The rate of buprenorphine prescriptions for treatment of opioid use disorder among Medicaid patients was far higher on average in Medicaid expansion states than non-expansion states, a new Urban Institute study found.
Between 2011 and 2018, Medicaid prescriptions for buprenorphine maintenance treatment per 1,000 enrollees jumped from 40 to 138 in states that expanded Medicaid to low-income adults under the Affordable Care Act. In non-expansion states, the rate increased from 16 to 41. That includes the combination buprenorphine-naloxone form of medication-assisted treatment.
The states with buprenorphine prescribing rates at or above the 90th percentile were all expansion states: Vermont (1,210), West Virginia (827), Kentucky (662), Montana (588) and Ohio (438). Those with rates at or below the 10th percentile were all non-expansion states, with the exception of Arkansas: Kansas (14), South Dakota (11), Texas (8) and Arkansas (5).
The authors said state-level differences in prescribing rates may partially reflect differences in underlying rates of opioid use disorder and prescribing practices. But it's unlikely that those factors account for the 31-fold state variation in prescriptions per enrollee in 2018, they said. That variation is far larger than the two- to threefold state differences in prescribing per capita for the total state population.
The study adds another piece of evidence to the growing research literature documenting the broad benefits of Medicaid expansion for health outcomes, coverage, access to services, affordability, state budget savings and overall economic growth.
Medicaid expansion advocates say it shows the importance of expanding coverage to low-income adults during the nation's continuing opioid addiction epidemic, which killed nearly 48,000 Americans last year. Only a small percentage of people with substance use disorders are receiving treatment. A significant portion of the Medicaid expansion population has serious behavioral health conditions.
"This study shows that states that did not expand Medicaid did their residents and themselves harm," said Paul Gionfriddo, CEO of Mental Health America, a behavioral health advocacy group. "They left on the table a really low-cost way to provide a really useful service that would save their state thousands and thousands of dollars per person in dealing with the continuing problems of addiction."
Vermont, with the highest buprenorphine prescribing rate, had the lowest opioid-related death rate among the New England states in 2017. In contrast, Missouri, South Carolina, Tennessee, Utah and Wisconsin — all non-expansion states — were in the lower half of states on buprenorphine prescribing in 2018 and had opioid-related death rates higher than the national average.
The Urban Institute's analysis did not cover two other types of medication-assisted treatment for opioid use disorder: methadone and naltrexone.
Even states that expanded Medicaid and have relatively high buprenorphine prescribing rates could learn from Vermont, the authors wrote. It expanded OUD treatment dramatically by using the expertise of methadone clinic staff in hubs to diffuse treatment throughout the spokes of the primary healthcare delivery system.
Vermont shrunk waiting periods for treatment, and now nearly 80% of people seeking treatment receive it. Vermont providers also offer higher treatment dosages, which research suggests is more effective.
The authors wrote that Medicaid expansion likely would boost the share of people with access to both overdose reversal and treatment drugs, and potentially increase provider capacity.
A number of states, including Georgia, Kansas, North Carolina and Oklahoma, currently are debating whether to expand Medicaid, while Idaho and Utah are considering how to implement voter-approved Medicaid expansion ballot initiatives.
"I would hope this study would affect state debates over Medicaid expansion," Gionfriddo said. "Those states not doing this are pound-foolish and could barely be called pennywise when it's so inexpensive to provide this drug."
