Medicaid and the Opioid Epidemic

Will Medicaid Cuts Decrease Treatment Options?

Substance Abuse Addiction
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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) report that 91 people die every day from opioid abuse, putting us on track for 32,400 deaths in 2017.

Medicaid plays a major role in the treatment of addiction.

With one in five Americans relying on Medicaid for their healthcare needs, what services does the program offer and will those services continue if the Republican party succeeds in repealing the ​Affordable Care Act, aka Obamacare?

Opioid Abuse Is Everywhere

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

Overdose deaths rose from coast to coast in 2014. 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.

Just as opioid abuse is not regional, Medicaid is not limited to the states. Medicaid, while technically managed by the states, is partially funded by federal dollars. The federal government sets the minimum standards for who is eligible for Medicaid and what basic coverage must be included in the program.

The American Health Care Act, as it was named in the U.S. House of Representatives, proposed a major overhaul to the Medicaid program. The bill, now referred to as the Better Care Reconciliation Act, awaits a vote in the U.S. Senate before it can become law. If passed, the law could change what essential health benefits - including mental health services and addiction treatments - are covered by your health insurance.

That includes Medicaid.

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.

The Better Care Reconciliation Act would end Medicaid expansion and stop the mandated treatment for addiction. 

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 states coverage for addiction 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 at 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 and 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.

If the Better Care Reconciliation Act becomes law, Medicaid expansion as we know it under the Affordable Care Act will cease to exist. The requirements to include substance abuse treatment as part of the Medicaid program will also go away.

Even states that did not participate in Medicaid expansion would be affected. This is because traditional funding to Medicaid programs would also change. Instead of the federal government matching what each state spends dollar for dollar, the Better Care Reconciliation Act would limit the states to per capita payments. That is to say, each state would receive a fixed dollar amount from the government based on the number of individuals on Medicaid in that state. 

According to the Congressional Budget Office, this change in funding would cut $772 billion from Medicaid by 2026.

This will put a significant burden on the states to find alternative funding when their own state budgets are already limited. It is expected that many states will need to cut Medicaid services in order to stay afloat. Sadly, mental health services and addiction treatment may be the first to go.

A Word from Verywell

There is no question that the Better Care Reconciliation Act would decrease access to mental health services. It does not matter if you are on Medicaid, a private health plan, or employer-sponsored insurance. Changes in what these plans must cover, i.e., changes in essential health benefits, will affect what services you will receive and will make it harder for those struggling with addiction to get the help they need.

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

H.R. 1628. U.S. Senate Office. https://www.budget.senate.gov/imo/media/doc/SENATEHEALTHCARE.pdf. Published June 22, 2017.

H.R. 1628, Better Care Reconciliation Act of 2017. Congressional Budget Office. https://www.cbo.gov/publication/52849. Published June 26, 2017.

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.

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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