The role of health insurance on treatment for opioid use disorders: Evidence from the Affordable Care Act Medicaid expansion

Medicaid expansion and medications to treat opioid use disorder in outpatient specialty care from 2010 to 2020

INTRODUCTION

Medications for opioid use disorder (MOUD) are considered the first line treatment for opioid use disorder. As states expanded Medicaid beginning in 2014 under the Affordable Care Act, policymakers and public health officials were interested in the potential for expansion to increase access to MOUD. This study examined whether there were changes in MOUD use within outpatient admissions to specialty treatment facilities in Medicaid expansion states beyond the initial expansion period.

METHODS

Analyses were conducted using 2010-2020 data from the Treatment Episode Data Set - Admissions. For states that expanded Medicaid prior to 2015, a difference-in-differences analysis was conducted to evaluate whether expansion was associated with an increased proportion of MOUD treatment comparing the initial 2014-2017 period and the 2018-2020 period to 2010-2013. We then conducted a difference-in-differences analysis to examine the overall effect of Medicaid expansion on outpatient MOUD using all states that passed expansion at any point during the study period.

RESULTS

Among outpatient treatment episodes for OUD in states that expanded Medicaid in 2014, there was a 9.5 percentage point (95 % CI: 0.7-18.2) increase in the probability of receiving MOUD during the initial expansion period from 2014 to 2017 compared to 2010-2013 period, and a 7.5 percentage point (95 % CI: -8.1 -23.1) increase in 2018-2020 (compared to the 2010-2013 period) after adjusting for individual-level covariates. After incorporating states that expanded Medicaid between 2015 and 2020, there was a 6.4 percentage point (95 % CI: -0.01-13.0) increase in the probability of receiving MOUD among individuals receiving care after expansion (compared to the pre-expansion period). During the study period, there was variability among states in the change in probability of receiving MOUD from prior to after Medicaid expansion from an almost 30 percentage point increase in New York to an almost 20 percentage point decrease in Washington, DC.

CONCLUSIONS

Medicaid expansion increased the probability of receiving MOUD in outpatient settings across states from initial expansion through 2020. However, these results were not statistically significant. Additionally, significant variability between states warrants further study and suggests that improving access to MOUD will require additional state and local strategies.

MOUD use among Hispanic clients increased post-ACA, yet differed by heritage and geographic location

BACKGROUND

Overdose death rates for Hispanic people rose 2010-2022. Opioid overdose rates grew faster among Hispanic people than non-Hispanic White people ("White"). Medication for opioid use disorder (MOUD) is an effective but underutilized intervention for decreasing overdose risk. The Affordable Care Act ("ACA") should have increased MOUD use, but insurance and behavioral health reforms differed by state. We examined to what extent MOUD use increased post-ACA implementation and differed for Hispanic people (overall and by heritage group) compared to White people who used opioids ("clients").

METHODS

We analyzed first annual ambulatory care episodes (TEDS-A, 2009-2019) for working-age Hispanic (N= 76,591) and White (N=444,753) clients. We categorized Hispanic clients by heritage group (Puerto Rican, Mexican, or Other Hispanic). We grouped states by Medicaid expansion status (California, Other Expansion States, and Non-Expansion States). We used logistic regression to compare the odds of MOUD use pre/post ACA within racial/heritage groups, and, separately, between racial/heritage groups using pre-ACA White clients as a reference group. We used linear probability difference-in-differences to confirm changes in MOUD use between Hispanic and White clients.

RESULTS

Among Hispanic clients in ambulatory care, MOUD use was lowest in the Non-Expansion States and highest in California. Nationally, only Puerto Rican and Other Hispanic heritage clients had higher odds of MOUD post-ACA compared to pre-ACA. Nationally and in Other Expansion States, Hispanic and White clients had similar increases in MOUD use post-ACA.

CONCLUSIONS

MOUD use among Hispanic clients rose post-ACA, but differences remained between Hispanic heritage groups and between states.

Ridesharing and substance use disorder treatment

We examine whether ridesharing provides a meaningful transportation alternative for those who require ongoing healthcare. Specifically, we combine variation in UberX entry across the U.S. with the Treatment Episode Data Set to estimate the effect of ridesharing on admissions to substance use disorder treatment. People needing such treatment report transportation as a barrier to receiving care. We find that UberX entry into a Core Based Statistical Area has no effect on the overall number of treatment admissions. However, we find a decline in non-intensive outpatient treatment which is fully offset by an increase in intensive outpatient treatment. Given the required relative frequency of non-intensive and intensive outpatient treatment in terms of visits per week, our findings indicate that UberX helps to reduce transportation barriers to accessing healthcare. Event-studies show parallel trends in outcomes before UberX entry and results are robust to numerous sensitivity checks.

State Medicaid Policies Governing Access to Medications for Opioid Use Disorder (MOUD) and MOUD Treatment Use in a Large Sample of People Who Inject Drugs in 20 U.S. States

BACKGROUND

People who inject drugs (PWID) are especially vulnerable to harms from opioid use disorder (OUD). Medications for OUD (MOUD) effectively reduce overdose and infectious disease transmission risks.

OBJECTIVE

We investigate whether state Medicaid coverage for methadone and buprenorphine is related to past-year MOUD use among PWID using cross-sectional, multilevel analyses with individual-level data on PWID from the Centers for Disease Control and Prevention's 2018 National HIV Behavioral Surveillance. The sample included 8,142 PWID aged 18-64 who reported daily opioid use from 22 U.S. metropolitan areas. Our outcome was any self-reported MOUD use in the past 12 months. Exposures were state Medicaid coverage and prior authorization requirements for methadone and buprenorphine. We interacted these exposures with PWID race/ethnicity, insurance status, and spatial access to treatment and harm reduction resources.

RESULTS

Compared with PWID in states without Medicaid methadone coverage, odds of past-year MOUD use were 73% (p<0.05) higher among PWID in states with methadone coverage requiring prior authorization and 80% (p<0.05) higher among PWID in states with coverage without prior authorization. Insured PWID were twice as likely to report MOUD use than uninsured PWID, with no statistically significant differences between Medicaid versus other insurance. Medicaid prior authorization requirements for buprenorphine were not significantly associated with MOUD use. Non-Hispanic Black PWID were significantly less likely to use MOUD than non-Hispanic White and Hispanic PWID.

CONCLUSIONS

State Medicaid methadone coverage was strongly associated with higher odds that PWID utilized MOUD, suggesting that expanding methadone insurance coverage could improve MOUD treatment in a vulnerable population.

The ACA Medicaid expansions and the supply of substance use disorder treatment services in Spanish

BACKGROUND

Given persistent disparities in substance use disorder (SUD) treatment for Spanish speakers, it is important to understand whether major health policy changes may improve access to linguistically competent services. We estimate changes in the supply of SUD treatment facilities that both accept Medicaid as payment and offer services in Spanish after the Medicaid expansions under the Affordable Care Act.

METHODS

We use data from the Mental Health and Addiction Treatment Tracking Repository for years 2010-2020 to calculate the number of facilities per 100 that offered both services in Spanish and accepted Medicaid as payment, facilities per 100 that accepted Medicaid as a form of payment overall, and facilities per 100 that offered Spanish language services overall. We use a difference-in-differences strategy exploiting variation in the timing of the Medicaid expansions across states, and county-level variation in the share of Spanish speaking Latinos across and within states.

RESULTS

We find that treatment facilities that both accepted Medicaid as a form of payment and offered Spanish language services increased by roughly 2-3 per 100, on average, in counties with the highest shares of Spanish speakers compared to counties with low to medium shares. This increase may be explained by more facilities accepting Medicaid as a form of payment.

CONCLUSION

The Medicaid expansions under the ACA produced a modest increase in the supply of SUD treatment facilities that both accepted Medicaid as payment and provided services in Spanish in areas with highest shares of Spanish speakers.

Barriers in Office-Based Opioid Treatment in Rural United States

Background The opioid crisis has severely impacted health outcomes in the United States, particularly in rural areas, where barriers to medication-based treatment for opioid use disorder (OUD) persist. Although medication-assisted treatment (MAT) for OUD is effective, access remains limited, especially in these communities. Aim This study identifies and examines barriers to accessing office-based OUD treatment in rural areas of the United States. Methods We conducted a cross-sectional survey of 49 adults with OUD treated at an outpatient facility in rural Missouri. The survey assessed familiarity with OUD medications, barriers to accessing treatment, difficulties finding providers, and support systems. Data were analyzed using descriptive statistics and chi-square tests to compare accessibility and emotional barriers. Results The primary barriers identified were related to accessibility (54%), including costs, insurance, clinic hours, and transportation, significantly outweighing emotional barriers like stigma or lack of support (26%). Accessibility barriers were notably higher than cases reporting no barriers (p<0.01) and higher than those who reported emotional barriers (p<.05). This highlights the need for improved infrastructure and support. Conclusion Cost, insurance, clinic location, and limited clinic hours are significant obstacles to OUD treatment in rural areas. Addressing these barriers through strategies like expanded clinic hours, telehealth, transportation assistance, and physician education is essential to improving access to care for OUD patients in rural settings.

Availability of Medications for Opioid Use Disorder in Community Mental Health Facilities

Importance

Medications for opioid use disorder (MOUD) are an effective but underutilized treatment. Opioid use disorder prevalence is high among people receiving treatment in community outpatient mental health treatment facilities (MHTFs), but MHTFs are understudied as an MOUD access point.

Objective

To quantify availability of MOUD at community outpatient MHTFs in high-burden states as well as characteristics associated with offering MOUD.

Design, Setting, and Participants

This cross-sectional study performed a phone survey between April and July 2023 among a representative sample of community outpatient MHTFs within 20 states most affected by the opioid crisis, including all Certified Community Behavioral Health Centers (CCBHCs). Participants were staff at 450 surveyed community outpatient MHTFs in 20 states in the US.

Main Outcomes and Measures

MOUD availability. A multivariable logistic regression was fit to assess associations of facility, county, and state-level characteristics with offering MOUD.

Results

Surveys with staff from 450 community outpatient MHTFs (152 CCBHCs and 298 non-CCBHCs) in 20 states were analyzed. Weighted estimates found that 34% (95% CI, 29%-39%) of MHTFs offered MOUD in these states. Facility-level factors associated with increased odds of offering MOUD were: self-reporting being a CCBHC (odds ratio [OR], 2.11 [95% CI, 1.08-4.11]), providing integrated mental and substance use disorder treatment (OR, 5.21 [95% CI, 2.44-11.14), having a specialized treatment program for clients with co-occurring mental and substance use disorders (OR, 2.25 [95% CI, 1.14-4.43), offering housing services (OR, 2.54 [95% CI, 1.43-4.51]), and laboratory testing (OR, 2.15 [95% CI, 1.12-4.12]). Facilities that accepted state-financed health insurance plans other than Medicaid as a form of payment had increased odds of offering MOUD (OR, 1.95 [95% CI, 1.01-3.76]) and facilities that accepted state mental health agency funds had reduced odds (OR, 0.43 [95% CI, 0.19-0.99]).

Conclusions and Relevance

In this study of 450 community outpatient MHTFs in 20 high-burden states, approximately one-third offered MOUD. These results suggest that further study is needed to report MOUD uptake, either through increased prescribing at all clinics or through effective referral models.

Simulated impact of medicaid expansion on the economic burden of opioid use disorder in North Carolina

BACKGROUND

Opioid use disorder (OUD) imposes significant costs on state and local governments. Medicaid expansion may lead to a reduction in the cost burden of OUD to the state.

METHODS

We estimated the health care, criminal justice and child welfare costs, and tax revenue losses, attributable to OUD and borne by the state of North Carolina in 2022, and then estimated changes in the same domains following Medicaid expansion in North Carolina (adopted in December 2023). Analyses used existing literature on the national and state-level costs attributable to OUD to estimate individual-level health care, criminal justice, and child welfare system costs, and lost tax revenues. We combined Individual-level costs and prevalence estimates to estimate costs borne by the state before Medicaid expansion. Changes in costs after expansion were computed based on a) medication for opioid use disorder (MOUD) access for new enrollees and b) shifting of responsibility for some health care costs from the state to the federal government. Monte Carlo simulation accounted for the impact of parameter uncertainty. Dollar estimates are from the 2022 price year, and costs following the first year were discounted at 3 %.

RESULTS

In 2022, North Carolina incurred costs of $749 million (95 % credible interval [CI]: $305 M-$1,526 M) associated with OUD (53 % in health care, 36 % in criminal justice, 7 % in lost tax revenue, and 4 % in child welfare costs). Expanding Medicaid lowered the cost burden of OUD incurred by the state. The state was predicted to save an estimated $72 million per year (95 % CI: $6 M-$241 M) for the first two years and $30 million per year (95 % CI: -$28 M-$176 M) in subsequent years. Over five years, savings totaled $224 million (95 % CI: -$47 M-$949 M).

CONCLUSION

Medicaid expansion has the potential to decrease the burden of OUD in North Carolina, and policymakers should expedite its implementation.

The impact of scope-of-practice restrictions on access to medical care

We study the impact of scope-of-practice laws in a highly regulated and important policy setting, the provision of medication-assisted treatment for opioid use disorder. We consider two natural experiments generated by policy changes at the state and federal level that allow nurse practitioners more practice autonomy. Both experiments show that liberalizations of prescribing authority lead to large improvements in access to care. Further, we use rich address-level data to answer key policy questions. Expanding nurse practitioner prescribing authority reduces urban-rural disparities in health care access. Additionally, expanded autonomy increases access to care provided by physicians, driven by complementarities between providers.

Association of Medicaid expansion with health insurance, unmet need for medical care and substance use disorder treatment among people who inject drugs in 13 US states

BACKGROUND AND AIMS

Impoverished people who inject drugs (PWID) are at the epicenter of US drug-related epidemics. Medicaid expansion is designed to reduce cost-related barriers to care by expanding Medicaid coverage to all US adults living at or below 138% of the federal poverty line. This study aimed to measure whether Medicaid expansion is (1) positively associated with the probability that participants are currently insured; (2) inversely related to the probability of reporting unmet need for medical care due to cost in the past year; and (3) positively associated with the probability that they report receiving substance use disorder (SUD) treatment in the past year, among PWID subsisting at ≤ 138% of the federal poverty line.

DESIGN

A two-way fixed-effects model was used to analyze serial cross-sectional observational data.

SETTING

Seventeen metro areas in 13 US states took part in the study.

PARTICIPANTS

Participants were PWID who took part in any of the three waves (2012, 2015, 2018) of data gathered in the Center for Disease Control and Prevention's National HIV Behavioral Surveillance (NHBS), were aged ≤ 64 years and had incomes ≤ 138% of the federal poverty line. For SUD treatment analyses, the sample was further limited to PWID who used drugs daily, a proxy for SUD.

MEASUREMENTS

State-level Medicaid expansion was measured using Kaiser Family Foundation data. Individual-level self-report measures were drawn from the NHBS surveys (e.g. health insurance coverage, unmet need for medical care because of its cost, SUD treatment program participation).

FINDINGS

The sample for the insurance and unmet need analyses consisted of 19 946 impoverished PWID across 13 US states and 3 years. Approximately two-thirds were unhoused in the past year; 41.6% reported annual household incomes < $5000. In multivariable models, expansion was associated with a 19.0 [95% confidence interval (CI) = 9.0, 30.0] percentage-point increase in the probability of insurance coverage, and a 9.0 (95% CI = -15.0, -0.2) percentage-point reduction in the probability of unmet need. Expansion was unrelated to SUD treatment among PWID who used daily (n = 17 584).

CONCLUSIONS

US Medicaid expansion may curb drug-related epidemics among impoverished people who inject drugs by increasing health insurance coverage and reducing unmet need for care. Persisting non-financial barriers may undermine expansion's impact upon substance use disorder treatment in this sample.

The Impact of State Medicaid Eligibility and Benefits Policy on Neonatal Abstinence Syndrome Hospitalizations

Rates of neonatal abstinence syndrome (NAS) resulting from opioid misuse are rising. However, policies to treat opioid misuse during pregnancy are unclear. We apply a difference-in-differences design to national pediatric discharge records to examine the effects of state Medicaid policies on NAS. Among states in which Medicaid covered two clinically-recommended medications for treating opioid misuse (buprenorphine, methadone), the Affordable Care Act's Medicaid expansion reduced Medicaid-covered NAS hospitalizations. Medicaid expansion did not affect NAS hospitalizations in other expansion states. These findings imply a nuanced relationship between Medicaid policy and NAS that should be considered in addressing opioid misuse among pregnant women.

Differences in medicaid expansion effects on buprenorphine treatment utilization by county rurality and income: A pharmacy data claims analysis from 2009-2018

Background

Although use of buprenorphine for treating opioid use disorder increased over the past decade, buprenorphine utilization remains limited in lower-income and rural areas. We examine how the Affordable Care Act Medicaid expansion influenced buprenorphine initiation rates by county income and evaluate how associations differ by county rural-urban status.

Methods

This study used nationwide 2009-2018 IQVIA retail pharmacy data and a comparative interrupted time series framework-a hybrid framework combining regression discontinuity and difference-in-difference approaches. We used piecewise linear estimation to quantify changes in buprenorphine initiation rates before and after Medicaid expansion.

Results

The sample included observations from 376,704 county-months. We identified 5,227,340 new buprenorphine treatment episodes, with an average of 9.2 new buprenorphine episodes per month per 100,000 county residents. Among urban counties, those with the lowest median incomes experienced significantly larger increases in buprenorphine initiation rates associated with Medicaid expansion than counties with higher median incomes (5-year rates difference est=3525.3, se=1695.3, p = 0.04). However, among rural counties, there was no significant association between buprenorphine initiation rates and county median income after Medicaid expansion (5-year rates difference est=979.0, se=915.8, p = 0.29).

Conclusions

Medicaid expansion was associated with a reduction in income-related buprenorphine disparities in urban counties, but not in rural counties. To achieve more equitable buprenorphine access, future policies should target low-income rural areas.

Trends in Geographic Proximity to Substance Use Disorder Treatment

INTRODUCTION

This study aims to assess the trends in the number and characteristics of substance use disorder (SUD) treatment facilities within the county of residence of adults aged 50+ years over time.

METHODS

Using retrospective longitudinal data from the 1992-2018 Health and Retirement Study merged with the county-level data on all licensed treatment facilities in the country, linear mixed models were estimated to calculate geographic accessibility to SUD treatment, adjusted for person-level demographics, state-level controls, and calendar year-fixed effects. Analysis was conducted in 2022.

RESULTS

Overall, older adults experienced a decline in the average number of SUD treatment facilities within their counties of residence from 4.80 per 100,000 residents (95% CI=4.69, 4.92) in 1992 to 4.50 (95% CI=4.35, 4.64) in 2018. However, the number accepting Medicare increased from 0.26 (95% CI=0.21, 0.30) in 1992 to 1.88 (95% CI=1.80, 1.96) facilities per 100,000 (42% of facilities); Medicaid increased from 0.20 (95% CI=0.13, 0.26) in 1992 to 3.50 (95% CI=3.39, 3.62) facilities per 100,000 (78% of facilities) in 2018. Older adults living in more rural areas experienced the most growth in SUD treatment facilities per capita in their counties but with less significant growth in facilities offering medication for opioid use disorder than those living in more urban areas.

CONCLUSIONS

Despite increases in the number of SUD treatment facilities in rural areas, there has been less growth in nearby facilities offering evidence-based medication treatment for opioid use disorder.

Impact of Medicaid expansion on inclusion of medications for opioid use disorder in homeless adults' treatment plans

INTRODUCTION

People experiencing homelessness (PEH) bear disproportionate opioid mortality. This article aims to determine how state Medicaid expansion under the Affordable Care Act impacted the inclusion of medications for opioid use disorder (MOUD) in treatment plans for housed versus homeless individuals.

METHODS

The Treatment Episodes Data Set (TEDS) provided data on 6,878,044 U.S. treatment admissions between 2006 and 2019. Difference-in-differences analysis compared MOUD treatment plans and Medicaid enrollment for housed versus homeless clients in states that did and did not expand Medicaid.

RESULTS

Medicaid expansion was associated with a 35.2 (95 % CI, 11.9 to 58.4) percentage point increase in Medicaid enrollment and an 8.51 (95 % CI, 1.13 to 15.9) percentage point increase in MOUD-inclusive treatment plans for housed and homeless clients alike. Yet the pre-existing MOUD disparity persisted, with PEH being 11.8 (95 % CI, -18.6 to -5.07) percentage points less likely to have MOUD-inclusive treatment plans.

CONCLUSIONS

Medicaid expansion may be an effective tool for increasing MOUD treatment plans for PEH in the 11 states that have not yet implemented the policy, but additional efforts to increase MOUD initiation for PEH will be necessary for closing their treatment gap.

Medicaid reimbursement rates for primary care services and behavioral health outcomes

We study the effects of changing Medicaid reimbursement rates for primary care services on behavioral health outcomes-defined here as mental illness and substance use disorders. Medicaid enrollees are at elevated risk for these, and other, chronic conditions and are likely to have unmet treatment needs. We apply two-way fixed-effects regressions to survey data specifically designed to measure behavioral health outcomes over the period 2010-2016. We find that higher primary care reimbursement rates reduce mental illness and substance use disorders among non-elderly adult Medicaid enrollees, although we interpret findings for substance use disorders with some caution as they may be vulnerable to differential pre-trends. Overall, our findings suggest positive spillovers from a policy designed to target primary care services to behavioral health outcomes.

A National Portrait of Public Attitudes toward Opioid Use in the US: A Latent Class Analysis

BACKGROUND

Opioid overdose rates have steadily been increasing in the United States (US) creating what is considered an overdose death crisis. The US has a mixture of public health and punitive policies aimed to address opioid use and the overdose crisis, yet little is known about public opinion relating to opioid use and policy support. Understanding the intersection of public opinion about opioid use disorder (OUD) and policy can be useful for developing interventions to address policy responses to overdose deaths.

METHODS

A national sample of cross-sectional data from the AmeriSpeak survey conducted from 27 February 2020 through 2 March 2020 was analyzed. Measures included attitudes toward OUD and policy beliefs. Latent class analysis, a person-centered approach, was used to identify groups of individuals endorsing similar stigma and policy beliefs. We then examined the relationship between the identified groups (i.e., classes) and key behavioral and demographic factors.

RESULTS

We identified three distinct groups: (1) "High Stigma/High Punitive Policy", (2) "High Stigma/Mixed Public Health and Punitive Policy", and (3) "Low Stigma/High Public Health Policy". People with higher levels of education had reduced odds of being in the "High Stigma/High Punitive Policy" group.

CONCLUSION

Public health policies are most effective in addressing OUD. We suggest targeting interventions toward the "High Stigma/Mixed Public Health and Punitive Policy" group since this group already displays some support for public health policies. Broader interventions, such as eliminating stigmatizing messaging in the media and redacting punitive policies, could reduce OUD stigma among all groups.

Medicaid expansion and access to naloxone in metropolitan and nonmetropolitan areas

PURPOSE

The opioid crisis remains a major public health concern in the United States. Naloxone is used to reverse opioid overdoses. This study examined Medicaid expansion on naloxone prescriptions in retail pharmacies in metropolitan (metro) and nonmetropolitan (nonmetro) areas (2011-2017).

METHODS

We used population average models to evaluate the association of Medicaid expansion at the state level on the number of naloxone prescriptions dispensed and the percentage paid by Medicaid, including adjustment for opioid-related and state-level policy covariates. Difference-in-difference modeling was performed as a sensitivity analysis.

FINDINGS

States that expanded Medicaid had higher unadjusted naloxone dispensing rates and Medicaid-paid percentage of naloxone in metro and nonmetro areas. Medicaid expansion was not associated with the number of naloxone dispensed in either metro (adjusted rate ratio (ARR) = 1.26, 95% CI: [0.80, 1.97]) or nonmetro (ARR = 0.67, 95% CI: [0.37, 1.19]) areas after covariate adjustment. In metro areas, Medicaid expansion was associated with a significant increase of 3.86 percentage points (95% CI: [0.09, 7.63]) in the Medicaid-paid percentage of naloxone dispensing compared to nonexpansion states, but this association was not significant in nonmetro areas. There was also a significant time by Medicaid expansion interaction on the Medicaid-paid percentage of naloxone dispensed (metro: estimate = 0.74, 95% CI: [0.36, 1.12]; nonmetro: estimate = 0.68, 95% CI: [0.17, 1.18]).

CONCLUSIONS

Medicaid expansion increased naloxone access by increasing the Medicaid-paid percentage of naloxone prescriptions in metro areas. States with Medicaid expansion had a faster rate of increase in the Medicaid-paid percentage of naloxone than states without Medicaid expansion in nonmetro areas.

Association of Medicaid expansion and 1115 waivers for substance use disorders with hospital provision of opioid use disorder services: a cross sectional study

INTRODUCTION

Opioid-related hospitalizations have risen dramatically, placing hospitals at the frontlines of the opioid epidemic. Medicaid expansion and 1115 waivers for substance use disorders (SUDs) are two key policies aimed at expanding access to care, including opioid use disorder (OUD) services. Yet, little is known about the relationship between these policies and the availability of hospital based OUD programs. The aim of this study is to determine whether state Medicaid expansion and adoption of 1115 waivers for SUDs are associated with hospital provision of OUD programs.

METHODS

We conducted a cross-sectional study of a random sample of hospitals (n = 457) from the American Hospital Association's 2015 American Hospital Directory, compiled with the most recent publicly available community health needs assessment (2015-2018).

RESULTS

Controlling for hospital characteristics, overdose burden, and socio-demographic characteristics, both Medicaid policies were associated with hospital adoption of several OUD programs. Hospitals in Medicaid expansion states had significantly higher odds of implementing any program related to SUDs (OR: 1.740; 95% CI: 1.032-2.934) as well as some specific activities such as programs for OUD treatment (OR: 1.955; 95% CI: 1.245-3.070) and efforts to address social determinants of health (OR: 6.787; 95% CI: 1.308-35.20). State 1115 waivers for SUDs were not significantly associated with any hospital-based SUD activities.

CONCLUSIONS

Medicaid expansion was associated with several hospital programs for addressing OUD. The differential availability of hospital-based OUD programs may indicate an added layer of disadvantage for low-income patients with SUD living in non-expansion states.

Impacts of Publicly Funded Health Insurance for Adults on Children's Academic Achievement. SOUTHERN ECONOMIC JOURNAL 2023;89:860-884. [PMID: 38845841 PMCID: PMC11156232 DOI: 10.1002/soej.12614]

Empirical evidence demonstrates that publicly funded adult health insurance through the Affordable Care Act (ACA) has had positive effects on low-income adults. We examine whether the ACA's Medicaid expansions influenced child development and family functioning in low-income households. We use a difference-in-differences framework exploiting cross-state policy variation and focusing on children in low-income families from a nationally representative, longitudinal sample followed from kindergarten to fifth grade. The ACA Medicaid expansions improved children's reading test scores by approximately 2 percent (0.04 SD). Potential mechanisms for these effects within families are more time spent reading at home, less parental help with homework, and eating dinner together. We find no effects on children's math test scores or socioemotional skills.

Health insurance coverage during the COVID-19 pandemic: The role of Medicaid expansion

Using data from the US Census Bureau's Household Pulse Survey, we analyzed the likelihood of loss of health insurance and enrollment into new health coverage during the early months of the COVID-19 pandemic. Loss of employment was associated with a significant increase in the likelihood of loss of health insurance and, specifically, an increase in the likelihood of employer-sponsored health insurance. However, individuals in Medicaid expansion states experienced a lower likelihood of loss of health insurance compared with individuals in nonexpansion states. At the same time, there was a statistically significant increase in Medicaid enrollment in expansion states, by 3.2 percentage points. Reemployment or acquiring employment was associated with a gain in health insurance coverage. During an economic downturn, eligibility, and coverage gaps leave many without affordable coverage options, and the pandemic will likely bring renewed attention to gaps in Medicaid coverage in nonexpansion states.

Gaps and barriers in drug and alcohol treatment following implementation of the affordable care act

Background

This study examines changes in the substance use disorder (SUD) treatment gap and barriers to treatment for low-income adults following Affordable Care Act (ACA) implementation.

Methods

National Survey on Drug Use and Health (NSDUH) data were pooled to assess pre-ACA (2009-2013) and post-ACA (2015-2019) implementation. The sample (n = 44,622) included respondents 18-64 years old, income <200% federal poverty level, and meeting SUD criteria for abuse or dependence of heroin, powdered cocaine, crack cocaine, marijuana, or alcohol. The primary outcome was NSDUH-defined past-year illicit drug or alcohol treatment gap (needing but not receiving SUD specialty treatment). A secondary analysis assessed barriers to SUD treatment including insurance-related barriers, stigma, barriers to access, priority of treatment, and no interest in stopping substance use.

Results

Ninety-three percent of respondents reported a drug or alcohol treatment gap before and after ACA implementation. No interest in stopping use was the greatest barrier (40%), followed by insurance-related barriers (39%) and stigma (20%). After adjusting for covariates, results did not show a significant change in SUD treatment gap post-ACA compared to pre-ACA (adjusted odds ratio [aOR]=1.11, 95% confidence interval [CI]=0.97, 1.28, p = 0.13). Compared to pre-ACA, odds of reporting stigma-related barriers (aOR=1.66, 95% CI=1.17, 2.37, p = 0.01) and access-related barriers (aOR=1.79, 95% CI=1.34, 2.38, p < 0.001) increased post-ACA.

Conclusions

There was no significant change in the prevalence of SUD treatment gap after ACA implementation. Increasing access to SUD treatment for low-income individuals will require intervening at multiple socioecological levels beyond reforming treatment financing.

Factors related to substance use treatment attendance after peer recovery coach intervention in the emergency department

Introduction

Brief intervention with peer recovery coach support has been used to generate referrals to substance use disorder treatment from the emergency department (ED). This retrospective study evaluated factors associated with successful linkage to treatment following brief intervention in the ED.

Methods

Data were extracted from the electronic health record for patients who were referred to substance use treatment from the ED and for whom follow-up data regarding treatment attendance was available (n=666). We examined associations between demographic and insurance variables, substance use, mental health diagnosis, prior abstinence, and stage of change with successful linkage to substance use treatment after ED referral.

Results

The sample was majority male (68%), White (62%), and had a mean age of 43 years (SD=12). Medicaid was the most common insurance (49%) followed by employer/private (34%). Multivariable logistic regression determined patients with Medicaid (OR=2.94, 95% CI:2.09-4.13, p=<.001), those who had a documented alcohol use disorder diagnosis (OR=1.59, 95% CI:1.074-2.342, p=.02), and those in the "Action" stage of change (OR=2.33, 95% CI:1.47-3.69, p=<.001) had greater odds of being successfully linked to treatment.

Conclusions

These results identify characteristics of patients available in the health record to determine who is more likely or less likely to attend substance use treatment following ED referral. Given appropriate screening, this information could be used to direct standard care resources to those with high likelihood of treatment attendance and strengthen follow-up interventions with peer recovery coaches for those with lower likelihood of treatment attendance.

Patterns in Geographic Distribution of Substance Use Disorder Treatment Facilities in the US and Accepted Forms of Payment From 2010 to 2021

Importance

The drug overdose crisis is a continuing public health problem and is expected to grow substantially in older adults. Understanding the geographic accessibility to a substance use disorder (SUD) treatment facility that accepts Medicare can inform efforts to address this crisis in older adults.

Objective

To assess whether geographic accessibility of services was limited for older adults despite the increasing need for SUD and opioid use disorder treatments in this population.

Design, Setting, and Participants

This longitudinal cross-sectional study obtained data on all licensed SUD treatment facilities for all US counties and Census tracts listed in the National Directory of Drug and Alcohol Abuse Treatment Programs from 2010 to 2021.

Main Outcomes and Measures

Measures included the national proportion of treatment facilities accepting Medicare, Medicaid, private insurance, or cash as a form of payment; the proportion of counties with a treatment facility accepting each form of payment; and the proportion of the national population with Medicare, Medicaid, private insurance, or cash payment residing within a 15-, 30-, or 60-minute driving time from an SUD treatment facility accepting their form of payment in 2021.

Results

A total of 11 709 SUD treatment facilities operated across the US per year between 2010 and 2021 (140 507 facility-year observations). Cash was the most commonly accepted form of payment (increasing slightly from 91.0% in 2010 to 91.6% by 2021), followed by private insurance (increasing from 63.5% to 75.3%), Medicaid (increasing from 54.0% to 71.8%), and Medicare (increasing from 32.1% to 41.9%). The proportion of counties with a treatment facility that accepted Medicare as a form of payment also increased over the same study period from 41.2% to 53.8%, whereas the proportion of counties with a facility that accepted Medicaid as a form of payment increased from 53.5% to 67.1%. The proportion of Medicare beneficiaries with a treatment facility that accepted Medicare as a form of payment within a 15-minute driving time increased from 53.3% to 57.0%. The proportion of individuals with a treatment facility within a 15-minute driving time that accepted their respective form of payment was 73.2% for those with Medicaid, 69.8% for those with private insurance, and 71.4% for those with cash payment in 2021.

Conclusions and Relevance

Results of this study suggest that Medicare beneficiaries have less geographic accessibility to SUD treatment facilities given that acceptance of Medicare is low compared with other forms of payment. Policy makers need to consider increasing reimbursement rates and using additional incentives to encourage the acceptance of Medicare.

Associations Between Inpatient Induction on Medications for Opioid Use Disorder and Postdischarge Medications for Opioid Use Disorder Adherence, Overdose, and Service Use

OBJECTIVES

This study aimed to examine outcomes of a pilot program designed to increase inpatient medications for opioid use disorder (MOUD) induction and to support MOUD adherence after discharge.

METHODS

This retrospective cohort analysis examined Medicaid adults diagnosed with opioid use disorder discharged from 2 freestanding inpatient withdrawal management facilities between October 1, 2018, and December 31, 2019. Participants had ≥90 days of continuous Medicaid enrollment before and after admission. Odds ratios (ORs) examined associations of inpatient MOUD induction with discharge against medical advice, 7- and 30-day all-cause hospital readmission, and postdischarge MOUD adherence. Mixed-effect models examined changes associated with MOUD induction and postdischarge MOUD adherence in acute service utilization and opioid overdose in the 90-day postdischarge period.

RESULTS

Of the 2332 patients discharged, 493 started MOUD inpatient care (21.1%), with most initiating buprenorphine (76.5%). Induction of MOUD was associated with a lower likelihood of discharge against medical advice (OR, 0.49; 95% confidence interval [CI], 0.37-0.64), 30-day all-cause hospital readmission (OR, 0.61; 95% CI, 0.47-0.80), and higher odds of postdischarge MOUD adherence (OR, 3.83; 95% CI, 3.06-4.81). In the 90 days after discharge, MOUD adherent patients had significant reductions in emergency department visits for behavioral health, inpatient days, withdrawal management episodes, and opioid overdoses compared with the 90-day preadmission period.

CONCLUSIONS

Inpatient MOUD induction is associated with a higher likelihood of short-term MOUD adherence after discharge, which in turn is associated with significant reductions in short-term service utilization and opioid overdose after discharge.

Impact of prenatal substance use policies on commercially insured pregnant females with opioid use disorder

INTRODUCTION

States' approaches to addressing prenatal substance use are widely heterogeneous, ranging from supportive policies that enhance access to substance use disorder (SUD) treatment to punitive policies that criminalize prenatal substance use. We studied the effect of these prenatal substance use policies (PSUPs) on medications for opioid use disorder (OUD) treatment, including buprenorphine, naltrexone, and methadone, psychosocial services for SUD treatment, opioid prescriptions, and opioid overdoses among commercially insured pregnant females with OUD. We evaluated: (1) punitive PSUPs criminalizing prenatal substance use or defining it as child maltreatment; (2) supportive PSUPs granting pregnant females priority access to SUD treatment; and (3) supportive PSUPs funding targeted SUD treatment programs for pregnant females.

METHODS

We analyzed 2006-2019 MarketScan Commercial Claims and Encounters data. The longitudinal sample comprised females aged 15-45 with an OUD diagnosis at least once during the study period. We estimated fixed effects models that compared changes in outcomes between pregnant and nonpregnant females, in states with and without a PSUP, before and after PSUP implementation.

RESULTS

Our analytical sample comprised 2,438,875 person-quarters from 164,538 unique females, of which 13% were pregnant at least once during the study period. We found that following the implementation of PSUPs funding targeted SUD treatment programs, the proportion of opioid overdoses decreased 45% and of any OUD medication increased 11%, with buprenorphine driving this increase (13%). The implementation of SUD treatment priority PSUPs was not associated with significant changes in outcomes. Following punitive PSUP implementation, the proportion receiving psychosocial services for SUD (12%) and methadone (30%) services decreased. In specifications that estimated the impact of criminalizing policies only, the strongest type of punitive PSUP, opioid overdoses increased 45%.

CONCLUSION

Our findings suggest that supportive approaches that enhance access to SUD treatment may effectively reduce adverse maternal outcomes associated with prenatal opioid use. In contrast, punitive approaches may have harmful effects. These findings support leading medical organizations' stance on PSUPs, which advocate for supportive policies that are centered on increased access to SUD treatment and safeguard against discrimination and stigmatization. Our findings also oppose punitive policies, as they may intensify marginalization of pregnant females with OUD seeking treatment.

How access to addictive drugs affects the supply of substance abuse treatment: Evidence from Medicare Part D

This paper documents how substance abuse treatment (SAT) providers and services respond to increases in population-level opioid addiction. I do this by exploiting the implementation of Medicare Part D as an exogenous increase in the availability of prescription opioids. Starting in 2006, states with higher shares of the population eligible for Medicare Part D experienced increases in residential and hospital inpatient SAT facilities, beds dedicated to SAT, and SAT facilities offering medication-assisted treatment, relative to states with lower shares. These results suggest that the supply of SAT in the United States is capable of responding significantly to changes in demand.

Management of opioid withdrawal and initiation of medications for opioid use disorder in the hospital setting

Opioid use disorder (OUD) has become increasingly prevalent among hospitalized patients in the United States and globally. As its prevalence increases, this provides a valuable opportunity for clinicians in the hospital setting to engage and initiate management and treatment of OUD. This article aims to provide hospitalists and other clinicians working in the hospital with a narrative review of the management of opioid withdrawal and the initiation of medications for opioid use disorder (MOUD) in the hospital and provide an update on a novel low dose approach to buprenorphine induction (also commonly referred to as the "microinduction" method). Management can initially include treating withdrawal symptoms with opioids as well as with a combination of non-opioid medications such as alpha 2 agonists, benzodiazepines, and/or antiemetics as needed. Besides simply managing withdrawal symptoms, clinicians can further improve the care of patients with OUD through initiating maintenance treatment with MOUD, ideally with opioids used in the initial management of withdrawal. Opioid detoxification is an inferior method of primary treatment and is associated with relapse and poor outcomes. In contrast, treatment with MOUD using methadone or buprenorphine is associated with superior treatment outcomes and reduced relapse compared to detoxification alone. Treatment with MOUD using methadone or buprenorphine can be successfully used in the hospital setting. A novel low dose approach to buprenorphine induction may be useful in minimizing precipitated withdrawals in patients who have recently used or received opioids, which makes this an attractive option in the hospital where patients are frequently on opioids for acutely painful conditions. The hospital setting also provides a valuable opportunity for clinicians to address harm reduction in patients with OUD. Finally, clinicians can improve the long-term outcomes of patients with OUD by ensuring a smooth discharge with adequate and timely follow-up.

Prenatal substance use policies and newborn health

We study the effect of punitive and priority treatment policies relating to illicit substance use during pregnancy on the rate of neonatal drug withdrawal syndrome, low birth weight, low gestational age, and prenatal care use. Punitive policies criminalize prenatal substance use, or define prenatal substance exposure as child maltreatment in child welfare statutes or as grounds for termination of parental rights. Priority treatment policies are supportive and grant pregnant women priority access to substance use disorder treatment programs. Our empirical strategy relies on administrative data from 2008 to 2018 and a difference-in-differences framework that exploits the staggered implementation of these policies. We find that neonatal drug withdrawal syndrome increases by 10%-18% following the implementation of a punitive policy. This growth is accompanied by modest reductions in prenatal care, which may reflect deterrence from healthcare utilization. In contrast, priority treatment policies are associated with small reductions in low gestational age (2%) and low birth weight (2%), along with increases in prenatal care use. Taken together, our findings suggest that punitive approaches may be associated with unintended adverse pregnancy outcomes, and that supportive approaches may be more effective for improving perinatal health.

State-level changes in health insurance coverage and parental substance use-associated foster care entry

For many families whose children are placed in foster care, initial contact with the child welfare system occurs due to interactions with the healthcare system, particularly in the context of the opioid epidemic and increased attention to prenatal drug exposure. In the last decade, many previously uninsured families have gained Medicaid health coverage, which has implications for their access to healthcare services and visibility to mandatory reporters. Using administrative foster care case data from the Adoption and Foster Care Analysis and Reporting System Foster Care Files and health insurance data from the American Community Survey, this study analyzes the associations between state-level health insurance coverage and rates of foster care entry due to parental substance use between 2009 and 2019. State-level fixed effects models revealed that public, but not private, health insurance rates were positively associated with rates of foster care entry due to parental substance use. These results support the hypothesis that health insurance coverage may promote greater contact with mandatory reporters among low-income parents with substance use disorders. Furthermore, this study illustrates how healthcare policy may have unintended consequences for the child welfare system.

County-level sociodemographic differences in availability of two medications for opioid use disorder: United States, 2019

BACKGROUND

Differences in availability of medications for opioid use disorder (MOUD) buprenorphine and methadone exist. Factors that may influence such differences in availability include sociodemographic characteristics but research in this area is limited. We explore the association between county-level sociodemographic factors and MOUD treatment availability.

METHODS

County-level Drug Enforcement Administration (DEA) data were used to determine the presence or absence of buprenorphine treatment or opioid treatment programs (OTPs) and the level of availability of these types of treatment in a county. Hurdle models were used to examine the associations of our covariates with any MOUD treatment availability and level of available treatment.

RESULTS

The odds of a county having OTP availability were higher for counties with higher percentages of non-Hispanic Black and Hispanic populations and higher drug overdose death rates. Counties with higher percentages of persons in poverty and drug overdose death rates had higher odds of maximum potential buprenorphine treatment capacity, while counties with high percentages of persons without health insurance, with disability, and rural counties had lower odds.

CONCLUSIONS

There are significant differences in the county-level availability of OTPs and buprenorphine treatment. Our findings expand on prior studies illustrating that barriers to accessing treatment persist and are not evenly distributed among sociodemographic groups, further study is needed to examine if barriers of availability translate to barriers in receiving treatment. Given the escalating overdose crisis in the U.S., expanding equitable availability of MOUD is critical. Informed strategies are needed to reach areas and populations in greatest need.

Trends In The Use Of Treatment For Substance Use Disorders, 2010-19

Rapidly rising drug overdose rates in the United States during the past decade underscore the need to increase access to treatment among people with substance use disorders (SUDs). We analyzed trends in the use of treatment services among people with SUDs during the period 2010-19, using data from the National Survey on Drug Use and Health. Compared with 2013, outpatient visits for general health in the prior year increased 3.6 percentage points by the 2017-19 period. Use of any SUD treatment in the prior year remained unchanged, but treatment use among people involved in the criminal legal system increased by about 6.2 percentage points by the end of the study period. Among those receiving SUD treatment, there was a 14.9-percentage-point increase in having treatment paid for by Medicaid between 2010-13 and 2017-19. Although access to general medical care and insurance coverage have improved for people with SUD, our study findings underscore the importance of renewed efforts to increase the use of SUD treatment.

Medicaid expansion and opioid overdose mortality among socioeconomically disadvantaged populations in the US: A difference in differences analysis

BACKGROUND

Opioid-related overdoses are a major cause of mortality in the US. Medicaid Expansion is posited to reduce opioid overdose-related mortality (OORM), and may have a particularly strong effect among people of lower socioeconomic status. This study assessed the association between state Medicaid Expansion and county-level OORM rates among individuals with low educational attainment.

METHODS

This quasi-experimental study used lagged multilevel difference-in-difference models to test the relationship of state Medicaid Expansion to county-level OORM rates among people with a high-school diploma or less. Longitudinal (2008-2018) OORM data on 2978 counties nested in 48 states and the District of Columbia (DC) were drawn from the National Center for Health Statistics. The state-level exposure was a time-varying binary-coded variable capturing pre- and post-Medicaid Expansion under the Affordable Care Act (an "on switch"-type variable). The main outcome was annual county-level OORM rates among low-education adults adjusted for potential underreporting of OORM.

FINDINGS

The adjusted county-level OORM rates per 100,000 among the study population rose on average from 10.26 (SD = 13.56) in 2008-14.51 (SD = 18.20) in 2018. In the 1-year lagged multivariable model that controlled for policy and sociodemographic covariates, the association between state Medicaid Expansion and county-level OORM rates was statistically insignificant.

CONCLUSIONS

We found no evidence that expanding Medicaid eligibility reduced OORM rates among adults with lower educational attainment. Future work should seek to corroborate our findings and also identify - and repair - breakdowns in mechanisms that should link Medicaid Expansion to reduced overdoses.

Spillover of Medicaid Expansion to Prescribing of Opioid Use Disorder Medications in Medicare Part D

OBJECTIVE

The authors examined whether there were positive spillovers in opioid use disorder medication prescribing to Medicare Part D beneficiaries in Medicaid expansion states. Although prior studies have shown several positive benefits of Medicaid expansion for Americans with opioid use disorder, research has not examined potential spillovers to Medicare beneficiaries who have been hit hard by the opioid crisis.

METHODS

Prescribing data were taken from the Medicare Part D Prescription Public Use File (2010-2017). A difference-in-differences linear regression framework was used to identify spillovers in prescribing of buprenorphine and injectable naltrexone to Medicare Part D beneficiaries in Medicaid expansion states. Three sets of dependent variables measured medication prescribing at the county-year level (N=24,850). All models included county and year fixed effects, with standard errors clustered at the state level to address within-state serial correlation.

RESULTS

Medicaid expansion was associated with an increase in the probability of a county having an injectable naltrexone provider (p<0.01). After expansion, the number of buprenorphine providers in expansion states increased by 5.6% (p<0.05), and the number of injectable naltrexone providers increased by 3.3% (p<0.01), relative to nonexpansion states. Expansion was associated with a 23.1% (p<0.01) increase in the number of daily doses of injectable naltrexone, relative to nonexpansion states.

CONCLUSIONS

Medicaid expansion states may be better equipped to address the opioid crisis because of direct benefits to Medicaid beneficiaries and availability of opioid use disorder medications for Medicare Part D beneficiaries. However, additional efforts are likely needed to close the opioid use disorder treatment gap for Medicare beneficiaries.

Medicaid expansion and opioid supply policies to address the opioid overdose crisis

Background: The opioid overdose crisis remains of critical concern after historic increases in overdose mortality in the United States between 2020 and 2021. Improving access to buprenorphine -a partial opioid agonist and one of three FDA-approved medications for opioid use disorder (OUD) treatment- and reducing inappropriate opioid prescriptions may help curb mortality. Here, we examined the impact of Medicaid expansion and pain management clinic laws on opioid prescription rates and buprenorphine availability. Methods: We examined both retail opioid prescriptions per 100 persons in the state population using data from the Centers for Disease Control and Prevention and data on buprenorphine distributions in kilograms per 100,000 persons in the state population from the Automated Reports and Consolidated Ordering System database. We employed difference-in-difference frameworks to estimate the impact of Medicaid expansion on buprenorphine access and retail opioid prescription rates. Models considered three separate treatment variables: Medicaid expansion, pain management clinic ("pill mill") laws, and the interaction of Medicaid expansion and pain management clinic laws. Results: Findings showed that Medicaid expansion was associated with increased access to buprenorphine in expansion states that also employed more stringent supply-side policies, including pain management clinic laws, relative to states that did not implement policies targeting the over-supply of prescription opioids over the same time period. Conclusions. Together, Medicaid expansion and policies limiting inappropriate opioid prescriptions show promise for improving the accessibility of buprenorphine treatment for OUD.

Impact of Medicaid expansion and state-level racial diversity on breast cancer endocrine therapy prescriptions: A quasi-experimental, comparative interrupted time series study

AIMS

To determine whether Medicaid expansion impacted racially more diverse states similarly as racially less diverse states in endocrine therapy (ET) prescriptions.

METHODS

A quasi-experimental, comparative interrupted time series study of Medicaid-financed ET prescriptions from 2011 to 2018 Medicaid State Drug Utilization Database. The exposures were state's Medicaid expansion and racial diversity status. The outcome was state's quarterly number ET prescriptions per 100,000 non-elderly adult females (NAFs).

RESULTS

During the year of expansion, ET prescriptions increased sharply in expansion states but remained flat in nonexpansion states (slope: 11.96 vs. 0.43 prescriptions per 100,000 NAFs per quarter, p < 0.001). After that, the slopes were similar between expansion and nonexpansion states (1.75 vs. 0.24, p = 0.057) but the level of prescriptions in expansion states maintained at a higher level. When stratified by state's racial diversity status, the slope of increase in the first year was sharper for raciallymore diverse expansion states (16.49, p = 0.008) than racially less diverse expansion states (8.46, p < 0.001), resulting in significant differences in ET prescriptions between racially more diverse expansion and nonexpansion states but largely nonsignificant differences between racially less diverse expansion and nonexpansion states.

CONCLUSIONS

Although Medicaid expansion significantly increased ET prescriptions in expansion vs. nonexpansion states, this difference was only observed among raciallymore diverse states. Racially more diverse nonexpansion states had the lowest rates of ET prescriptions and the gaps from racially more diverse expansion states significantly widened after expansion.

POLICY SUMMARY

Our study shows that, before expansion, racially more diverse nonexpansion states had the lowest rates of ET prescriptions. After expansion, the gaps between these states and racially more diverse expansion states significantly widened. These results highlighted the importance of continuing to examine the health impacts of states not expanding Medicaid, including the health equity impacts for low income racial/ethnic minority populations with cancer and other life-threatening diseases.

Variation in Initiation, Engagement, and Retention on Medications for Opioid Use Disorder Based on Health Insurance Plan Design

BACKGROUND

The association between cost-sharing and receipt of medication for opioid use disorder (MOUD) is unknown.

METHODS

We constructed a cohort of 10,513 commercially insured individuals with a new diagnosis of opioid use disorder and information on insurance cost-sharing in a large national deidentified claims database. We examined 4 cost-sharing measures: (1) pharmacy deductible; (2) medical service deductible; (3) pharmacy medication copay; and (4) medical office copay. We measured MOUD (naltrexone, buprenorphine, or methadone) initiation (within 14 d of diagnosis), engagement (second receipt within 34 d of first), and 6-month retention (continuous receipt without 14-d gap). We used multivariable logistic regression to assess the association between cost-sharing and MOUD initiation, engagement, and retention. We calculated total out-of-pocket costs in the 30 days following MOUD initiation for each type of MOUD.

RESULTS

Of 10,513 individuals with incident opioid use disorder, 1202 (11%) initiated MOUD, 742 (7%) engaged, and 253 (2%) were retained in MOUD at 6 months. A high ($1000+) medical deductible was associated with a lower odds of initiation compared with no deductible (odds ratio: 0.85, 95% confidence interval: 0.74-0.98). We found no significant associations between other cost-sharing measures for initiation, engagement, or retention. Median initial 30-day out-of-pocket costs ranged from $100 for methadone to $710 for extended-release naltrexone.

CONCLUSIONS

Among insurance plan cost-sharing measures, only medical services deductible showed an association with decreased MOUD initiation. Policy and benefit design should consider ways to reduce cost barriers to initiation and retention in MOUD.

The effect of Medicaid expansion on state-level utilization of buprenorphine for opioid use disorder in the United States

BACKGROUND

Research on the impact of Medicaid expansion on buprenorphine utilization has largely focused on the Medicaid program. Less is known about its associations with total buprenorphine utilization and non-Medicaid payers.

METHODS

Monthly prescription data (June 2013-May 2018) for proprietary and generic sublingual as well as buccal buprenorphine products were purchased from IQVIA®. Population-adjusted state-level utilization measures were constructed for Medicaid, commercial insurance, Medicare, cash, and total utilization. A difference-in-differences (DID) approach with population weights estimated the association between Medicaid expansion and buprenorphine utilization, while controlling for treatment capacity.

RESULTS

Monthly total buprenorphine prescriptions increased by 68% overall and increased 283% for Medicaid, 30% for commercial insurance, and 143% for Medicare. Cash prescriptions decreased by 10%. The DID estimate for Medicaid expansion was not statistically significant for total utilization (-19.780, 95% CI = -45.118, 5.558, p = .123). For Medicaid buprenorphine utilization, there was a significant increase of 27.120 prescriptions per 100,000 total state residents (95% CI = 9.458, 44.782, p = .003) in expansion states versus non-expansion states post-Medicaid expansion. Medicaid expansion had a negative effect on commercial insurance (DID estimate = -37.745, 95% CI = -62.946, -12.544, p = .004), cash utilization (DID estimate = -6.675, 95% CI = -12.627, -0.723, p = .029), and Medicare utilization (DID estimate = -1.855, 95% CI = -3.697, -0.013, p = .048).

DISCUSSION

The associations between Medicaid expansion and buprenorphine utilization varied across different types of payers, such that the overall impact of Medicaid expansion on buprenorphine utilization was not significant.

State health policies and interest in PrEP: evidence from Google Trends

This study investigated the association between interest in Pre-exposure Prophylaxis (PrEP) in the US using Google Health Trends as a source of big data and state policy variables of Medicaid expansions under the Affordable Care Act (ACA) and initiation of PrEP Assistance Programs (PrEP-AP). As of December 2019, thirty-three states and the District of Columbia have accepted federal Medicaid funding provided through the ACA to expand eligibility to low-income adults. Among these expansion states, eight states also implemented PrEP-AP, a program that finances PrEP. A difference-in-differences approach estimated how changes in Google search for PrEP before and after the expansion differed across expansion and non-expansion states. Analyses also gauged whether the magnitude of the correlation between Medicaid expansions and Google searches was higher in states that also initiated PrEP-AP. Findings indicated that the Medicaid expansions were associated with a higher share of Google searches for PrEP keywords (β=1.536, S.E. =.36, p<.001). Moreover, the magnitude of correlation for some keywords was higher in states that also implemented PrEP-APs.

Effects of Medicaid expansion on alcohol and opioid treatment admissions in U.S. racial/ethnic groups

BACKGROUND

Excessive drinking and opioid misuse exact a high toll on U.S. lives and differentially affect U.S. racial/ethnic groups in exposure and resultant harms. Increasing access to specialty treatment is an important policy strategy to mitigate this, particularly for lower-income and racial/ethnic minority persons who face distinctive barriers to care. We examined whether the U.S. Affordable Care Act's Medicaid expansion improved treatment utilization in the overall population and for Black, Latino, and White Americans separately.

METHODS

We analyzed total and Medicaid-insured alcohol and opioid treatment admissions per 10,000 adult, state residents using 2010-2016 data from SAMHSA's Treatment Episode Data Set (N = 20 states), with difference-in-difference models accounting for state fixed effects and time-varying state demographic characteristics, treatment need, and treatment supply.

RESULTS

Total treatment admission rates in the overall population declined for alcohol and remained roughly flat for opioids in both expansion and non-expansion states from 2010 through 2016. By contrast, estimated Medicaid-insured alcohol and opioid treatment rates rose in expansion states and decreased in non-expansion states following Medicaid expansion in 2014. The latter results were found for alcohol treatment in the total population and in each racial/ethnic group, as well as for Black and White Americans for opioid treatment.

CONCLUSIONS

Medicaid expansion was associated with greater specialty treatment entry at a time when alcohol and opioid treatment rates were declining or flat. Findings underscore benefits of expanding Medicaid eligibility to increase treatment utilization for diverse racial/ethnic groups, but also suggest an emerging treatment disparity between lower-income Americans in expansion and non-expansion states.

Self-Reported Treatment Need and Barriers to Care for Adults With Opioid Use Disorder: The US National Survey on Drug Use and Health, 2015 to 2019

Objectives. To explore barriers to care and characteristics associated with respondent-reported perceived need for opioid use disorder (OUD) treatment and National Survey on Drug Use and Health (NSDUH)‒defined OUD treatment gap. Methods. We performed a cross-sectional study using descriptive and multivariable logistic regression analyses to examine 2015-2019 NSDUH data. We included respondents aged 18 years or older with past-year OUD. Results. Of 1 987 961 adults, 10.5% reported a perceived OUD treatment need, and 71% had a NSDUH-defined treatment gap. There were significant differences in age distribution, health insurance coverage, and past-year mental illness between those with and without a perceived OUD treatment need. Older adults (aged ≥ 50 years) and non-White adults were more likely to have a treatment gap compared with younger adults (aged 18-49 years) and White adults, respectively. Conclusions. Fewer than 30% of adults with OUD receive treatment, and only 1 in 10 report a need for treatment, reflecting persistent structural barriers to care and differences in perceived care needs between patients with OUD and the NSDUH-defined treatment gap measure. Public Health Implications. Public health efforts aimed at broadening access to all forms of OUD treatment and harm reduction should be proactively undertaken. (Am J Public Health. 2022;112(2):284-295. https://doi.org/10.2105/AJPH.2021.306577).

Black clients in expansion states who used opioids were more likely to access medication for opioid use disorder after ACA implementation

INTRODUCTION

Black people in the United States who use opioids receive less treatment and die from overdoses at higher rates than White people. Medication for opioid use disorder (MOUD) decreases overdose risk. Implementation of the Affordable Care Act (ACA) in the United States was associated with an increase in MOUD. To what extent racial disparity exists in MOUD following ACA implementation remains unclear. Using a national sample of people seeking treatment for opioids (clients), we compared changes in MOUD after the ACA to determine whether implementation was associated with increased MOUD for Black clients relative to White clients.

METHODS

We identified 878,110 first episodes for clients with opioids as primary concern from SAMHDA's Treatment Episodes Dataset-Admissions (TEDS-A; 2007-2018). We performed descriptive and logistic regression analyses to estimate odds of MOUD for Black and White clients by Medicaid expansion status. We interacted ACA implementation with racial group and performed subpopulation analyses for Medicaid enrollees and criminal justice-referred clients.

RESULTS

In expansion states post-ACA, MOUD increased from 33.6% to 51.3% for White clients and from 36.2% to 61.7% for Black clients. Pre-ACA, Black clients were less likely than White clients to use MOUD (adjusted odds ratio (aOR) = 0.88, 99th Confidence Interval (CI) = [0.85, 0.91]), and post-ACA, the change in odds of MOUD did not differ. Criminal justice-referred clients experienced less of a change in odds of MOUD among Black clients than among White clients (aOR = 0.74, CI = [0.62, 0.89]). Among Medicaid-insured clients, the change in odds of MOUD among Black clients was larger (aOR = 1.16, CI = [1.03, 1.30]). In the non-expansion states before 2014, Black clients were less likely to receive MOUD (aOR = 0.86, CI = [0.77, 0.95]) than White clients. After 2014, the change in odds of MOUD increased more for Black clients relative to White clients (aOR = 1.24, CI = [1.07, 1.44]). We did not find significant changes in MOUD for clients referred through the criminal justice system or with Medicaid.

CONCLUSION

The ACA was associated with increased use of MOUD among Black clients and reduction in treatment disparity between Black and White clients. For criminal justice-referred Black clients, disparities in MOUD persist. Black clients with Medicaid in expansion states had the greatest reduction in disparities.

Association Between Assistance With Medicaid Enrollment and Use of Health Care After Incarceration Among Adults With a History of Substance Use

IMPORTANCE

The transition from prison to community is characterized by elevated morbidity and mortality, particularly owing to drug overdose. However, most formerly incarcerated adults with substance use disorders do not use any health care, including treatment for substance use disorders, during the initial months after incarceration.

OBJECTIVE

To evaluate whether a prerelease Medicaid enrollment assistance program is associated with increased health care use within 30 days after release from prison.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included 16 307 adults aged 19 to 64 years with a history of substance use who were released from state prison between April 1, 2014, and December 31, 2016. The Wisconsin Department of Corrections implemented prerelease Medicaid enrollment assistance in January 2015. Statistical analysis was performed from January 1 to August 31, 2021.

EXPOSURE

A statewide Medicaid prerelease enrollment assistance program.

MAIN OUTCOMES AND MEASURES

The main outcome was Medicaid-reimbursed health care, associated with substance use disorders and for any cause, within 30 days of prison release, including outpatient, emergency department, and inpatient care. Mean outcomes were compared for those released before and after implementation of prerelease Medicaid enrollment assistance using an intention-to-treat analysis and person-level data from the Wisconsin Department of Corrections and Medicaid.

RESULTS

The sample included 16 307 individuals with 18 265 eligible releases (men accounted for 16 320 of 18 265 total releases, and 6213 of 18 265 releases were among Black individuals; mean [SD] age at release, 35.5 [10.7] years). The likelihood of outpatient care use within 30 days of release increased after implementation of enrollment assistance relative to baseline by 7.7 percentage points for any visit (95% CI, 6.4-8.9 percentage points; P < .001), by 0.7 percentage points for an opioid use disorder visit (95% CI, 0.4-1.0 percentage points; P < .001), by 1.0 percentage point for any substance use disorder visit (95% CI, 0.5-1.6 percentage points; P < .001), and by 0.4 percentage points for receipt of medication for opioid use disorder (95% CI, 0.2-0.6 percentage points; P < .001). There was no significant change in use of the emergency department (0.7 percentage points [95% CI, -0.15 to 1.4 percentage points]). The probability of an inpatient stay increased by 0.4 percentage points (95% CI, 0.03-0.7 percentage points; P = .03).

CONCLUSIONS AND RELEVANCE

The results of this cohort study suggest that prerelease Medicaid enrollment assistance was associated with increased use of outpatient health care after incarceration and highlights the value of making this assistance universally available within correctional settings. More tailored interventions may be needed to increase the receipt of treatment for substance use disorders.

Medicaid expansion and variability in mortality in the USA: a national, observational cohort study

BACKGROUND

The expansion of the Medicaid public health insurance programme has varied by state in the USA. Longer-term mortality and factors associated with variability in outcomes after Medicaid expansion are under-studied. We aimed to investigate the association of state Medicaid expansion with all-cause mortality.

METHODS

This was a population-based, national, observational cohort study capturing all reported deaths among adults aged 25-64 years via death certificate data in the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database in the USA from Jan 1, 2010, to Dec 31, 2018. We obtained national demographic and mortality data for adults aged 25-64 years, and state-level demographics and 2010-18 mortality estimates for the overall population by linking federally maintained registries (CDC WONDER, Behavioral Risk Factor Surveillance System, Health Resources and Services Administration, US Census Bureau, and Bureau of Labor Statistics). States were categorised as Medicaid expansion or non-expansion states as classified by the Kaiser Family Foundation. Multivariable difference-in-differences analysis assessed the absolute difference in the annual, state-level, all-cause mortality per 100 000 adults after Medicaid expansion.

FINDINGS

Among 32 expansion states and 17 non-expansion states, Medicaid expansion was associated with reductions in all-cause mortality (-11·8 deaths per 100 000 adults [95% CI -21·3 to -2·2]). There was variability in changes in all-cause mortality associated with Medicaid expansion by state (ranging from -63·8 deaths per 100 000 adults [95% CI -134·1 to -42·9] in Delaware to 30·4 deaths per 100 000 adults [-39·8 to 51·4] in New Mexico). State-level proportions of women (-17·8 deaths per 100 000 adults [95% CI -26·7 to -8·8] for each percentage point increase in women residents) and non-Hispanic Black residents (-1·4 deaths per 100 000 adults [-2·4 to -0·3] for each percentage point increase in non-Hispanic Black residents) were associated with greater adjusted reductions in all-cause mortality among expansion states.

INTERPRETATION

After 4 years of implementation, Medicaid expansion remains associated with significant reductions in all-cause mortality, but reductions are variable by state characteristics. These results could inform policy makers to provide broad-based equitable improvements in health outcomes.

FUNDING

University of Southern California Research Center for Liver Diseases.

Better Late Than Never: Effects of Late ACA Medicaid Expansions for Parents on Family Health-Related Financial Well-Being

Public health insurance eligibility for low-income adults has improved adult economic well-being. But whether parental public health insurance eligibility has spillover effects on children's health insurance coverage and family health-related financial well-being is less understood. We use the 2016 to 2020 National Survey of Children's Health (NSCH) to estimate the effects of Medicaid expansions through the Affordable Care Act (ACA) for parents on child health insurance coverage, parents' employment decisions due to child health, and family health-related financial well-being. We compare children in low-income families in states that expanded Medicaid for parents after 2015 to states that never expanded in a difference-in-differences framework. We find that these expansions were associated with increases in children's public health insurance coverage by 5.5 percentage points and reductions in private coverage by 5 percentage points. We additionally find that parents were less likely to avoid changing jobs for health insurance reasons and children's medical expenses were less likely to exceed $1000. We find no evidence that the expansions affected children's dual coverage and uninsurance. Our estimates are robust to falsification and sensitivity analyzes. Our findings also suggest that benefits on children's medical expenses are concentrated in the families with the greatest financial need.

Association Between Interorganizational Collaboration in Opioid Response and Treatment Capacity for Opioid Use Disorder in Counties of Five States: A Cross-Sectional Study

Background:

Local governments on the front lines of the opioid epidemic often collaborate across organizations to achieve a more comprehensive opioid response. Collaboration is especially important in rural communities, which can lack capacity for addressing health crises, yet little is known about how local collaboration in opioid response relates to key outputs like treatment capacity.

Purpose:

This cross-sectional study examined the association between local governments’ interorganizational collaboration activity and agonist treatment capacity for opioid use disorder (OUD), and whether this association was stronger for rural than for metropolitan communities.

Methods:

Data on the location of facilities providing buprenorphine and methadone were merged with a 2019 survey of all 358 counties in 5 states (CO, NC, OH, PA, and WA) that inquired about their collaboration activity for opioid response. Regression analysis was used to estimate the effect of a collaboration activity index and its constituent items on the capacity to provide buprenorphine or methadone in a county and whether this differed by urbanicity.

Results:

A response rate of 47.8% yielded an analytic sample of n = 171 counties, including 77 metropolitan, 50 micropolitan, and 44 rural counties. Controlling for covariates, a 1-unit increase in the collaboration activity index was associated with 0.155 (95% CI = 0.005, 0.304) more methadone facilities, ie, opioid treatment programs (OTPs), per 100 000 population. An interaction model indicated this association was stronger for rural (average marginal effect = 0.354, 95% CI = 0.110, 0.599) than for non-rural counties. Separate models revealed intergovernmental data and information sharing, formal agreements, and organizational reforms were driving the above associations. Collaboration activity did not vary with the capacity to provide buprenorphine at non-OTP facilities. Spatial models used to account for spatial dependence occurring with OUD treatment capacity showed similar results.

Conclusion:

Rural communities may be able to leverage collaborations in opioid response to expand treatment capacity through OTPs.

Estimating the impact on initiating medications for opioid use disorder of state policies expanding Medicaid and prohibiting substance use during pregnancy

BACKGROUND

Medicaid expansion increased access to addiction treatment services for pregnant women. However, states' imposition of civil or criminal child abuse sanctions for drug use during pregnancy could inhibit access to treatment. We estimated the effects of Medicaid expansion on pregnant women's medications for opioid use disorder (MOUD) use, and its interaction with statutes that prohibit substance use during pregnancy.

METHODS

Using the Treatment Episode Dataset for Discharge (2010-2018), we identified the initial treatment episode of pregnant women with opioid use disorder (OUD). We described changes in MOUD use and estimated adjusted difference-in-differences and event study models to evaluate differences in changes in MOUD between states that prohibit substance use during pregnancy and states that do not.

FINDINGS

Among a total of 16,070 treatment episodes for pregnant women with OUD from 2010 to 2018, most (74%) were in states that expanded Medicaid. By one year post-expansion, the proportion of episodes receiving MOUD in states not prohibit substance use during pregnancy increased by 8.7% points (95% CI: 2.7, 14.7) from the pre-expansion period compared to a 5.6% point increase in states prohibiting substance use during pregnancy (95% CI: -3.3, 14.8). In adjusted event study analysis, the expansion was associated with an increase in MOUD use by 15.3% by year 2 in states not prohibiting versus 1.5% percentage points in states prohibiting substance use during pregnancy, respectively.

CONCLUSIONS

State policies prohibiting substance use during pregnancy may limit the salutary effects of Medicaid expansion for pregnant women who could benefit from MOUD treatment.

Marijuana liberalization policies and perinatal health

We studied the effect of marijuana liberalization policies on perinatal health with a multiperiod difference-in-differences estimator that exploited variation in effective dates of medical marijuana laws (MML) and recreational marijuana laws (RML). We found that the proportion of maternal hospitalizations with marijuana use disorder increased by 23% (0.3 percentage points) in the first three years after RML implementation, with larger effects in states authorizing commercial sales of marijuana. This growth was accompanied by a 7% (0.4 percentage points) decline in tobacco use disorder hospitalizations, yielding a net zero effect over all substance use disorder hospitalizations. RMLs were not associated with statistically significant changes in newborn health. MMLs had no statistically significant effect on maternal substance use disorder hospitalizations nor on newborn health and fairly small effects could be ruled out. In absolute numbers, our findings implied modest or no adverse effects of marijuana liberalization policies on the array of perinatal outcomes considered.

Buprenorphine prescriber monthly patient caseloads: An examination of 6-year trajectories

BACKGROUND

Many active buprenorphine prescribers treat few patients monthly, but little information is available regarding how prescribers' buprenorphine caseload fluctuates over time or how long it takes new prescribers to reach higher patient caseloads. We examine buprenorphine-prescribing clinicians' patient caseloads over time and explore prescriber characteristics associated with different caseload trajectories.

METHODS

Using 2006-2018 national buprenorphine pharmacy claims, we calculate monthly patient caseloads for buprenorphine prescribers for 6 years following a clinician's first filled buprenorphine prescription. We use K-means clustering to identify clusters of clinician caseload trajectories and bivariate analyses to examine prescriber and county characteristics associated with different trajectory classes.

RESULTS

We identified 42,067 buprenorphine prescribers with 3 trajectory classes. High-volume (1.4%;n = 571) whose mean monthly patient caseload increased to approximately 40 patients through the initial 20 months and stabilized at 40 or more patients; moderate-volume (9.2%;n = 3891) whose mean patient caseload increased during the initial 20 months, stabilizing at 15-20 patients; and low-volume (89.4%;n = 37,605), who typically had fewer than 5 patients monthly. Most low-volume prescribers (n = 31,470; 83.7% of all prescribers) initially treated 1-2 patients for several months, followed by no subsequent prescribing.

CONCLUSION

Almost three-quarters of buprenorphine prescribers treated no more than a few patients for several months before ceasing buprenorphine prescribing; only 10% of prescribers averaged more than 10 patients per month over the next 6 years. Efforts are needed to identify factors contributing to prescribers being willing to continue prescribing buprenorphine over time and to prescribe to more patients in order to increase access to buprenorphine treatment.

Impact of Medicaid expansion and methadone coverage as a medication for opioid use disorder on foster care entries during the opioid crisis

Between 2012 and 2018, incidents of opioid-involved injuries surged and the number of children in foster care due to parental drug use disorder increased. Treatments for opioid use disorder (OUD) might prevent or reduce the amount of time that children spend in the child welfare system. Using administrative data, we examined the impact of Medicaid expansion and state support for methadone as a medication for opioid use disorder (MOUD) on first-time foster care placements. Results show that first-time foster care entries due to parental drug use disorder experienced a reduction of 28 per 100,000 children in Medicaid expansion states with methadone MOUD covered by their state Medicaid programs. The largest reduction was found among non-Hispanic Black children and the youngest children (age 0-1 years). Policies that increase OUD treatment access may reduce foster care placements by reducing parents' drug use, a risk factor for child abuse/neglect and subsequent home removal.

Opioid abuse and austerity: Evidence on health service use and mortality in England

Opioid abuse has become a public health concern among many developed countries, with policymakers searching for strategies to mitigate adverse effects on population health and the wider economy. The United Kingdom has seen dramatic increases in opioid-related mortality following the financial crises in 2008. We examine the impact of spending cuts resulting from government prescribed austerity measures on opioid-related hospitalisations and mortality, thereby expanding on existing evidence suggesting a countercyclical relationship with macroeconomic performance. We take advantage of the variation in spending cuts passed down from central government to local authorities since 2010, with reductions in budgets of up to fifty percent in some areas resulting in the rescaling of vital public services. Longitudinal panel data methods are used to analyse a comprehensive, linked dataset that combines information from spending records, official death registry data and large administrative health care data for 152 local authorities (i.e., unitary authorities and county councils) in England between April 2010 and March 2017. A total of 280,827 people experienced a hospital admission in the English National Health Service because of an opioid overdose and 14,700 people died from opioids across the study period. Local authorities that experienced largest spending cuts also saw largest increases in opioid abuse. Interactions between changes in unemployment and spending items for welfare programmes show evidence about the importance for governments to protect populations from social-risk effects at times of deteriorating macroeconomic performance. Our study carries important lessons for countries aiming to address high rates of opioid abuse, including the United States, Canada and Sweden.