Effective addiction treatment requires good health coverage

The opioid crisis is a public health emergency that shows no signs of abating. In 2016, the most recent year with data, 63,600 people died from drug-related causes, a 21 percent increase from 2015. More recent data from the Centers for Disease Control and Prevention (CDC) reveal that emergency department visits for suspected opioid overdoses — including fatal and non-fatal apparent overdoses — increased by 30 percent from 2016 to 2017, an ominous sign that rates of drug overdose deaths are continuing to escalate. 

The federal response to the opioid epidemic has been sluggish and anemically funded going back several administrations since data on the dangers of opioid addiction have only started to become generally understood.

{mosads}President Trump this week unveiled a plan to address the opioid epidemic, coming nearly five months after the administration first declared the opioid crisis a public health emergency. Last month, Congress approved $6 billion over the next two years for the response, the first new federal money to combat the opioid epidemic since the Obama administration. The omnibus appropriations bill, released Wednesday, would supplement this amount with an additional $3.3 billion in opioid spending for 2018.

Congress is now tasked with developing a plan for how to spend this funding, which will likely go toward serving the17.2 million people needing but not receiving treatment for substance use disorders. Policymakers from both parties have proposed a wealth of policy instruments to achieve this, including deregulating the prescribing of medications to treat addiction, removing barriers to funding inpatient treatment facilities, and delivering treatment to vulnerable populations like prisons. Yet one of the simplest and most impactful tools for facilitating treatment and recovery for substance use has come under continuous political attack — access to Medicaid.

Medicaid provides coverage for four in 10 non-elderly Americans living with opioid use disorder. However, since last summer, some members of Congress have repeatedly asserted that Medicaid has fueled the opioid epidemic. Citing the low cost of prescription drugs for Medicaid patients, these members have accused patients of selling prescribed opioids for profit. After a Senate hearing these lawmakers released a report reiterating claims that “growing evidence” of fraud in the Medicaid program has worsened the epidemic and asserted that Medicaid caused the opioid epidemic. Some lawmakers have made spurious comparisons of opioid death rates in states that expanded and did not expand Medicaid eligibility. 

Our findings, published in American Journal of Public Health, show these claims have no basis in fact. By comparing states that did and did not expand Medicaid eligibility, we find that while opioid prescribing in the Medicaid population has increased in recent years, there is no statistical difference between states that did expand Medicaid and states that did not. The findings are in line with other assessments, including a recent Health Affairs blog describing that the trend toward higher drug-related deaths in expansion states came before the Affordable Care Act was even signed.  

In fact, the most profound effect of Medicaid expansion on the opioid epidemic is increased access to addiction treatment. Our analysis finds that per-enrollee rates of buprenorphine and naltrexone, two medications used to treat opioid use disorders, increased by more than 200 percent after states expanded Medicaid eligibility. By contrast, prescribing rates increased by less than 50 percent in the states that did not expand eligibility.

Coupled with the finding that opioid prescribing increased no more in expansion states than non-expansion states, this reveals that the expansion successfully opened up access to treatment for people with opioid use disorder. Trump himself acknowledged the importance of Medicaid in addressing the opioid epidemic by taking aim at the Medicaid Institutions for Mental Diseases (IMD) exclusion, which prohibits federal Medicaid funding from reimbursing large residential treatment facilities, in his recent opioid plan.

Americans do not experience substance use disorders in a vacuum. Nearly 40 percent of people with opioid addictions are also experiencing mental health disorders. Injecting drugs increases the chances that people will acquire infective endocarditis, HIV, or viral hepatitis. For those who developed an addiction through the misuse of drugs prescribed for chronic pain, injury, cancer, or other illnesses, those same underlying health conditions may require ongoing health care.

The rhetoric that substance use disorders can be addressed through siloed funding earmarked only for treatment, or worse, suggesting that expanding health care coverage is actually driving the opioid epidemic, fundamentally undervalues the holistic health needs of people experiencing addiction. For many, the complex health needs associated with addiction are best served by an integrated health system that is accessible and affordable.

As we map the way forward towards ending the opioid epidemic, we must not forget that Medicaid is one of the most powerful tools in our arsenal. Attempts to undermine or discredit the role of Medicaid in improving the lives of Americans living with substance use disorders are counterproductive and not supported by the best available evidence.

Alana Sharp is a policy associate for amfAR, The Foundation for AIDS Research.