AMA Study: Decline in Overdose Deaths in States That Expanded Medicaid Under ACA

A new study, Association of Medicaid Expansion With Opioid Overdose Mortality in the United States, finds that jurisdictions that expanded access to Medicaid under the Affordable Care Act (ACA) had a six percent reduction in opioid deaths. The study published in JAMA Network Open, more specifically counties in expansion states, had an 11 percent lower rate of death involving heroin and a10 percent lower rate of death involving synthetic opioids other than methadone compared with counties in non-expansion states.

The extensive study examined data from January 1, 2001, through the end of 2017, evaluating 383,091 opioid overdose fatalities across U.S. counties. The ACA permits states to expand Medicaid coverage for low-income adults to 138 percent of the federal poverty level ($16,643 for an individual in 2017). The expanded coverage of Medicaid via the ACA was made optional when the Supreme Court ruled on the legality of the ACA in 2012. Approximately 13 states are still not taking the option, although some states have opted in different ways over the past three years, especially since the Trump Administration was rebuffed in its ACA repeal efforts in 2017.

At the time of the end of the study (2017), only 32 states and the District of Columbia had taken the Medicaid expansion. The expansion of Medicaid also includes a requirement to provide mental health and substance use disorder services on parity with other medical and surgical coverage.

Several states with the biggest increases in opioids use, including states such as West Virginia, Ohio, and Pennsylvania over the past decade, have experienced increases in foster care placements. Several analyses have demonstrated the connection between child welfare and the opioid epidemic, including the overall increases in foster care numbers (now at 437,000).

Last year Child Trends unveiled state data on child maltreatment and child welfare that showed that one in three children entered care due to parental substance abuse in 2017. The rate of 131 children per 100,000 represented a 5 percent increase over the previous year. That rate also represented a 53 percent increase over 2007. In 2018, an HHS study by the Assistance Secretary for Planning and Evaluation (ASPE), The Relationship Between Substance Use Indicators and Child Welfare Caseloads found that hospitalizations related to substance use had an impact on foster care entry rates with hospitalizations due to opioids resulting in a 2.2 percent increase in foster care entry rates compared to a 2.8 percent increase in foster care rates when the hospitalization was due to alcohol abuse.

The AMA fatalities study focus on the most extreme results of opioid abuse; beyond the fatalities, numbers are all the instances of addiction, which also have significant impacts on families and communities. The study concludes with:

“Medicaid expansion was associated with reductions in total opioid overdose deaths, particularly deaths involving heroin and synthetic opioids other than methadone but increases in methadone-related mortality. As states invest more resources in addressing the opioid overdose epidemic, attention should be paid to the role that Medicaid expansion may play in reducing opioid overdose mortality, in part through greater access to medications for opioid use disorder.”

About the Author:

John Sciamanna is CWLA's Vice President of Public Policy.

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