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August 22, 2017

Is Medicaid Helping Fuel the Opioid Crisis?

Probably.

According to Express Scripts, which is a large manager of pharmacy benefit plans including Medicaid, “Medicaid members are 10 times more likely to suffer from addiction and substance abuse than the general population.” Unfortunately Express Scripts doesn’t give a source for this statistic and it doesn’t appear in the full text of their report. This sentence may refer to both drug and alcohol abuse and it doesn’t help us untangle cause and effect.

Some people qualify for Medicaid because substance abuse restricts their income.  Almost 25% of 3.1 million Medicaid subscribers whose records were scrutinized in the Express Scripts study had opioid prescriptions in 2015.   Having Medicaid available to pay for pain killers relieves pain which people might otherwise have suffered. But does having Medicaid available encourage opioid abuse?

In an editorial, The Wall Street Journal  says: “Evidence suggests the program may contribute to the epidemic… Overdose deaths per million residents rose twice as fast in the 29 Medicaid expansion states—those that increased eligibility to 138% from 100% of the poverty line—than in the 21 non-expansion states between 2013 and 2015.”  Their argument comes from a statement Senator Ron Johnson (R-WI) made, which doesn’t appear on his website and for which I can’t find a link.

In the statement Johnson quotes a letter he sent to the Inspector General for the Department of Health and Human Services, which I also can’t find online: “it appears that the program has created a perverse incentive for people to use opioids, sell them for large profits and stay hooked.”

If Johnson is right, this is a huge problem. The incentives are easy to understand. If an addict has anything of value, he’ll sell it to feed his habit (except possibly pills which he can take himself). The copay on legally prescribed opiates is far, far less than their street value. If there were no abuse, it would be truly extraordinary. What matters is whether the abuse is significant and is helping fuel the crisis

The WSJ’s only source for this statistic is “a federal Health and Human Services analysis requested by the Senator”. No link to any such study. No study I can find on Google. Because I think the subject is crucially important, I did some research. Age-adjusted opioid deaths by state for 2013 and 2015 can be found in a report from the Centers for Disease Control. I found a list of states which expanded their Medicaid programs here. Note that my source lists 19 states which didn’t expand eligibility while WSJ says 21. Since they didn’t give their list, I can’t reconcile the difference.

Using these sources, I get the same results as the WSJ. The statistical method is somewhat suspect, however, since it averages results from states with different populations. Population adjusted, deaths from opioids increased “only” 59% faster in expansion states.  Statistically, the fact that this correlation exists both state by state and in the aggregate increases the likelihood that it is more than a coincidence  , and so this is not good news.

Another possible reason to discount the statistic as being evidence of cause and effect is that there are demographic differences between the mostly red states which rejected Medicaid expansion and the mostly blue states which implemented it. WSJ tries to address this by comparing states with similar demographics: “Deaths increased twice as much in New Hampshire (108%) and Maryland (44%)—expansion states—than in Maine (55%) and Virginia (22%). Drug fatalities shot up by 41% in Ohio while climbing 3% in non-expansion Wisconsin.”

Here WSJ is cherry-picking to some extent. Vermont is more like Maine than New Hampshire is and Vermont is an expansion state. There was “only” a 6% increase in opioid-related deaths in Vermont from 2013 to 2015; but I can’t find many such exceptions among similar states. There are states like Vermont which did support Medicaid expansion and had relatively low increases: California (5%), Oregon (11%), Arizona (4%); but these are exceptions. Maine is the “no” state with the highest increase; most of the rest of the “no”s had relatively low increases or, in a few cases, decreases.

It looks like there is a statistical correlation between expanding Medicaid eligibility and increases in opioid related death rates. A statistical correlation does NOT prove cause and effect. There is also a possible explanation for cause and effect: the huge difference between the copay on opioids and their street value coupled with the need of addicts for money.

Only 4.1% of Medicaid’s costs are the direct fulfillment of opioid prescriptions according to The Express Scripts study. However, the indirect costs of addiction to Medicaid must be much higher both since addiction itself needs treatment which must be paid for and because addiction leads to diseases and accidents which must be treated. If Medicaid is fueling addiction, then its costs will keep spiraling up.

The cost of addiction to society is huge and growing. Addiction is devastating both to addicts and to their families.

If expanding Medicaid caused drug-abuse to increase significantly, then base Medicaid is also likely fueling the problem, which is actually a crisis. Although nothing above proves that expanded Medicaid causes increased drug abuse, there is clearly enough reason for urgent study. Since Medicaid administration is a state responsibility (with many federal rules), states – including Vermont – ought to both examine the safeguards against over-prescription and resale and do actual forensic investigation of possible abuse including, of course, doctors and pharmacies. Of course, the feds should be looking as well.

Making sure everybody has access to affordable basic health care is a laudable goal. Avoiding the unintended consequence of damaging public health and safety with misspent healthcare dollars is a necessity.

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