Medicaid and the Opioid Epidemic: Failure to Treat

Will Medicaid Cuts Decrease Treatment Options?

Macro of oxycodone opioid tablets
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Opioid addiction is a growing problem in the United States. From 1999 to 2015, whether from prescription drugs or from illicit opioids like heroin, more than half a million people died from an opioid overdose. The Centers for Medicare and Medicaid Services (CMS) reports that 91 people die every day from opioid abuse, putting us on track for 32,400 deaths in 2017.

What can we do to stop or at least slow down the epidemic?

Opioid Abuse Is Everywhere

Opioid abuse is not only a state problem. It is a national problem.

A report in Becker's Hospital Review found that overdose deaths in 2014 rose from coast to coast. Ohio and California suffered the most with more than 2,000 opioid-related deaths each, while New York, Florida, Illinois, Texas, Massachusetts, Pennsylvania, and Michigan each had more than 1,000 overdose deaths reported. For clarification, the states are listed here in order from most to least deaths.

Just as opioid abuse is not regional, Medicaid is not limited to the states. Medicaid may be technically run by the states, but it is also a federally-funded program. The federal government sets the standards for who is eligible for Medicaid and what basic coverage must be included in the program. The states then decide if they want to expand their eligibility rosters or if they want to add additional services to their coverage.

Should Medicaid include treatment of opioid addiction as one of those additional services?

Treating Opioid Addiction

The Affordable Care Act required that states participating in Medicaid expansion cover substance use disorder treatment. However, the law offered flexibility and allowed each state to decide which individual services they wanted to reimburse.

There are four different levels of treatment to take into consideration:

  • Outpatient services (including group therapy, individual therapy, and recovery support services)
  • Intensive outpatient services
  • Short- and long-term residential inpatient services
  • Intensive inpatient care for detoxification

A study in Health Affairs assessed what states covered in these levels of treatment from 2015 to 2016. Interestingly, the researchers found that coverage was not necessarily higher in states that had Medicaid expansion.

Thirteen states and the District of Columbia covered all services, and 26 states covered at least one service in each level of treatment. Nine states did not provide Medicaid coverage for any substance abuse care in two or more levels of treatment.

However, offering these services did not mean they were easy to access. Nearly half of the states required a type of pre-approval process called a prior authorization before they would pay for intensive inpatient care. Nine states added a cap on how much could be spent on addiction recovery services.

Treating Opioid Abuse With Medications

The main medications used to treat opioid addiction are buprenorphine (brand-name Suboxone), methadone, and naltrexone (brand-names Depade, Revia, and Vivitrol).

Each medication binds to opioid receptors in the brain to enact its effect:

  • Buprenorphine: Buprenorphine tends to be preferred as therapy because it lasts longest in the body. It prevents the euphoric effect that opiates usually trigger, and it has a half-life ranging from 24 to 42 hours.
  • Methadone: Methadone is a synthetic opiate that helps to decrease cravings. However, like other opioids, it can cause physical dependence. Methadone is often used as maintenance therapy and may be weaned off over time. Its half-life is variable, ranging from 8 to 59 hours.
  • Naltrexone: Naltrexone is intended to decrease opioid cravings and in some cases is even used to treat alcohol addiction. The half-life is 4 to 13 hours.

    The Health Affairs study showed that every state and the District of Columbia covered buprenorphine, and forty-eight states covered naltrexone. Coverage for methadone, however, was less consistent. Only 32 states included coverage for methadone in their Medicaid programs.

    Similar to counseling for recovery and use of inpatient services, prior authorization played a role in medication coverage. Most states required prior authorization for buprenorphine while a third of them required copays.

    It is disconcerting when you think about it. People seeking help for opioid addiction are denied quick access to treatment when they need it most. Delays in treatment are the very thing that could lead them to relapse.

    Funding Cuts to Medicaid

    Expecting Medicaid to fix a national epidemic is not realistic, not if funding to the program is cut. Unfortunately, that is what may happen. With the impending planned repeal of the Affordable Care Act, aka Obamacare, Medicaid funding is possibly about to undergo a major overhaul.

    The federal government contributed a large portion of the funds to states that participated in Medicaid expansion. Specifically, they paid 100 percent of the expansion costs through 2016 and committed to paying 90 percent of those costs through 2020. Would a repeal of Obamacare put a stop to the promised funding?

    Republican plans for an Obamacare replacement have not been finalized, but it is believed that they may allow those Medicaid expansion payments to continue through 2020. Regardless, Medicaid expansion as we know it under the Affordable Care Act will cease to exist. That also means that the requirements to include substance abuse treatments as part of the Medicaid program will go away.

    Not all federal funding for the program is about Medicaid expansion. Traditional funding to Medicaid programs is also expected to change. Instead of federal matching for state spending and increased payments to hospitals that care for large numbers of people on Medicaid, current proposals include transitions to block grants or per capita limits.

    How will this affect treatment for opioid addiction? If states have less funding overall for their Medicaid programs, they may have little left to fight the opioid epidemic.

    Sources:

    Grogam CM, Andrews C, Abraham A, et al. Survey Highlights Differences In Medicaid Coverage For Substance Use Treatment And Opioid Use Disorder Medications. Health Aff. December 2016. 35(12): 2289-2296. doi: 10.1377/hlthaff.2016.0623

    Health Care Costs from Opioid Abuse: A State-by-State Analysis. Matrix Global Advisors, LLC. http://www.drugfree.org/wp-content/uploads/2015/04/Matrix_OpioidAbuse_040415.pdf. Published April 2015.

    Injury Prevention & Control: Opioid Overdose - Understanding the Epidemic. Centers for Disease Control and Prevention website. https://www.cdc.gov/drugoverdose/epidemic/index.html. Updated June 21, 2016.

    Rappleye E. Opioid overdose deaths by state. Becker's Hospital Review. http://www.beckershospitalreview.com/population-health/opioid-overdose-deaths-by-state.html. Published June 27, 2016.

    Rodriguez CH. Medicaid Coverage For Addiction Treatment Varies Dramatically. Kaiser Health News website. http://khn.org/news/medicaid-coverage-for-addiction-treatment-varies-dramatically/. Published December 6, 2016.

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