Link Between Medicaid Expansion & Increased Opioid Deaths Not Supported By Data, New Study Finds

As the opioid epidemic continues, many are searching for solutions and a better understanding of underlying causes.

Some have blamed the expansion of Medicaid under the Affordable Care Act for helping fuel America’s opioid epidemic, noting how states that expanded the federal-state health insurance program for low-income people have seen higher rates of opioid overdose deaths. 

But a new study from the University of Illinois at Chicago casts doubt on this theory. The findings are published in the journal Addiction.

UIC social work professor James Swartz said the data shows the largest uptick in opioid prescribing rates for Medicaid patients in expansion states actually occurred several years prior to the ACA’s full implementation. On top of that, both expansion and non-expansion states saw an increase in opioid-related mortality in the years following the full implementation of the ACA in 2014. The increase occurred, in spite of a decrease in the availability of Medicaid-reimbursed prescription opioids in non-expansion states.

While it’s true that the overdose death rate was higher in states that expanded Medicaid, the difference in death rates between states that expanded Medicaid and those that didn’t doesn’t appear until four to five years after opioid prescription rates spiked. 

Swartz said this suggests there are other factors that could be to blame.

“I’ve ruled out, in my own mind at least, that it was some kind of a massive diversion of drugs onto the black market by people getting them through Medicaid prescriptions,” Swartz said. “That probably happens to some extent but not a large extent.”

Instead, Swartz said he suspects increased access to heroin, fentanyl and more deadly illicit opioids are to blame for the uptick in overdose deaths seen in all states. 

“What I think happened is that over that time period, post-ACA, coincidentally perhaps, you saw a great increase in the availability of heroin,” Swartz said. “And then after about 2015 or 2016, a much greater increase in heroin that had been mixed with fentanyl,” a particularly deadly combination.

Swartz said he can’t rule out the possibility that some patients started on prescription opioids through Medicaid expansion, lost access when states clamped down on doctors for overprescribing opioids, and were then driven to more deadly street drugs like heroin and fentanyl. 

But he said there’s no direct data to determine that conclusively. 

To conclusively determine this would require linking data for individuals who got access to prescription opioids through Medicaid expansion to data on opioid-related fatalities from state coroners’ officers, looking for whether a direct link can be found.

But since those data are collected by separate entities, Swartz said it would be extremely challenging to conduct such an analysis on a person-by-person basis; and studies done on aggregated data are not as conclusive.

Swartz and his co-author on the study Susanny J. Beltran, social work assistant professor at the Univeristy of Central Florida, acknowledge several limitations, such as the use of federal data on Medicaid-reimbursed prescriptions, which rely on the accurate reporting by states to the U.S. Centers for Medicare and Medicaid Services. 

The study also relies on mortality-rate data from state coroners’ officers, which could vary by state.

Other factors that vary by state include poverty rates and the availability of illegal opioids, as well as differences in laws and compliance with state-level prescription drug monitoring programs, the authors note.

Swartz is part of a working group addressing addiction and substance use disorders led by the U of I’s Institute for Government and Public Affairs.

Follow Christine on Twitter: @CTHerman