Can We Combat the Opioid Epidemic Without Obamacare?

In August President Trump said he was preparing to officially declare the opioid crisis a national emergency. Just a day earlier, he was criticizing Senate Majority Leader Mitch McConnell on social media for failing to repeal the Affordable Care Act (ACA).

When ACA became law in 2010, it was accompanied by legislation that expanded Medicaid coverage to millions of Americans. 

“Were Congress to repeal federal funding for the expansion group, coverage for these newly eligible enrollees — estimated at 11 million as of 2015 — inevitably would disappear,” Sara Rosenbaum, professor of health policy at George Washington University wrote in February. 

The Republican-led Congress has so far been unable to find the votes to repeal ACA, but if that changes and Medicaid benefits are rolled back, would states be capable of coping with the opioid epidemic without that funding?

Medicaid currently covers three in 10 people with opioid addiction. Proponents of Medicaid expansion believe that coverage can help Americans gain access to treatment services before an overdose occurs. Leighton Ku, director of the Center for Health Policy Research at George Washington University’s Milken Institute School of Public Health, says that insurance coverage, whether through private insurance or under Medicaid, can help people afford preventive treatments, detox and rehabilitation services, behavioral treatments, and medications that can alleviate the symptoms of addiction and withdrawal. Without insurance coverage, people lose that access to preventive care. But it doesn’t necessarily stop them from accessing emergency services.

A Leading Cause of Death

According to the National Institutes of Health, opioids — including pain relievers like oxycodone — are generally safe for short-term use as pain relievers when prescribed properly by a doctor. However, they are often overprescribed. As a result, some can become addicted and some may eventually shift to illegal opioids like heroin or illegally- obtained potent synthetic fentanyl.

In 2016, approximately 64,000 people in the United States died as a result of a drug overdose. Many of those deaths were the result of an overdose of opioids, but that number also included deaths from drugs like methamphetamine, which are classified separately.

The most recent statistics on overdose deaths specifically from opioids show that more than 33,000 Americans died from an opioid overdose in 2015. Overdose deaths from prescription opioids started to level off around 2011 while overdose deaths from heroin and fentanyl continued to increase. Drug deaths involving fentanyl alone more than doubled between 2015 and 2016, according to the New York Times

This drastic increase in overdoses has inundated emergency rooms across the United States, where more than 1,000 people are treated each day for conditions related to the misuse of prescription opioids. According to the Department of Health and Human Services, the annual cost of emergency and inpatient care for opioid poisoning in the United States is upwards of $20 billion.

“ER visits and overdoses, that’s the worst case scenario,” said Ku. “Your goal is trying to save their life in the moment.”

But conservatives have argued that Medicaid expansion made the opioid problem worse.

Sam Adolphsen, a senior fellow at the Foundation for Government Accountability, wrote in the National Review that the seven states with the highest drug-overdose death rates in 2015 were among the 31 states that expanded Medicaid through ACA.

“While Medicaid may in some cases provide additional treatment options for an addict who is willing to engage,” Adolphsen wrote, “it also provides a ‘free’ plastic card loaded with unlimited government funds that often increases access to opioids.” 

Ku disagrees with the claim that just because Medicaid provides coverage for some opioids, it is responsible for the opioid epidemic. Doctor shopping and overprescribing are problems that need to be addressed throughout the health system, including in the private insurance sector. 

“We need to change medical practice patterns,” Ku said, “and we also need monitoring systems. They exist, but they need to be improved.”

Medical personnel play a crucial role in limiting the spread of the opioid epidemic. In September doctors from the Anne Arundel Health System in Maryland found an extreme variation in the dose of painkillers prescribed to patients by different doctors. Health system officials have set a goal for halving the amount of opioids prescribed by 2019.

“We don’t want to create a new generation of addicts,” Dr. Barry Meisenberg, head of the opioid task force at Anne Arundel Health System, told the Baltimore Sun. “We don’t want to contribute to the problem.” 

State Comparisons

Proposals to repeal ACA would significantly scale back Medicaid. So, when new Healthcare Cost and Utilization Data was released in July 2017 by the Department of Health and Human Services, Ku and his colleague, Professor Naomi Seiler, became interested in exploring the “confluence of two big national discussions” — the opioid crisis and potential Medicaid cuts.

Their analysis looks into four states that have seen increases in emergency room visits and hospital admissions related to opioids. Two of the four states (West Virginia and Kentucky) chose to expand Medicaid while the other two (Virginia and North Carolina) did not. In a comparison of opioid-related hospital stays in West Virginia and Virginia, West Virginia’s Medicaid expansion significantly reduced hospitals’ uncompensated care burden.

Figure 1 shows that West Virginia’s 2014 Medicaid Expansion helped to increase the percentage of opioid-related hospital stays covered by Medicaid. In Virginia, which did not expand Medicaid, little changed in the cost coverage of opioid-related hospitals stays.

Ku also compared insurance status for emergency room visits related to opioid abuse in Kentucky and North Carolina. By the end of 2014, visits covered by Medicaid accounted for over half of all emergency room visits related to opioid abuse in Kentucky, which chose to expand Medicaid. But North Carolina, which did not expand Medicaid, saw no changes in its uncompensated care burden.

Figure 2 shows that Kentucky’s 2014 Medicaid Expansion helped to cover the costs of opioid-related emergency visits by increasing the percentage of emergency room visits covered by Medicaid. In North Carolina, which did not opt to expand Medicaid, little changed in the cost coverage of opioid-related emergency room visits.

The Commonwealth Fund defines uncompensated care as “any treatment or service not paid for by an insurer or patient.” If you are uninsured and seek emergency care at a hospital, the hospital will first try to collect payment from you directly. But if you’re an ordinary American without health insurance, chances are you would struggle to afford the cost of an ER visit or hospital stay. If hospitals are unable to collect money, it adds to their deficit.

Ku said hospitals can try to recover their uncompensated care costs from payments from Medicaid, Medicare or private insurance or from other sources of revenue. Cost-cutting measures like hiring freezes inevitably reduce the quality of care. Safety-net hospitals, especially in rural areas, face the possibility of going out of business if they can’t make up for the losses due to uncompensated care. The cost of leaving some people without coverage can be as high as leaving others without care.

If the Trump administration decides to officially declare the opioid epidemic a state of emergency, it could allocate additional funds and resources to help the crisis. However, if Congress decides to repeal or replace the ACA, the resources from that declaration still might fall short in providing states with adequate means of providing treatment options to individuals in dire need.

“Without Medicaid expansion,” Ku said, “it is far harder to address the opioid epidemic.”

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