February 21, U.S. News & World Report
If states want to drastically improve access to opioid addiction treatment, expanding Medicaid is the best place to start, a new analysis indicates.
Medicaid expansion draws a clear divide along state lines in terms of who has access to opioid use disorder treatment and who does not – despite some federal action in recent years to try to make treatment more accessible to all Americans, according to the report, published Thursday by the Urban Institute, an economic and social policy think tank based in the nation's capital.
Researchers measured Medicaid spending and prescriptions from 2010 to 2017 for the opioid overdose reversal medication naloxone, as well as buprenorphine and naltrexone, two drugs that can blunt opioid cravings and are often paired with counseling for an approach called medication-assisted treatment. While both Medicaid expansion and non-expansion states saw gains in prescriptions to treat opioid use disorder during the time period studied, patients in states that had expanded Medicaid may have been better off.
"There were increases in almost every state for the treatment of opioid use disorder using buprenorphine and naltrexone, but the states that expanded Medicaid more rapidly had higher treatment rates per enrollee," says Lisa Clemans-Cope, a principal research associate and health economist in the Health Policy Center at the Urban Institute.
Between 2013 – the year before major Affordable Care Act provisions went into effect – and 2017, Medicaid spending on opioid treatment prescriptions climbed 171 percent in states that had expanded the federal health program, compared with 72 percent in states that had not expanded Medicaid by 2017, the analysis shows.
The study's authors also cited previous research that found "no evidence of large-scale substitution from cash or other payers to Medicaid" – indicating most of the gains were among patients who previously had no access to treatment.
"In the non-expansion states, they're really leaving their people without a good option for affordable treatment," Clemans-Cope says. "These medications are really effective, and part of more comprehensive care for many individuals that can really make a big difference in mortality, as well as the experience of their families and their communities."
Overall spending on the three medications rose from $190 million in 2010 to $887.6 million in 2017, after researchers adjusted for the average rebates drugmakers paid to states. The fastest growth was between 2014 and 2016, when most states adopted Medicaid expansion.
As of January 2019, 17 states had not enacted Medicaid expansion, though three – Idaho, Nebraska and Utah – have approved expansion via ballot measure. Several of the non-expansion states saw an above-average number of opioid deaths in 2017, including Florida, Missouri, North Carolina, South Carolina, Tennessee, Utah and Wisconsin. Taken together, those seven states saw 10,502 opioid deaths that year, roughly a fifth of the national total.
Yet the number of overdose deaths remained high in some expansion states as well – such as Ohio and West Virginia – indicating that while expanding Medicaid is a major step policymakers can take to improve access to treatment, it isn't enough to ensure access for covered patients, who are disproportionately affected by opioid use disorder.
Some expansion states also have been hit hard by street fentanyl, a synthetic substance that is significantly more potent than heroin. In 2017, for example, the majority of Ohio's 4,293 opioid overdose deaths involved fentanyl and related substances.
That means more people could be getting into treatment in an area, but parallel to those gains, others could be dying at a rapid pace as fentanyl and its analogues creep into the drug supply, sometimes without users realizing, Clemans-Cope says.
"It's a little bit of a complicated picture to separate treatment from what's basically a poisoning of the opioid supply," she says.
A slew of other state-level policies also affect patients' treatment access. While buprenorphine is covered by all state Medicaid programs, some require prior authorization to prescribe the medication. Others have enacted dosage limits for the drugs, or have limited formulations of the medications available.
Still, Clemans-Cope says that as the epidemic continues to take its toll on the country, more doctors should be prepared to treat opioid use disorder, even if they aren't addiction specialists. In California, for example, a tiny share of prescribers had waivers to prescribe buprenorphine, according to Urban Institute researchers.
"Mostly, prescribers are not stepping up to the plate to provide treatment," she says. While some patients will need more specialized treatment, "there are people who can be treated effectively in primary care office, by someone who isn't an addiction specialist but has received some special training to prescribe buprenorphine."