needs. We  also reported that the Medicaid expansion states we examined generally  reported an increase in the availability of behavioral health treatment for  previously uninsured low-income adults who enrolled in Medicaid,  particularly in states that had no prior coverage available for this  population.
section_title: From 17 to 25 Percent of Expansion Enrollees in Selected States Had a Behavioral Health Diagnosis; Enrollees’ Gender and Age Were Similar across the States From 17 to 25 Percent of Expansion Enrollees had a Behavioral Health Diagnosis in Selected States, Most Commonly a Mental Health Condition
paragraphs: Across our four selected states in 2014, from 17 to 25 percent of  expansion enrollees were diagnosed with a behavioral health condition.  Diagnoses of mental health conditions were more common than  diagnoses of substance use conditions. The distribution of expansion  enrollees with a behavioral health diagnosis by gender and age was  generally similar across states.
Behavioral health diagnoses among expansion enrollees ranged from 17  to 25 percent across our selected states in 2014, with mental health  conditions being more common than substance use conditions. From 11  to 20 percent of expansion enrollees were diagnosed with a mental health  condition, compared with 6 to 8 percent diagnosed with a substance use  condition. (See table 2.) However, patterns of specific mental health and  substance use diagnoses were similar across selected states. The most  common mental health condition categories were mood disorders, such  as depression, and anxiety disorders, such as panic disorder. Among  expansion enrollees diagnosed with a substance use condition, a greater  percentage were diagnosed with a substance-related condition, such as  cocaine dependence, compared with alcohol-related conditions. From 1  to 3 percent of all expansion enrollees were diagnosed with opioid abuse  or dependence, a subset of substance-related conditions. (See app. III for  more information on this group of enrollees.)
subsections: section_title: Age and Gender of Expansion Enrollees with a Behavioral Health Diagnosis Were Generally Similar across Selected States, while Enrollees’ Geographic Location Varied
paragraphs: The distribution of expansion enrollees with diagnosed behavioral health  conditions by age and gender was generally similar across the selected  states. Expansion enrollees with diagnosed behavioral health conditions  were fairly evenly divided among age groups across all selected states.  (See fig. 2.) Women accounted for a larger percentage of enrollees with  diagnosed behavioral health conditions in three of the four selected  states—Iowa, Washington, and West Virginia. In New York, men  accounted for 58 percent of expansion enrollees with diagnosed  behavioral health conditions.
Geographic location of enrollees in selected states varied, with some  states having a greater proportion of rural enrollees. The geographic  location of expansion enrollees diagnosed with behavioral health  conditions was consistent with the more general urban/rural distribution of  residents in these states. State officials discussed efforts to meet the  behavioral health needs of rural residents, who may have difficulty  accessing care, because of the need to travel long distances to access  relatively fewer providers. For example, officials in Iowa, Washington, and  West Virginia discussed the important role of telehealth services in  allowing rural residents to access care for behavioral health conditions.  Officials in Iowa also noted that the state has provided funding to help  rural communities establish the infrastructure needed to host psychiatric  telehealth appointments. In West Virginia, as of July 1, 2014, 85 percent  of procedure codes in the Medicaid program were eligible for  reimbursement when provided via telehealth. West Virginia officials also  emphasized the role of Federally Qualified Health Centers, which can  provide a “one-stop shop” for both medical and behavioral health  treatment for residents in rural areas who have to travel long distances to  access care.
section_title: From 20 to 34 Percent of Expansion Enrollees in Selected States Received Behavioral Health Treatment; Psychotherapy and Antidepressant Medications Were Most Common
paragraphs: Use of behavioral health treatment—services and drugs to address  mental health and substance use conditions—ranged from 20 to 34  percent in selected states in 2014. Among expansion enrollees who used  a behavioral health service, the two most commonly used service  categories were psychotherapy services and diagnostic services.  Antidepressants were the most commonly used category among  expansion enrollees who used a behavioral health drug.
subsections: section_title: Expansion Enrollee Use of Behavioral Health Treatment Ranged from 20 to 34 Percent in Selected States, and Medicaid Expansion Generally Increased Treatment Availability
paragraphs: Use of behavioral health treatment ranged from 20 percent of expansion  enrollees in New York to 34 percent in Iowa. (See table 3.) These rates  exceeded the rates of diagnosed conditions presented above, in part,  because prescription drugs are not recorded with diagnosis codes. Thus,  enrollees who only used behavioral health prescription drugs—and no  outpatient services—were not counted in the diagnosis totals.
Rates of behavioral health prescription drug use were higher than the use  of services across the four selected states. The higher rates of  prescription drug use suggest that some enrollees received drugs without  also receiving behavioral health services. Officials from one state  commented that this may be appropriate for some conditions, such as  mild depression, where a prescription drug may be adequate without  accompanying counseling. In addition, some enrollees may have received  evaluation and management services, which may have included  treatment for behavioral health conditions, but which are not included in  our measure of behavioral health treatment.
Officials we spoke with from three of the selected states told us that  expansion enrollees likely had greater access to behavioral health  treatment after enrolling in Medicaid.
Iowa officials noted that some county-based mental health agencies,  which were responsible for serving uninsured residents as of 2014,  had waiting lists for mental health services prior to the state  expanding Medicaid.
Washington officials said that Medicaid expansion had resulted in a  significant increase in access to services for enrollees, particularly for  less acute, community-based services for people who needed  ongoing therapy. Officials explained that uninsured residents not  eligible for Medicaid would generally rely on the state’s Regional  Support Networks—managed care entities responsible for providing  mental health services for uninsured residents—generally provided  crisis services, or services for individuals with serious and persistent  mental illnesses. Officials also noted that the expansion had resulted  in more consistent access to behavioral health prescription drugs,  because Medicaid covers such prescriptions with no copayment.
Uninsured residents, according to the officials, would have been  limited to charity programs from drug manufacturers or block-grant- funded prescriptions, neither of which consistently funds medications  for everyone who needs them. Officials noted that consistent access  to medications can make a big difference for individuals whose  conditions are stable on medications, but unstable off medications.
West Virginia officials said that access to behavioral health  prescription drugs, particularly MAT for substance use conditions,  increased for Medicaid expansion enrollees. West Virginia’s charity  care program for uninsured residents does not pay for behavioral  health prescription drugs. Officials said that some uninsured residents  may have relied on family members or may have sold personal  belongings to afford their medications prior to Medicaid expansion.
By contrast, there was less of a change for expansion enrollees in New  York. Due to New York’s Medicaid waiver program, which covered low- income childless adults up to 100 percent of the FPL, most Medicaid  expansion enrollees in New York were already eligible for Medicaid prior  to 2014. One state official said that these enrollees would not have  experienced a change in access to treatment, because New York’s  expansion coverage was modeled on its existing Medicaid coverage.  The official said that newly eligible enrollees who were previously  uninsured would have had access to state-licensed and funded  behavioral health programs prior to enrollment. However, the official said  that New York did not generally pay for behavioral health prescription  drugs for uninsured individuals.
section_title: The Most Commonly Used Behavioral Health Service Categories were Psychotherapy and Diagnostic Services
paragraphs: Among the 9 to 16 percent of expansion enrollees who used a behavioral  health service in the four selected states, the two most commonly used  service categories were psychotherapy—regular visits with a provider to  help a patient understand, reduce, and manage symptoms—and  diagnostic services. Diagnostic services involve sessions with a provider  designed to collect information to determine whether a patient has a  behavioral health condition and to make a diagnosis, if appropriate. (See  fig. 3.) In New York, substance-use-specific services were almost as  common as diagnostic services. New York officials noted that the state  has a more extensive array of specialty substance use services available  than other states. For example, New York covers methadone  administration through Medicaid, whereas West Virginia does not.  Diagnostic services may have been less used in New York than in other  states, because most of the expansion enrollees were not newly eligible;  consequently, enrollees with behavioral health needs may have already  been seen by a Medicaid provider and received a diagnosis prior to 2014.
We also examined use of evaluation and management services—more  general medical visits with a physician or other medical provider—and  found that 8 to 17 percent of expansion enrollees used this type of  service. Although, by definition, evaluation and management services  may address a wide range of physical or behavioral health conditions, we  examined these services because some individuals may have received  behavioral health treatment during these visits, including services  provided by a psychiatrist. An evaluation and management visit with a  psychiatrist, for example, may include prescribing or monitoring the  effects of behavioral health prescription drugs. Evaluation and  management services also encompass services provided by primary care  physicians, who are often the first point of contact for individuals with  conditions like depression.
Our examination of emergency room use, which involved comparing rates  of use among expansion enrollees with and without behavioral health  diagnoses, found that up to 3 times as many enrollees with a behavioral  health diagnosis had an emergency room visit compared to enrollees  without such a diagnosis. From 42 to 57 percent of individuals with a  behavioral health condition had an emergency room visit, compared with  13 to 32 percent of individuals without a behavioral health condition. (See  table 4.) Most emergency room visits among enrollees with behavioral  health conditions were not primarily for a behavioral health condition (81  to 92 percent across selected states). Our finding that emergency room  use is more common among enrollees with behavioral health conditions is  consistent with previous research, including research showing that  Medicaid enrollees with a behavioral health condition typically have more  complex health needs, including comorbid physical health conditions.
section_title: Antidepressants Were the Most Frequently Used Category among Users of Behavioral Health Drugs
paragraphs: Among expansion enrollees who used a behavioral health drug,  antidepressants were the most commonly used category, and patterns of  use by drug category were similar across our four selected states. From  67 to 78 percent of expansion enrollees who used a behavioral health  drug took an antidepressant. Anti-anxiety medications, anticonvulsants,  and antipsychotics were the next most commonly used categories,  respectively, in three of the four selected states. (See fig. 4.) Together,  these four drug categories accounted for upwards of 80 percent of total  prescriptions in each state. The fifth most common drug category varied  by state and included sedative/hypnotic medications in Iowa, smoking  cessation medications in New York, and attention-deficit/hyperactivity  disorder (ADHD) medications in West Virginia.
Use of behavioral health prescription drugs was greater among women  and enrollees aged 30 and over. (See table 5.) In all four selected states,  a greater percentage of women received behavioral health prescription  drugs than did men, ranging from 2 percentage points greater in New  York to 13 percentage points greater in West Virginia. Use of behavioral  health drugs was 8 to 12 percentage points greater among enrollees  aged 30 and above compared with enrollees aged 19 to 29 across the  four states. Clinical experts from QuintilesIMS noted that women in  general have greater rates of prescription drug use, including non- behavioral-health drugs, and are also generally more likely to seek  medical care than men. They also noted that although many behavioral  health conditions first occur in late adolescence and early adulthood,  there is a time lag between development of symptoms and treatment that  may partially explain why more individuals aged 30 and over received  drug treatment.
Patterns of behavioral health prescription drug use by category also  varied by gender and age in selected states.
Gender: Among the drug categories with the biggest gender  differences were antidepressants, used by more women than men,  and antipsychotics, used by more men than women. Clinical experts  from QuintilesIMS noted that the prevalence of depression is  significantly higher in women than in men; in men there are more  concerns about agitation and behavior management, which can be  treated with antipsychotics.
Age: Among the drug categories with the biggest age differences  were ADHD medications, which had greater use among 19 to 29 year  olds compared with enrollees aged 30 and older, and  sedative/hypnotic medications, used by more enrollees aged 30 and  over compared with enrollees aged 19 to 29. QuintilesIMS clinical  experts said that the prevalence of ADHD declines rapidly in the late  teen years, which may explain the lower use of these drugs in the  older age group. The sedative/hypnotic drug category includes drugs  that address insomnia, which is a condition that increases with age;  this may partially explain the higher use of these drugs in the 30 and  over age group.
Over a quarter of expansion enrollees in the selected states who took a  behavioral health prescription drug in 2014 took drugs from three or more  different drug categories. From 25 to 31 percent of enrollees in selected  states who took a behavioral health drug took drugs from three or more  drug categories, and 4 to 6 percent took drugs from five or more  categories. These enrollees may have used drugs from multiple  categories at the same time to treat their conditions (concomitant use), or  they may have filled prescriptions for these drugs at different points in  time during 2014. QuintilesIMS clinical experts noted that a common  example of concomitant use is taking both an antidepressant and a sleep  medication, which are often prescribed together during initial treatment for  depression. Regarding the use of different categories of drugs over time,  experts said that sometimes when a patient does not improve after taking  a drug, a physician may switch the patient to a drug from a different  category. For example, a patient with bipolar disorder who is initially  treated with an anticonvulsant may be switched to an antipsychotic if  symptoms do not adequately resolve. We also found that more enrollees  aged 30 and over used drugs from three or more categories than  enrollees aged 19 to 29, which our clinical experts said could be partly  because some behavioral health conditions become more difficult to treat  with age, which may result in more drugs being prescribed.
section_title: Agency Comments
paragraphs: We provided a draft of this report to the Department of Health and Human  Services (HHS) for review. HHS provided technical comments, which we  incorporated as appropriate.
As discussed with your offices, unless you publicly announce the contents  of this report earlier, we plan no further distribution until 30 days after its  issuance date. At that time, we will send copies of this report to the  Secretary of Health and Human Services and other interested parties. In  addition, the report will be available at no charge on the GAO website at  http://www.gao.gov.
If you or your staff members have any questions, please contact me at  (202) 512-7114 or yocomc@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. Major contributors to this report are listed in appendix IV.
section_title: Appendix I: Behavioral Health Prescription Drugs Included in Utilization Analyses, by Category
subsections: section_title: Drug ingredient Fluvoxamine
section_title: Drug category Antipsychotic
section_title: Appendix II: Scope and Methodology
paragraphs: To describe the population of Medicaid expansion enrollees with  behavioral health diagnoses and their use of behavioral health treatment  in 2014 in selected states, we analyzed enrollment, service utilization,  and prescription drug data from the Medicaid Statistical Information  System (MSIS) for calendar year 2014 for selected states. Our analysis  consisted of the following three steps: (1) state selection, including  assessing the reliability and usability of MSIS data; (2) enrollee, service,  and drug identification; and (3) utilization analysis.
subsections: section_title: Step 1: State Selection
paragraphs: We selected four states: Iowa, New York, Washington, and West Virginia.  These were the only states that met the following criteria as of January  2016. The four selected states  1.  were among the 25 states that expanded Medicaid as allowed under  the Patient Protection and Affordable Care Act (PPACA) as of  January 1, 2014;  2.  had enrollment and utilization data for expansion enrollees in MSIS for  all of calendar year 2014 that were sufficiently reliable for the  purposes of our reporting objectives; and  3.  had available information and documentation on Medicaid behavioral  health benefits, and on how enrollment, service utilization, and  prescription drug data were recorded for expansion enrollees.
There were eight expansion states with data for all of calendar year 2014  in MSIS as of January 2016. In addition to our selected states, we  reviewed information from Arkansas, Connecticut, New Jersey, and  Vermont, but ultimately did not select these states for review for the  following reasons.
Arkansas was not selected because it implemented its expansion  through premium assistance, also known as the private option,  whereby the state pays premiums to purchase private insurance for  enrollees through a state or federal exchange. According to the  Centers for Medicare & Medicaid Services (CMS), states are not  required to submit data on the utilization of services or drugs for  enrollees who receive premium assistance; consequently, no data  were available for our utilization analyses.
Connecticut was not selected because the enrollment data in MSIS  for 2014 were not reliable enough for the purpose of identifying its  population of expansion enrollees. CMS officials told us that  Connecticut had entered enrollment data incorrectly for the expansion  population in 2014.
New Jersey was not selected due to the lack of available information  on behavioral health benefits and how its data were recorded in MSIS.
Vermont was not selected because its Medicaid program had  coverage for adults with incomes up to 150 percent of the federal  poverty level (FPL) that pre-dated the enactment of PPACA.
Iowa and New York were also missing key information in MSIS that we  needed to identify all expansion enrollees, but we conducted our analyses  after receiving the necessary data from the states directly. We limited our  analysis of Iowa’s data to individuals with incomes at or below 100  percent of the FPL, because individuals with higher incomes were served  through premium assistance as of 2014; consequently, there were no  utilization data available for them. Our selected states are not  representative of all expansion states and their Medicaid programs. In  addition, a number of state-specific factors—such as differences in  population health status and provider supply—could contribute to  variation across our selected states, but attributing this variation to such  factors was beyond the scope of this study.
We assessed the reliability and usability of MSIS data for our purposes by  interviewing knowledgeable federal and state officials; reviewing related  documentation, such as studies that assessed the reliability of Medicaid  data; comparing the results of our analysis of expansion enrollment to  published enrollment figures from CMS; and testing the data for logical  errors and missing information. Based on our assessment, we excluded  data from Iowa for months in which expansion enrollees were served  under comprehensive managed care, because the results of our reliability  testing suggested missing data. This resulted in the exclusion of data  from about 17 percent of expansion enrollees. We excluded data from  Washington for months in which expansion enrollees were served under  fee-for-service arrangements, because of missing diagnosis codes, which  were needed for our analysis. This resulted in the exclusion of data from  about 2 percent of expansion enrollees. Following these exclusions, we  determined the data were sufficiently reliable for the purposes of our  reporting objectives.
section_title: Step 2: Enrollee, Service, and Drug Identification
paragraphs: Based on enrollment information in MSIS, supplemented by state- provided information from Iowa and New York, we restricted our analysis  to nonpregnant adults aged 19-64 who were not eligible for Medicare and  whose income did not exceed 138 percent of the FPL, i.e., the “new adult  group” under Section 1902(a)(10)(A)(i)(Vlll) of the Social Security Act. We  included both newly eligible and not newly eligible expansion enrollees  who were enrolled for at least one month in calendar year 2014 (i.e.,  ever-enrolled). We excluded the following individuals, who represented 3  percent or less of expansion enrollees across the four states:  1.  Individuals who did not appear to be eligible for Medicaid expansion,  because they were recorded as dually eligible for Medicare and  Medicaid; were younger than 19 years of age as of December 31,  2014; or were older than 64 years of age as of January 1, 2014; and  2.  Individuals with multiple dates of birth, multiple values for gender; or  multiple values for MSIS identification number.
To describe the population of Medicaid expansion enrollees with  behavioral health diagnoses in selected states in 2014, we analyzed  enrollment and service utilization data in MSIS for each state. We  considered an enrollee to have a diagnosed behavioral health condition if  that enrollee received any outpatient services with a recorded diagnosis  code for a behavioral health condition in 2014. The presence of such  diagnosis codes on claims does not necessarily indicate that a clinical  interview was conducted. In addition, because we measured behavioral  health conditions based on outpatient service utilization data, our  estimates do not include individuals with conditions who did not use  outpatient services during 2014—such as individuals who used no  services or who only used inpatient services—or those who used only  behavioral health prescription drugs. Using the Agency for Healthcare  Research and Quality’s Clinical Classifications Software groupings, we  further categorized mental health conditions into 11 categories:  3.  attention-deficit, conduct, and disruptive behavior disorders;  4.  delirium, dementia, and amnestic and other cognitive disorders;  6.  disorders usually diagnosed in infancy, childhood, or adolescence;  7.  impulse control disorders not elsewhere classified;  10. schizophrenia and other psychotic disorders; and  11. miscellaneous mental health disorders.
We further categorized substance use disorders into substance-related  (i.e., addiction to drugs like cocaine or heroin) and alcohol-related  disorders. Among the substance-related conditions, we also identified  opioid abuse and dependence as a unique category, and we selected  these codes based on prior research on opioid treatment use in  Medicaid. We considered enrollees to have a behavioral health condition  if they had any diagnosis code within our selected range. Substance use  conditions were all diagnosis codes within the Agency for Healthcare  Research and Quality’s substance-related and alcohol-related disorders  categories, including opioid abuse and dependence, but excluding  tobacco use disorder. While we considered tobacco use disorder to be a  behavioral health condition, we did not consider it to be a substance use  condition, which is consistent with how the Substance Abuse and Mental  Health Services Administration collects and reports data on substance  use. For the group of enrollees with a behavioral health condition, we  used enrollment data to describe their characteristics; specifically, we  examined age, gender, and geographic location. We measured enrollees’  age based on date of birth and latest month of enrollment in 2014.  Gender was determined as recorded in the relevant MSIS data field. We  defined geographic location based on enrollees’ zip code of residence  using the most recent available rural-urban commuting area codes from  the Department of Health and Human Services and the Department of  Agriculture. The set of rural-urban commuting area codes has 10 tiers  along the spectrum of rurality, each of which is further broken down into  secondary codes. We used the four-tiered data consolidation  recommended for analysis by the Washington State Department of  Health.
To describe the use of behavioral health services among Medicaid  expansion enrollees in selected states in 2014, we selected a set of  behavioral health services for each state based on each state’s coverage  and utilization of services in 2014. We defined behavioral health services  as outpatient screening, assessment, diagnostic, treatment, rehabilitation,  and habilitation services used primarily or exclusively to evaluate and  address the needs of individuals with behavioral health conditions. To  identify behavioral health services, we reviewed the following for each  state: (1) Medicaid provider manuals and other coverage documentation  that contained the procedure codes and descriptions for covered  services, and (2) a list of all services that were provided to expansion  enrollees in calendar year 2014 that were recorded with a primary  diagnosis of a behavioral health condition. We selected codes from these  two sources that we determined to be behavioral-health-specific based on  their descriptions. We gave each state the opportunity to review and  comment on the list of services selected for analysis, and made revisions  as appropriate based on their input. To further examine behavioral health  service use by category, we reviewed the top 25 most-used services (by  number of enrollees who used the service at least once) for each state.  Based on service descriptions, we divided them into the following service  categories: diagnostic services, psychotherapy services, rehabilitation  and habilitation services, substance-use-specific services, and other  services.
To more fully examine service utilization patterns among expansion  enrollees, we also examined evaluation and management services— more general medical visits with a physician or other medical provider— because some individuals may have received behavioral health treatment  during these visits, including services provided by a psychiatrist. We  limited our analysis of evaluation and management services to those  visits recorded with a primary diagnosis of a behavioral health condition.  However, because of the uncertainty of the extent to which behavioral  health treatment was provided as part of evaluation and management  services, we do not count them as behavioral health services, or include  them in our overall definition of behavioral health treatment.
We also examined outpatient emergency room visits—for any condition,  not just a behavioral health condition—among expansion enrollees with  and without a behavioral health diagnosis. Emergency room visits were of  interest, because prior research has suggested that individuals who have  a behavioral health condition may access emergency care more  frequently than those without such conditions.
For both behavioral health and evaluation and management services, we  accounted for the possibility of duplicate claims or encounters by  restricting our analysis to a single claim or encounter for the same service  for the same patient on the same day, and by counting services with add- on codes as a single service. We excluded all inpatient and laboratory  services from our analysis. In addition, because our analysis was limited  to Medicaid claims and encounters, our results do not reflect the use of  services not paid for by Medicaid, such as state- or grant-funded  services.
To examine behavioral health prescription drug use, we examined both  filled prescriptions and services that included physician administration of  drugs. We defined behavioral health prescription drugs as Food and Drug  Administration (FDA)-approved drugs used, on- or off-label, to treat adults  with behavioral health conditions in the United States as of 2014. We  excluded drugs used to treat the side effects of other behavioral health  prescription drugs, such as drugs for diabetes that may be used to  address the metabolic effects of antipsychotic drugs. To identify  behavioral health prescription drugs, we worked with a contractor— QuintilesIMS—that developed a list of behavioral health drugs based on  drug reference information (i.e., how drugs are classified), survey data on  prescribing patterns, and expert clinical opinion. From among drugs that  were classified as psychotherapeutic or were identified as being  prescribed to treat a behavioral health condition based on survey data,  QuintilesIMS identified those drugs and drug categories that are primarily  or exclusively used to treat behavioral health conditions. We counted  these drugs as behavioral health prescription drugs whenever an  expansion enrollee filled a prescription for them. QuintilesIMS also  identified drugs that may be used for behavioral health purposes, but are  also used to treat non-behavioral-health conditions. For this group of  drugs, we used information about the characteristics of the drug, such as  dose, form, or route of administration, if applicable, to identify whether  they were likely to have been used for a behavioral health purpose. For  drugs without characteristics that distinguished their use, we counted  them as a behavioral health drug only when an individual had an  outpatient service some time in 2014 that was recorded with a related  behavioral health diagnosis (i.e., a behavioral condition that survey data  identified as one a prescriber intended to treat by prescribing that drug.)  As a result, our analysis does not account for the use of these drugs by  individuals who did not have an outpatient service in 2014 that included a  relevant diagnosis code. See appendix I for the list of behavioral health  drugs we included in our analyses.
Based on our prior work and consultation with the contractor, we  categorized the 126 behavioral health drugs on our list into 12  categories:  4.  Antidepressant combination medications  7.  Attention-deficit/hyperactivity disorder medications  9.  Sexual function disorder medications  10. Smoking cessation medications  11. Substance use disorder medications  As part of our analysis of individuals with opioid abuse and dependence,  we looked at the use of drugs used for medication-assisted treatment  (MAT). We defined MAT drugs as drugs that are FDA-approved to treat  opioid use disorder: methadone, buprenorphine, buprenorphine/naloxone,  and naltrexone. For the purposes of our analysis, we counted  methadone administration as a service rather than a prescription drug.
section_title: Step 3: Utilization Analyses
paragraphs: We conducted interviews with officials from our four selected states to  discuss behavioral health benefits for Medicaid expansion enrollees; how  enrollment, service utilization, and prescription drug data were recorded  in MSIS; officials’ perspectives on the results of our analysis; and whether  Medicaid expansion affected the availability of behavioral health  treatment for expansion enrollees, relative to what was available for low- income, uninsured adults prior to the first year of expansion in 2014. We  also interviewed a physician group specializing in addiction medicine and  consulted with clinical experts from QuintilesIMS for additional  perspectives on our results.
We conducted our performance audit from November 2015 through June  2017 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
section_title: Appendix III: Use of Treatment and Opioid Pain Medications among Enrollees with Diagnosed Opioid Abuse or Dependence
paragraphs: In light of increased interest among policy makers in addressing the  negative effects of opioid addiction, we focused a portion of our analyses  on the subset of expansion enrollees diagnosed with opioid abuse or  dependence. We analyzed Medicaid enrollment, service utilization, and  prescription drug data for 2014 to determine the characteristics of  expansion enrollees with diagnosed opioid abuse or dependence,  including gender, age, and geographic location, as well as the extent to  which these enrollees accessed medication-assisted treatment (MAT) or  received outpatient services. We also considered the extent to which  expansion enrollees diagnosed with opioid abuse or dependence  received prescriptions for opioid pain medications following their  diagnosis. While opioid pain medication can constitute proper medical  care for enrollees suffering from painful conditions, their use among  enrollees with previously diagnosed opioid abuse or dependence also  raises concerns about potential inappropriate prescribing.
subsections: section_title: Characteristics of Expansion Enrollees Diagnosed with Opioid Abuse or Dependence
paragraphs: Characteristics of expansion enrollees diagnosed with opioid abuse or  dependence were generally similar across our four selected states.  Across all the selected states, men represented a greater proportion of  enrollees diagnosed with opioid abuse or dependence than women. (See  fig. 5.) This is especially the case in New York, where 71 percent of  expansion enrollees diagnosed with opioid abuse or dependence were  men. Across all four selected states, those aged 19-29 and 30-39  accounted for a greater proportion of enrollees diagnosed with opioid  abuse or dependence compared with older enrollees. The geographic  location of enrollees diagnosed with opioid abuse or dependence varied  based on state demographics more generally.
section_title: Use of Treatment among Expansion Enrollees Diagnosed with Opioid Abuse or Dependence
paragraphs: Large proportions of expansion enrollees diagnosed with opioid abuse or  dependence utilized outpatient services, while use of MAT was lower and  varied greatly across our selected states. Outpatient services in our  analysis include behavioral health services such as diagnostic services  and psychotherapy, as well as evaluation and management services  recorded with a primary behavioral health diagnosis. From 62 to 81  percent of expansion enrollees in the selected states diagnosed with  opioid abuse or dependence received an outpatient service for a  behavioral health condition in 2014. (See table 6.) Expansion enrollees  with diagnosed opioid abuse or dependence received MAT at divergent  rates among the selected states, from 11 to 41 percent. A physician  group we interviewed noted that while not every enrollee diagnosed with  opioid addiction is a candidate for MAT, they would like to see all patients  diagnosed with opioid addiction offered MAT as an option. We previously  reported that factors that affect patients’ access to MAT for opioid  addiction include laws and regulations, the availability of qualified  practitioners and their capacity to meet patient demand for MAT, and  perceptions of MAT and its value among patients, practitioners, and  institutions.
Recent federal guidance and state actions seek to connect Medicaid  enrollees diagnosed with opioid abuse or dependence to treatment. In  January 2016, the Centers for Medicare & Medicaid Services released an  informational bulletin outlining best practices for addressing prescription  opioid overdose, misuse, and addiction, which recommends expanding  the use of MAT. In interviews, state officials discussed ongoing efforts to  ensure that enrollees diagnosed with opioid abuse or dependence receive  appropriate treatment. Many of these efforts seek to increase the number  of providers that can prescribe drugs for MAT. For example, Iowa is using  a Certified Community Behavioral Health Clinics planning grant from the  Substance Abuse and Mental Health Services Administration to train  providers and increase the number of providers that can prescribe  buprenorphine, a drug used for MAT. In Washington, officials discussed  efforts to recruit primary care physicians to prescribe buprenorphine,  which would make MAT more accessible to enrollees living in rural areas  who might have to travel great distances to receive MAT from a clinic.
section_title: Use of Opioid Pain Medications among Expansion Enrollees Diagnosed with Opioid Abuse or Dependence
paragraphs: The use of opioid pain medications was generally higher among the 1 to 3  percent of expansion enrollees diagnosed with opioid abuse or  dependence compared with all other expansion enrollees. From 24 to 48  percent of expansion enrollees diagnosed with opioid abuse or  dependence in selected states were prescribed opioid pain medication  following their diagnosis, compared with 14 to 35 percent of all other  expansion enrollees. (See table 7.) Authors of previous research on the  use of opioid pain medication among individuals with opioid abuse or  dependence have suggested that such use could reflect a lack of  coordination between specialists providing addiction treatment and those  treating patients for pain. However, representatives from a physician  group we interviewed noted that patients diagnosed with opioid addiction  suffer from the same issues that would result in an opioid prescription for  patients without an addiction, such as recovery after surgery. In addition,  those with opioid addiction also face additional medical issues resulting  from their addiction that may warrant treatment with pain medication.  However, these representatives also emphasized that the prescription of  opioids for someone diagnosed with opioid abuse or dependence is  nonetheless a “medical crisis” that requires a high level of attention. In  addition, representatives from this physician group advised providers to  ensure that there is no better treatment option available, and follow up  with patients regularly.
Recent state actions seek to address and prevent opioid abuse and  ensure appropriate prescribing of opioid pain medication. All four selected  states have implemented some form of prescription drug monitoring  program, although the extent to which providers are required to  participate varies by state. According to state officials in New York and  West Virginia, use of the prescription drug monitoring database is  mandated for providers in those states. Iowa officials said that providers  must review the state’s prescription drug monitoring database before  obtaining prior authorization from Medicaid to prescribe certain opioid  pain medications, and Washington encourages, but does not require,  providers to enroll in and use the state’s database. The selected states  have also initiated provider education campaigns. For example, officials in  Iowa said the state has worked to educate providers and pharmacists by  providing them with individual patient profiles and narcotics reports for  patients with three or more prescribers, while West Virginia has provided  feedback to providers about their prescribing patterns.
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, William Black (Assistant  Director), Hannah Locke (Analyst-in-Charge), Britt Carlson, Giselle Hicks,  Drew Long, Diona Martyn, Sean Miskell, Vikki Porter, and Emily Wilson  made key contributions to this report.