Medicaid Expansion Improves OUD Treatment Statistics

Medicaid Expansion Improves OUD Treatment Statistics

Medicaid expansion in some states clearly has improved access to OUD treatment and is saving countless lives. But overall U.S. death rates remain high, especially in states choosing not to opt into expanded Medicaid.

States that have expanded Medicaid programs to make "evidence based treatment" more accessible are seeing more positive results than non-expansion states, says a detailed new report just published by the Urban Institute.

Medicaid spending for the years 2010 to 2017 for naloxone, buprenorphine and naltrexone increased in all states, but patients in states opting for expanded Medicaid availability fared better, says the report.

"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," said Lisa Clemans-Cope, a principal research associate in the Health Policy Center at the Urban Institute.

The report shows that from 2013 (before the Affordable Care Act of 2014) to 2017, Medicaid-covered buprenorphine prescriptions for OUD nearly tripled from 1.79 million to 5.18 million. Spending for buprenorphine, naltrexone, and naloxone increased from $190.0 million to $887.6 million, after adjusting for the average rebates drug manufacturers paid to states. Naltrexone prescriptions more than quadrupled from 99,000 to 444,000, and naloxone prescriptions rose more than 23-fold from 5,000 to 125,000, the report says.

However, comparing Medicaid expansion vs non-expansion states really tells the tale. In expansion states, prescriptions soared 171 percent, while in non-expansion states, prescriptions increased only 72 percent.

Previous research shows "no evidence of large-scale substitution from cash or other payers to Medicaid," the report says, indicating that most of the gains seen are among patients who had no access to treatment before Medicaid expansion.


Other factors in play

According to an article in US News, 17 states have not enacted Medicaid expansion as of January 2019. Recent ballot measures in Utah, Nebraska and Idaho, however, have approved expansion.

"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," the article says. "Taken together, those seven states saw 10,502 opioid deaths that year, roughly a fifth of the national total."

The report points out that drug-related overdose deaths remain at high levels in some Medicare expansion states, including Ohio and West Virginia. This indicates that although Medicaid expansion can and does improve access to treatment, it doesn't ensure access for patients who are disproportionately affected by OUD.

A significant reason for this is certainly street fentanyl and its many analogues, a drug so powerful and quick-killing that it renders access to Medicaid unhelpful. For example, says the US News report, the majority of Ohio's 4,293 opioid overdose deaths in 2017 involved fentanyl.

It's not only Medicaid policies that cut across access to treatment. For example, buprenorphine is covered by all state Medicaid programs. However, some states require prior authorizations, have dosage limits, or limit formulations, which can impede treatment availability.


MACPAC meeting confirms problems

Meanwhile, a Medicaid and CHIP Payment Access Commission (MACPAC) panel meeting in January invited concerned public to discuss factors that delay access to "clinically appropriate" OUD treatment.

Issues included requiring proof of psychosocial support, prior authorization, treatment duration limits, and the problem of finding physicians and prescribers who accept Medicaid.

Proponents of prior authorization argue that it helps limit diversion of treatment drugs. But several speakers described situations where any delays can be dangerous for patients. As an example, a health care official described a pregnant, heroin-using woman seeking medical help on a Friday, and being told authorization will take until Monday.

Treatment duration limits ignore the harsh reality of frequent relapse and the very real need for continuation of treatment for some patients. And psychosocial support is also problematic, said Anika Alvanzo, MD, medical director of Johns Hopkins Substance Use Disorders. "If a patient needs behavioral health services then they should absolutely receive them without delay," she said.

Finding prescribers who accept Medicaid remains a major issue. Most who accept Medicare have no openings available because of patient caps defined by law. And because of stigma or other reasons, too few new prescribers are being added.

MACPAC will publish its draft recommendations later this spring.

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