By Barbara Goodheart, ELS
Much has been written about the impact of Medicaid expansion on the opioid crisis and access to medication-assisted treatment (MAT). A group associated with amfAR, the Foundation for AIDS Research, has helped put the issue to rest.
Under lead author Alana Sharp, the group gathered data from all states, from 2011 to 2016—covering the years before and after expansion—to assess the effects of expansion.
Did Medicaid Expansion Worsen the Opioid Crisis?
More opioid prescriptions were written for Medicaid enrollees after expansion than before. The number written increased almost equally in expansion states and in nonexpansion states.
Expansion states saw a marked increase—more than 200%, the authors estimated—in prescriptions written for buprenorphine and naltrexone. In nonexpansion states, the increase in prescriptions written was far less— estimated at less than 50%.
Methadone prescribing dropped in all states, but the drop was greatest in expansion states.
Unlike buprenorphine and naltrexone, methadone is prescribed for pain as well as for opioid use disorder (OUD). This meant that investigators couldn’t separate the data to figure out what effect Medicaid expansion had on the number of methadone prescriptions written specifically for OUD.
So, has Medicaid expansion worsened the opioid crisis? “No.”
Is Medicaid expansion helping patients with SUDs obtain opioid medications and treatment? Clearly the answer is, “Yes.”
Putting Medicaid Expansion to Work
Medicaid expansion can be a useful tool—but Medicaid itself must be “substantially strengthened” first. That’s the opinion of Keith Humphreys, PhD, the Esther Ting Memorial Professor of Psychiatry and Behavioral Sciences at Stanford University, expressed in an editorial in the same issue. Dr. Humphreys, who is a member of the Stanford Neurosciences Institute, works with policy makers to reduce the negative impact of substance use on public health and safety.
Regarding the amfAR team’s findings, Dr. Humphreys called them “a welcome indication that Medicaid can in fact contribute to resolving the most destructive epidemic that the United States has faced in decades.” The American Journal of Public Health published the amfAR article and Dr. Humphreys’ editorial in its May issue.
States can use Section 1115 Medicaid waivers to shape some Medicaid provisions to their advantage. Medicaid expansion has been critically important for low-income adults in New York and three other states, according to an October 4, 2017 report from the Center on Budget and Policy Priorities. New York received $7.7 billion for adults in Medicaid expansion in federal fiscal year 2015, a Medicaid in New York fact sheet said.
In Pennsylvania, health leaders are reportedly “thrilled” by a dramatic drop in the state’s uninsured population. A 16-county area that includes Philadelphia has enrolled nearly 10,000 newly eligible people. (Enrollment updates are available on the waiver-tracker from the Kaiser Family Foundation; see References.)
Getting the Best Results From Medicaid Expansion
How can states get the most out of Medicaid expansion? Dr. Humphreys listed several requirements if Medicaid expansion is to reach its maximum effectiveness.
All states need to participate in the expansion
The map below shows 10 remaining holdouts—9 states and Washington, DC—as of May 24.
All Medicaid programs should cover the four levels of care specified by the American Society of Addiction Medicine (ASAM) (see citation in References).
The levels of care are standard outpatient, intensive outpatient, residential inpatient, and medical inpatient. Usually patients with OUD need more than just medication. At this writing, estimates indicate that only about a dozen state Medicaid programs cover all four.
Medicaid programs should cover—at higher rates—more services related to substance use.
States that do currently reimburse may be setting their rates too low, Dr. Humphreys said. Because current average rates are lower than those of other insurances, it’s difficult for patients to find providers. Dr. Humphreys believes that broader coverage would likely drop crime levels and cut transmission of hepatitis C virus (HCV) and HIV—probably resulting in fewer overdoses, and a healthier population of patients with OUD.
All insurance plans—not just Medicaid—need to find ways to reduce opioid overprescribing, misuse, and related problems.
Dr, Humphreys noted in his article the value of Medicaid in the response to the opioid epidemic—but he added that decisions “to not sufficiently expand its number of enrollees and the scope of its services” have limited Medicaid’s potential.
(As we were closing this issue, a spokesperson at ASAM alerted us to a new publication, Report to Congress on Medicaid and CHIP. This report includes a lengthy chapter with helpful information for opioid treatment programs: “Access to Treatment for Substance Use Disorders in Medicaid” [see Resources].)
AT Forum asked Dr. Humphreys what types of additional Medicaid expansion would be most useful. He referred us to a paper he coauthored on this topic, published in Health Affairs (see References).
The article noted that the failure of many states to cover all levels of care restricts treatment providers who are trying to make the best decisions for patients. For example, patients assessed as “needs close monitoring” are at high risk in states that fail to cover residential treatment, or level 3 residential, or level 2 intensive outpatient services.
The article also questioned the clinical guidelines used to decide on preauthorization policies and annual maximums, and those used to determine if access to “needed substance use disorder services are unnecessarily or inappropriately denied.”
A third key concern: lack of coverage of all four medications for opioid use disorders—something that’s necessary for effective treatment. They point in particular to methadone—“the medication covered by the fewest states”—despite the fact that methadone remains the “most efficacious and rigorously studied medication” for opioid use disorders.
What Comes Next?
Now that it’s clear that Medicaid expansion isn’t at fault for the opioid crisis, where does the real problem lie?
Dr. Humphreys has raised a possibility—one that he hopes a Senate hearing will explore—that what really has worsened the opioid crisis is not Medicaid expansion, but “our failure to expand Medicaid.”
Perhaps the Senate will take another look at the problem, with a fresh eye.
Sharp A, Jones A, Sherwood J, Kutsa O, Honermann B, Millett G. Impact of Medicaid expansion on access to opioid analgesic medications and medication-assisted treatment. AJPH. 2018;108(5):642-648. Epub April 4, 2018.
Humphreys K. How Medicaid can strengthen the national response to the opioid epidemic [editorial]. AJPH. 2018;108(5):589-590. Epub April 4, 2018.
Broaddus M, Bailey P, Aron-Dine A. Medicaid Expansion Dramatically Increased Coverage for People with Opioid-Use Disorders, Latest Data Show. Washington, DC: Center on Budget and Policy Priorities; February 28, 2018. https://www.cbpp.org/sites/default/files/atoms/files/2-28-18health.pdf.
Medicaid in New York. June 2017. Fact Sheet. The Henry J. Kaiser Family Foundation. http://files.kff.org/attachment/fact-sheet-medicaid-state-NY.
One Year in, Pennsylvania Medicaid expansion prompts celebration and new outreach. Elana Gordon, April 29, 2016. From a reporting partnership that includes WHYY, NPR, and Kaiser Health News. https://whyy.org/articles/one-year-in-pennsylvania-medicaid-expansion-prompts-celebration-and-new-outreach/.
Medicaid Waiver Tracker: Which States Have Approved and Pending Section 1115 Medicaid Waivers? May 24, 2018. The Henry J. Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/which-states-have-approved-and-pending-section-1115-medicaid-waivers/.
What are the ASAM Levels of Care? Continuum: The ASAM Criteria Decision Engine. Knowledge Base. May 13, 2015. https://www.asamcontinuum.org/knowledgebase/what-are-the-asam-levels-of-care.
Katch H. Medicaid Expansion is Critical for States Fighting Opioid Epidemic. Washington, DC: Center on Budget and Policy Priorities; October 4, 2017. https://www.cbpp.org/blog/medicaid-expansion-is-critical-for-states-fighting-opioid-epidemic.
Grogan CM, Andrews C, Abraham A, et al. Survey highlights differences in Medicaid coverage for substance use treatment and opioid use disorder medications. Health Affairs. 35:2016;12:2289-2296.
MACPAC. Penny Thompson, MPA, Chair. Chapter 4: Access to Substance Use Disorder Treatment in Medicaid. In: Medicaid and CHIP Payment and Access Commission. Report to Congress on Medicaid and CHIP. South Washington, DC. June 2018;80-112. https://www.macpac.gov/wp-content/uploads/2018/06/Access-to-Substance-Use-Disorder-Treatment-in-Medicaid.pdf. Accessed June 21, 2018.