21st Century Healthcare Challenges: A Case Study

Abstract 

The current paper outlines efforts by the Indiana General Assembly (IGA) to create a policy response to the opioid epidemic that currently plague the State of Indiana. The paper presents evidence from empirical studies which demonstrate the well-informed policy decisions made by the IGA. The laws passed not only seek to prevent and treat negative health outcomes due to opioid overdose, but also enforce laws that serve to deter illicit drug peddling. In addition, a synopsis of the policymaking process is discussed. 

Introduction 

The Senate Health and Provider Services Committee is one of the Senate Standing Committees and I had the privilege of being the assigned Legislative Intern during the Second Regular Session of the 120^th General Assembly. The committee was assigned several bills during the just-ended session. Among the bills are some that most impact public health in Indiana and are currently part of the Digest of Enactments. They include but are not limited to: the expansion of mental health access, the INSPECT program, and the investigation of overdose deaths. The following paragraphs will elaborate more on the lawmaking process in Indiana. 

The Lawmaking Process

Before a bill becomes an act in the State of Indiana, it must go through several stages. When a legislator has an idea for a bill, it must first go through the Office of Bill Drafting and Research, which is part of the Legislative Services Agency (LSA). Lobbyists represent entities in various sectors of the economy and often have vital information that can help a legislator draft a bill that accomplishes the intended aim. Once the LSA drafts a bill in acceptable legal language, it must go through First Reading, Committee Action, Second Reading, Third Reading, Conference Committee and then Governor’s Action in that order.

Depending on the chamber - Senate or House of Representatives - the Bill is read by its title in the chamber of origin on First Reading. The Speaker of the House or President Pro Tempore of the Senate will then refer the bill to a committee. The committee is tasked with the responsibility of determining the merits of a bill and whether changes need to be made or not. The public at this stage has the right to express their views on measures being deliberated upon.

Second Reading gives legislators the opportunity to propose amendments or have it recommitted to a committee for further study. For the bill to be ordered to engrossment it must win the support of a majority of the legislators. A bill with amendments incorporated is referred to as an engrossed bill. On third reading, the legislators have an opportunity to vote on the engrossed bill. Third reading requires a constitutional majority to be approved. A clerk is tasked with reading the measure number, title and the name of the author or sponsor in a process sometimes referred to as putting the bill across the desk. For each chamber, a constitutional majority implies that fifty percent of legislators plus one must be in support for a bill to be officially approved.

A conference committee consists of two members from each chamber. The only circumstance under which the conference committee becomes necessary is if a bill is passed by one chamber but amended by the second chamber. The two members will have to meet and deliberate on an acceptable version of the bill for each chamber.

The final step involved before a bill is enacted as law is for the attorney general to advise the governor on the legality of the bill content. After that determination is made the governor has two options: either sign the bill into law or allow it to stay on his/her desk for eight days without a signature after which it automatically becomes law. 

Contents of a Bill Packet 

A bill packet has several components that together make it complete. It consists of a calendar, body of the bill, fiscal impact statement and any amendments as and when they are available. The calendar is an itemized list of bills scheduled to be heard on an official day of session. The body of a bill consists of the Digest, Title, Enacting Clause, Body and Fiscal Statement. The fiscal impact statement identifies the financial requirements and subsequent economic outcomes should the bill be enacted. 

Improving Public Health in Indiana 

The State Government of Indiana is made up of three components namely, the Executive, Judiciary and Legislative. The branch that most closely aligned with my interests as it relates to public health during the application phase was the Legislative branch. Often referred to as the Indiana General Assembly (IGA), the legislature is made up of two chambers – Senate and House of Representatives – comprising 50 and 100 members respectively. Indiana’s constitution grants the IGA authority to enact laws that have a bearing on the lives of residents (Chamber 2018). To carry out its constitutional duties effectively, the IGA has Committees and Councils which focus on specific areas of interest to the economy. 

The Case for Expanding Mental Health Access

Overdose deaths due to opioids is a growing public health concern in the United States currently (Ray et al. 2017; Philip et al. 2017). Between the year 2000 and 2016, the death rate due to heroin and pain medications rose approximately 200% (Rudd et al., 2016). The State of Indiana is among the most affected, ranking 7^th in the nation in terms of death rate increase from 2016 to 2017 (Donnelly 2018). There is also growing evidence which suggests that the increasing rate of incident Hepatitis C virus infections has a connection to injection drug usage and opioid overdose rates (Zibbell et al 2018).

In California, between 2014 and 2016, a single-blinded randomized controlled trial using a behavioral-based intervention was carried out to determine its potential to reduce overdose deaths (Philip et al 2017). Results from prior studies suggested that while Naloxone can reduce death due to overdose and even in some cases emergency department visits (Coffin et al 2016), it may be a contributory factor to higher rates of non-life-threatening overdoses (Coffin & Sullivan 2013). Results of this nature prompted researchers at the San Francisco Department of Public Health to conduct a study aimed at assessing additional methods to complement administration of current treatment methods for at-risk individuals.

The inclusion criteria consisted of an age range within the 18-65 yr. old group, dependent on opioids as determined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), an opioid overdose incident 5 years prior to the beginning of the study and had been the recipients of naloxone as part of the Drug Overdose Prevention and Education (DOPE) Project. Other criteria included willingness to adhere to the visit schedule and ability to provide informed consent.

A total of 43 test subjects were randomly assigned to the repeated-dose brief behavioral intervention addressing opioid overdose and related risk behaviors (REBOOT) while 20 were assigned to the treatment as usual (TAU) group. The total number of participants included in the study was 63. The treatment for REBOOT participants consisted of a 45-minute motivational interviewing coupled with behavioral interventions provided by trained mental health counselors. With the help of the counselors, participants initially reviewed risk factors for overdose and helped them recognize a potential overdose and respond appropriately. Counselors helped test subjects examine personal overdose incidents to recognize risk behaviors that led to the adverse outcome. A treatment plan was then discussed with the participant which included a delayed gratification response between using opioids and other pain medications that result in overdose incidents. The treatment as usual group received information about substance abuse treatment programs and harm reduction sites. In addition, participants were made aware of other services available to them upon request. The purpose of TAU was to demonstrate the general nature of services provided by most substance abuse treatment centers. Test subjects were scheduled for visits at four month intervals beginning with month 0, 4, 8 and 12. At each visit urine screening tests were conducted in addition to administering the intervention.

Data analysis indicated that before the intervention, approximately half of all participants had had an instance of opioid overdose in the preceding 12 months while a little over one-third had overdosed in the previous four. For both groups, the average number of overdose incidents prior to intervention was about the same. However, after sixteen months of follow-up visits there was a statistically significant difference in the average number of overdose incidents among the REBOOT subjects in comparison to the TAU group. The average number of overdose incidents at month 16 for REBOOT participants was 0.03 compared to 0.65 for the control participants - TAU group. The incident rate ratio which is a relative difference measure that compares incidence rate of events at a given point in time was lower for the REBOOT participants than the treatment as usual group. It is evident from the study results that the addition of mental health services to existing substance use treatment programs will be immensely beneficial to populations most at risk.

Although the sample size was not as high as normally would be, the results still make a very good case for incorporating behavioral health management techniques into substance use disorder treatment programs. One of the aims of House Enrolled Act (HEA) 1007 is that it directs the office of Medicaid Policy and Planning to give approval for the addition of nine additional opioid treatment programs where there is demonstrated need, to provide mental health and addiction treatment for affected citizens in Indiana (Mental Health Access Act 2018). 

INSPECT Program

Further efforts to reduce opioid-related adverse events include the INSPECT Program (Senate Enrolled Act 2018). Over the past few years, several studies have documented the relationship between over prescription of opioids and consequent sentinel events and other forms of adverse health outcomes (Bohnert et al., 2011; Dunn et al., 2010). While there is a medically valid reason to prescribe pain medications, there are instances where limiting the prescribed dosages can contribute to a reduction in overdose-related adverse events (McLellan & Turner 2008). A reduction in over prescribed medications will decrease the chances of excess medication being used by individuals other than the patient, and subsequently getting misused.

A case-cohort study by Bohnert et al (2011) specifically highlighted the adverse effects of morphine in noncancer diagnosed patients when it is prescribed in excess of 50 mg/d. Patients who received 100 mg/d or more of opioids versus a maximum of 20 mg/d were found to have a hazards ratio of 7.18, 6.64 and 11.99 for chronic pain, acute pain, and cancer patients respectively. 

The ratios indicate a substantially higher probability of suffering adverse health outcomes due to increased dosage. In the case of patients in chronic pain for instance, at least a 50 mg/d prescription of morphine was associated with a little over 7 times the likelihood of an adverse health outcome as compared to patients with at most 20 mg/d. Senate Enrolled Act (SEA) 221 therefore is a step in the right direction as it calls for physician participation in Indiana’s prescription-monitoring system called INSPECT. House Enrolled Act 1359 deals with the criminal justice system as it relates to a fatal overdose because of illicit peddling of medications. 

Discussion and Conclusion 

Thus far, the Final Paper has given a thorough overview of my experience with the Senate Republican Internship during the Second Regular Session of the 120th General Assembly of Indiana. The paper has shed light on the legislative process and its role in addressing current public health challenges.

Overall, the internship experience has been instrumental in enhancing my appreciation for the legislative process. Having come from a country with a unicameral legislature, the uniqueness of the bicameral system fills me with hope in view of what Public Health has achieved so far and the many positive expectations we can all have for the future. For a system that affords its citizenry the opportunity to voice their opinions, we as a people must cease the opportunity now to safeguard a secure future for generations yet unborn. A future devoid of chronic conditions and communicable disease outbreaks. A future where posterity will think back to our time and be proud to say we have laid the foundations for the very excellent ideals of public health that forever will enhance the well-being of all and sundry.