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 Under the ACA, also known as Obamacare, some U.S. states expanded
coverage through Medicaid - the joint federal and state insurance
program for the poor - starting in 2014. While previous studies have
linked Medicaid expansion to gains in the number of people treated
for substance use disorders, the current study offers fresh evidence
that the law helped to improve access to buprenorphine, a drug for
treating opioid addiction.
"When people get signed up for Medicaid, it increases the likelihood
that they will seek all types of medical care including more visits
to primary care doctors, and even when patients are not explicitly
seeking care for opioid addiction, the greater contact with the
health system creates more opportunities for screening and
diagnosis," said lead study author Brendan Saloner of the Johns
Hopkins Bloomberg School of Public Health in Baltimore.
"Our study did not look at the outcome of overdose or deaths, but
there is a clearly established benefit of getting treated with
buprenorphine and lower overdose risk," Saloner said by email.
For the study, researchers focused on West Virginia, one of the
states hardest hit by the nation's opioid crisis.
As of 2016, West Virginia had a fatal opioid overdose rate of 43.4
deaths for every 100,000 residents, more than triple the U.S.
average of 13.3 fatalities for every 100,000 people, the researchers
note in Health Affairs.
In the first three years of Medicaid expansion in West Virginia, an
average of 5.5 percent of all enrollees had a diagnosis of opioid
use disorder each year, the study found. Over this same period,
monthly opioid use disorder diagnoses nearly tripled.
During the study, the proportion of people diagnosed with opioid use
disorder who filled prescriptions for buprenorphine climbed from
about one-third to three-fourths. Over this period, average
treatment duration also rose from 161 to 185 days.
Most people filling buprenorphine prescriptions also received
counseling and drug testing.
Naltrexone, another drug for addiction, didn't see dramatic gains in
use during the study, and people tended to take it for shorter
periods of time than buprenorphine.
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"Methadone and buprenorphine have the strongest evidence supporting
their effectiveness in opioid use disorder, but there are reasons a
patient may prefer naltrexone," said Lucas Hill of the University of
Texas at Austin College of Pharmacy.
"The optimal duration of opioid use disorder treatment with
medications has not been identified, but available evidence
indicates longer treatment is generally better," Hill, who wasn't
involved in the study, said by email.
The study wasn't designed to determine the effectiveness of any
treatments people received. It's also not clear how accessibility or
affordability of addiction treatment might have changed for people
with other types of insurance.
"Buprenorphine/naloxone is more attainable through doctors' offices,
but it's costly unless you are insured," said Dr. Stefan Kertesz of
the University of Alabama at Birmingham School of Medicine.
"The issue comes down to who will pay for the doctor's office visit,
the prescription medicine and the additional services that are
needed," Kertesz, who wasn't involved in the study, said by email.
Many patients may also need treatment for health problems that
contribute to opioid misuse like chronic pain or mental illness, as
well as for conditions that can be caused by needle sharing among IV
drug users like hepatitis and AIDS, said Talia Puzantian of the Keck
Graduate Institute in Claremont, California.
"Medicaid clearly has a role in facilitating access to treatment,"
Puzantian, who wasn't involved in the study, said by email.
"Repealing ACA or imposing new barriers to obtaining or maintaining
Medicaid - for example work or premium requirements - would result
in a significant barrier to life-saving treatment for which
utilization is already low."
SOURCE: https://bit.ly/2WDiFmY Health Affairs, online April 1, 2019.
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