Medicaid waivers have limited impact on opioid overdose crisis

For generations, the federal government has largely refrained from paying for mental health and substance use treatment in large residential facilities.

That changed in 2015 when, in response to increasing overdose deaths nationwide from illicit drugs, the federal government allowed states to waive a longstanding prohibition against using federal Medicaid funding for services in so-called institutions of mental diseases. In turn, states were required to improve their addiction care with an emphasis on increasing treatment with medications.

Yet a new study by researchers at Oregon Health & Science University finds no overall benefit in terms of increased treatment or decrease in nonfatal overdoses among the 17 states that received those waivers between 2017 and 2019, compared with 18 that did not. Medicaid is a joint federal-state health insurance program that covers about 90 million Americans, although not every state extends Medicaid coverage to all low-income adults.

The study published today in this month’s edition of the journal Health Affairs.

The waivers have been important to update Medicaid’s program to treat opioid use disorder, however they alone do not appear to have meaningfully improved the situation in terms of uptake of medication to treat opioid use disorders or in reducing overdoses.”

Stephan Lindner, Ph.D., lead author, associate professor in the OHSU Center for Health Systems Effectiveness and faculty member of the OHSU-Portland State University School of Public Health

Lindner noted that the null result highlights the fact that the waivers may be necessary but are clearly insufficient to bring the nation’s overdose epidemic under control.

“These waivers started about 10 years ago,” he said. “Back then, about 50,000 people died of drug overdoses per year. Fast forward 10 years, and more than 100,000 people die of drug overdoses in the United States per year.

“We have made some progress in addressing the opioid crisis, but we need more substantial action at the federal level to make sure all people with opioid use disorder get the treatment they need.”

Waivers aren’t enough, but Lindner pointed to several initiatives backed by research and law that could better address the nation’s illicit drug overdose crisis:

• Treatment across the full spectrum of care. A federal law sponsored by former U.S. Rep. Greg Walden, R-Hood River, in 2018 already requires states to cover the three FDA-approved medications to treat opioid use disorder (methadone, buprenorphine and naltrexone), however Lindner said enforcement may have been lax.
• Improve access to methadone. Research, including a series of evidence reviews conducted at OHSU, recommends easing access to methadone, which has historically been dispensed only in specialized clinics. A recent study by OHSU physician Honora Englander, M.D., found that 87% of people with opioid use disorder in France received access to methadone compared with less than 20% in the United States.
• Step up distribution of life-saving naloxone. OHSU recently hosted a series of events promoting the widespread distribution of naloxone to reverse overdoses, especially to young people.
• Increase access to buprenorphine. Previous research by Lindner found that access to buprenorphine varied widely between U.S. states. Stigma remains a hurdle in medical settings, including pharmacies.

In addition to Lindner, co-authors included Kyle Hart, M.S., Brynna Manibusan, M.S., and Kirbee Johnston, M.P.H., of the OHSU Center for Health Systems Effectiveness; Dennis McCarty, Ph.D., professor emeritus of public health and preventive medicine in the OHSU School of Medicine and the OHSU-PSU School of Public Health; and K. John McConnell, Ph.D., director of the OHSU Center for Health Systems Effectiveness and a faculty member of the OHSU-PSU School of Public Health.

This research was supported by the National Institute on Drug Abuse of the National Institutes of Health, grant number R01DA052388. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.