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Obamacare’s insurance expansion isn’t enough for the opioid epidemic

Insurance can only go so far in getting people into care.

One of the touted benefits of Obamacare, particularly in the midst of the opioid epidemic, is it can link drug users to insurance needed to pay for potentially life-saving addiction treatment. But a new study suggests that Obamacare is ultimately limited in just how far it can go.

The study, conducted by researchers Johanna Catherine Maclean and Brendan Saloner and published by the National Bureau of Economic Research, tells a mixed story about Obamacare’s Medicaid expansion. Obamacare allowed states to expand their Medicaid programs to include anyone whose income is up to 138 percent of the federal poverty level, with the federal government paying for at least 90 percent of the costs starting in 2014.

In the first year of the expansion’s official implementation, the study found that the share of people using Medicaid to pay for drug treatment increased in states that adopted the expansion, while the share of patients who were uninsured or used local and state subsidies declined.

But the number of people actually admitted into specialty treatment for drug use disorders did not increase, suggesting that Obamacare’s Medicaid expansion didn’t actually increase access to treatment overall — or, at least, increase access enough to lead more people to use care.

It’s certainly great for people in drug use treatment and local and state governments that patients were now able to use Medicaid, instead of their personal funds or local and state dollars, to pay for treatment. This is a reduced financial burden for individuals, cities, and states as the federal government pays for more of the costs of drug treatment.

Still, one of the goals of Obamacare is to actually let more people access the care they need. That’s particularly necessary for drug use disorders: According to 2014 federal data, at least 89 percent of people who met the definition for a drug use disorder did not get treatment.

This latest study, however, suggests that Obamacare isn’t living up to that goal with drug use disorders. That may be, Saloner told me, because there just aren’t enough drug treatment clinics — or at least space in these clinics — to actually treat people even after they get insurance.

To understand that, let’s break down the study’s specific findings, and then the lessons we can pull out from it.

What the study found

The study looked at some of the latest administrative data available — the Treatment Episodes Data Set between 2010 and 2014 and Medicaid State Drug Utilization Data between 2011 and 2015 — to gauge the effects of the Medicaid expansion.

It had three big findings:

  1. The number of people admitted to specialty drug treatment did not increase more in expansion states compared to non-expansion states in the first year of the Medicaid expansion.
  2. The number of people in drug treatment programs who used Medicaid increased, as fewer people went into these programs without insurance or with the help of state or local subsidies. In expansion states, the number of patients who used Medicaid to pay for specialty drug treatment increased by 57 percent. And Medicaid-reimbursed prescriptions for medications used to treat drug use disorders in outpatient settings increased by 33 percent more in expansion states than they did in non-expansion states.
  3. There was no evidence that expanding Medicaid led to more drug overdoses or alcohol poisonings than not expanding Medicaid, suggesting that having insurance did not lead to more drug-related deaths.

It’s the first finding that’s a bit surprising. One would expect that if more people have insurance, they would be able to access services they couldn’t before — like treatment for drugs. And other research, the authors note, suggests that more insurance does increase admissions into specialty drug treatment. But this new study suggests that’s not the case for Obamacare so far.

There are a few reasons for why that may be the case.

First, it’s possible that the study was just looking at too early of a time period. The Medicaid expansion officially began in 2014, and back then fewer states participated in the expansion than do today. It’s possible that patients didn’t have enough time to sign up for Medicaid and get drug treatment in just one year of the newly expanded program.

“It takes a while for these changes to develop,” Saloner told me. “The process of seeking out and finding services is not straightforward, especially in places where there’s a shortage of treatment providers.”

Second, it’s possible that some patients substituted specialty drug treatment with medication-assisted treatment, mitigating any aggregate effects on specialty drug treatment. After all, Medicaid spent more in expansion states on drugs used to treat substance use disorders. It’s possible that the patients using these drugs would have instead relied on specialty drug treatment in the past, but instead went to medication-assisted treatment now that it was more easily available through Medicaid.

Third, the federal data that it used wasn’t comprehensive, with insurance and payment analysis of the Treatment Episode Data Set limited to just over half the states. Perhaps, then, the study missed effects seen in some of the states that weren’t included.

But there’s another possibility, Saloner told me: Maybe insurance expansions alone just aren’t enough to expand access to drug treatment.

Insurance is limited in addressing the opioid crisis

“Health insurance may well be necessary but not sufficient to addressing some of these challenges,” Saloner said. “It’s important to look not only at insurance, but all the non-insurance barriers that may keep people out of treatment.”

Imagine, for example, that everyone has insurance. It’s still possible, in this hypothetical scenario, that there are only enough drug treatment facilities to take in just half of drug users who need care. That would mean that, even though the other half of these drug users can still technically afford care through their insurance, they still can’t get into treatment.

Something like this is playing out in the US. Only about 10 percent of people with substance use disorder get specialty treatment, according to a landmark 2016 report from the US surgeon general. The report found that a big reason for the disparity is a lack of access to drug treatment clinics — and not just due to a lack of insurance:

Well-supported evidence shows that the current substance use disorder workforce does not have the capacity to meet the existing need for integrated health care, and the current general health care workforce is undertrained to deal with substance use–related problems. Health care now requires a new, larger, more diverse workforce with the skills to prevent, identify, and treat substance use disorders, providing “personalized care” through integrated care delivery.

Put another way, the health care system simply doesn’t have the capacity to handle all the patients suffering from drug addiction. This is why drug users often face weeks- or months-long waiting periods to get into care — if there even are any treatment clinics in their communities that can take them in to begin with.

The good news is this could change over time. Now that patients do have the means to pay for drug treatment, it’s likely that the capacity of these services will naturally increase — since hospitals and doctors will know that there will be someone to pay for it. (Though part of this will involve overcoming stigma attached to addiction, which may prevent some places from adopting a health care–focused approach that leads to more clinics.)

The federal government has also taken some steps to address this. In 2016, Congress passed $1 billion in new spending over two years for drug treatment. And in general, the Obama administration put more funding toward drug prevention and treatment than previous administrations.

But experts widely believe that more needs to be done, given that drug overdoses are now killing more people than at any other time in US history. This latest study exposes one more place where policymakers could act.

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