Medicaid Expansion Alone Won't Stop the Opioid Overdose Crisis

Medicaid Expansion Alone Isn’t Enough to Stop the Opioid Overdose Crisis

Expanding the state and federal insurance program helps prevent overdoses. But that only happens with enough treatment, and legal reform, to make it work

Three unidentifiable people walking outside a clinic

People are seen outside a methadone clinic that is located across from Taunton Police Station in May 2019, in Taunton, MA. The clinic administer daily Methadone doses.


Salwan Georges/The Washington Post via Getty Images

Drug overdoses have claimed more than one million lives in the U.S. since 1999, most tied to illicit opioids such as heroin and the nonmedical use of fentanyl. Although people from all walks of life die each day from overdoses, poverty stands out as a driver of this staggering toll. The risk of dying from an overdose is 36 percent higher among people living at or below the poverty line, compared with people living at five times that line, a typical middle class income.

That’s why expansion of Medicaid, the state and federal health insurance program for low-income individuals, has been hailed as an essential policy to prevent this disproportionate suffering. Implemented in 40 states, Medicaid expansion is a pillar of the Affordable Care Act that extends its coverage to all adults living at or below 138 percent of the federal poverty line (equivalent to a yearly income of $20,120 for an individual). Health insurance can help tackle the overdose crisis because it allows people in need to afford substance use disorder treatment, and treatment is a highly effective way to reduce overdoses.

So far, however, Medicaid expansion has not fully realized its lifesaving potential for helping to end the overdose epidemic. One reason why is that it takes more than insurance alone to stave off overdoses.

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In fact, our recent analysis of all overdose deaths in the U.S. from 2008 to 2018 found that Medicaid expansion did not prevent fatal overdoses among people facing poverty; the opioid overdose mortality rate was the same—about 14.5 deaths per 100,000 residents—in states that expanded Medicaid and in states that did not.

This was not the result we expected.

So, we dug deeper by analyzing nationwide data gathered by the Centers for Disease Control and Prevention on people who inject drugs. We looked at 19,946 people who subsisted below 138 percent of the poverty line (Medicaid expansion’s eligibility threshold). Some of the states we analyzed had expanded Medicaid, while others had not, allowing us to compare individuals who injected drugs in states that had and had not expanded coverage.

These comparisons highlight a breakdown in a key pathway that should link Medicaid expansion to improved substance use disorder treatment and thus to reduced overdoses. In a sign of the policy’s success, we found that insurance coverage rates increased by 19 percentage points among people facing poverty who inject drugs and live in states that had expanded Medicaid, while rates remained unchanged among similar residents of states that had not. Moreover, we also found people experienced a nine percentage point increase in their probability of getting needed medical care if they lived in expansion states, with no parallel bump in states that did not expand Medicaid.

Strikingly, increased rates of insurance did not,however, lead to increased utilization of substance use disorder treatment; we found no difference in treatment use across these two groups of people who inject drugs. Other studies have reached similar conclusions.

So, why might health insurance not be enough to effectively link people to treatment? First, the U.S. has long suffered a marked shortage of treatment slots, so insured individuals who want treatment may still not be able to get it. For example, residential treatment programs operated at 90 percent capacity in 2022, but about three quarters of the people needing treatment that year did not receive it. We need investments to increase treatment capacity, particularly in low-income and rural areas, which have been historically underresourced.

Second, even with enhanced capacity, Medicaid expansion can only substantially impact overdoses among individuals facing poverty if treatment providers accept its insurance. Unfortunately, in 2020 only 71 percent of treatment facilities nationwide accepted Medicaid. Residents of expansion states do not fare better; a previous study by one of us found that Medicaid expansion did not result in greater increases in treatment programs accepting Medicaid in expansion states versus states that had not expanded. Low reimbursement rates are a longstanding barrier to provider acceptance of Medicaid. In 2021, the national average Medicaid reimbursement for methadone treatment—a common treatment for opioid use disorder—was nearly half that of Medicare, the federal insurance program for people age 65 and over. This Medicaid–Medicare reimbursement gap was larger than that seen for other services, including primary care. To help ensure that Medicaid expansion truly translates into increased financial access to substance use disorder treatment, policy makers must increase reimbursement for providers.

These days, people with an opioid use disorder don’t have to rely only on formal programs for treatment; they can also access the pharmaceutical treatment buprenorphine through their primary care physicians and other health care providers. Buprenorphine is a highly effective medication to treat opioid use disorder that also greatly reduces overdose risk. “Secret shopper” studies in which undercover researchers pose as potential patients, however, have found that potential patients struggle to get appointments with physicians who prescribe buprenorphine when they disclose that they are on Medicaid. Increasing Medicaid reimbursement rates, bolstering buprenorphine prescribing among providers within federally qualified health centers (which provide care for low-income individuals) and expanding the role of telemedicine are three pathways toward effectively linking insured people in need to lifesaving treatment.

Finally, even insured individuals who can access treatment may still not be able to use it because of oppressive policies. Methadone, for example, is a highly effective treatment for opioid use disorder that also reduces overdoses. Federal law, however, requires that only specialized clinics can offer it, and that patients must come in person daily for observed medication dosing. These mandates are contemporary practices of the war on drugs, which created barriers to care by punishing even public health programming for drug-related harms. Daily travel to clinics may be impossible for people who have jobs, for people who lack transportation and for those juggling childcare or eldercare. These barriers are common among impoverished people who use drugs, particularly those who are Black, Indigenous or people of color, or those who live in rural communities.

During the COVID pandemic, the federal emergency declaration temporarily replaced these punitive policies with a more patient-centered model. Emergency policies permitted some patients to take home up to a 28-day supply of methadone. While this policy has remained in effect even after the federal emergency declaration ended, it is only temporary. The Department of Health and Human Services should make this policy permanent, and support states and treatment programs as they revise policies to support this federal change.

Our study showed expansion was successful at enrolling people facing poverty who use drugs in Medicaid, and that it also helped them access needed medical care. However, our analysis also served as a compelling reminder that insurance coverage alone is insufficient to reverse the overdose crisis for this vulnerable population, because it is not adequately connecting those in need to substance use disorder treatment. We must bolster treatment to meet demand, expand program and provider acceptance of Medicaid, and permanently relax oppressive methadone policies before another million lives are lost.

This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.

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