When Medicaid expansion was enacted under the Affordable Care Act (ACA), expectations were that patients with opioid use disorders (OUDs) in specialty substance use settings in expansion states would have better access to opioid agonist treatment (OAT). Several studies have now shown that to be the case.
A new study provides additional verification—and offers suggestions for even better access.
The study team, led by Ramin Mojtabai, MD, PhD, of Johns Hopkins, found that OAT did indeed increase after expansion: Medicaid admissions rose markedly in expansion states, but not in nonexpansion states. The paper was published April 30 on ps.psychiatryonline.org.
Investigators used administrative data on 943,430 admissions from the Treatment Episodes Data Set-Admissions (TEDS-A) data base. (TEDS-A, managed by the Substance Abuse and Mental Health Services Administration [SAMHSA], monitors admissions to specialty programs that accept public funds, and gathers information from most facilities that treat substance use disorders.)
The TEDS-A patients were admitted to regular or intensive outpatient treatment in the 31 states and two territories that reported appropriate insurance and payment data. The study focused on ambulatory care settings—the primary site for specialty OAT. About 80% of patient admissions who had Medicaid insurance listed Medicaid as primary payment source.
Increase in Admissions (%)
|With Medicaid Coverage||Involving Use of OAT|
Continuing the analysis, but restricting it to expansion states, revealed the following:
Increase in Admissions (%) 2010-2016 With Use of OAT in Expansion States
|States that included methadone in OAT coverage||41.1 to 52.7|
|States that did not include methadone in OAT coverage||11.7 to 20.8|
- After expansion, the increase in OAT use was greater in expansion states than in nonexpansion states (in large part because of proportionally more Medicaid admissions)
- Medicaid insurance was “strongly associated with OAT use”—supporting the theory that the increase in the use of OAT after expansion resulted from the increase in admissions with Medicaid in expansion states
How Access Can be Further Increased
Noting that many patients did not access treatment, the authors commented that “insurance coverage alone may not be sufficient to ensure access to evidence-based treatments.” They suggested steps for helping these patients access treatment: outreach, reorganization of treatment services, and recruitment of staff that can prescribe OAT medications. (They did not provide details on these steps, but one example that comes to mind about recruiting staff is bringing back to active prescribing status some of the many practitioners who are qualified to prescribe buprenorphine, but are not doing so.)
Medicaid coverage empowers patients to choose better treatment programs and to select sites where OAT is easily available. Covering more patients under Medicaid would enable services to hire caregivers that have prescribing privileges; these caregivers could then offer OAT to more patients.
A better understanding of how Medicaid expansion increases access to OAT could suggest ways to provide even better access for more patients.
Limitations of Other Studies
The Authors’ Take. The research team expressed some uncertainty about the findings of other studies—such as the use of OAT “may have increased”—and they cite the fact that those studies “were mainly based on drug utilization and pharmacy data, the number of providers able to prescribe OAT, or service-level data.”
Our Take. But no study is perfect. We see a limitation in the current study, because of the TEDS-A data base. TEDS-A does not include information from medical offices, where most buprenorphine patients receive their medication.
After reading other published studies in the field, we find it difficult to evaluate overall the effects of expansion. Here’s why: The studies use a variety of data bases; admission criteria vary; patient populations differ; dates used to define “expansion states” vary; state Medicaid programs vary—some do not cover methadone—and so forth.
But every study contributes some information to the knowledge base. And, as publication of studies on OAT access continues, we’ll have a clearer picture of the reasons behind the effects of expansion.
The authors of the current study close with this summary: “Although Medicaid expansion and other ACA provisions try to improve financial access to OAT, optimal use of OAT calls for reorganization of services and health system reforms to make these treatments more readily available.”
Mojtabai R, Mauro C, Wall MM, Barry CL, Olfson M. The Affordable Care Act and opioid agonist therapy for opioid use disorder. Psychiatr Serv. Ps.psychiatryonline.org. Apr. 30, 2019. doi: 10.1176/appi.ps.201900025
This study was supported by a grant from the National Institute on Drug Abuse.