Medicaid expansions linked to slower rises in overdose deaths

The United States in recent years has increased healthcare access by broadening Medicaid coverage, but some worry that these Medicaid expansions lead to more abuse of prescription painkillers and thus worsen the opioid epidemic. A new study suggests that Medicaid expansions may, in fact, have the opposite effect. In a study examining the potential impact of 2001-02 Medicaid expansions by Arizona, Maine and New York—expansions that occurred just prior to the rise in overdose mortality nationwide—researchers from the Perelman School of Medicine at the University of Pennsylvania found that from the time of these expansions through 2008, overdose mortality rates (mostly driven by fatal overdoses of opioids) rose significantly less in the expansion states than in non-expansion states. The study is published online this month in the Journal of General Internal Medicine.

"These findings suggest that Medicaid expansions were unlikely to have contributed to the subsequent rise in drug overdose deaths, and may even have been protective," said study lead author Atheendar S. Venkataramani, MD, Ph.D., an assistant professor of Medical Ethics and Health Policy at the Penn Medicine. "The results should provide reassurance to policymakers who are concerned that state Medicaid expansions, including the recent expansions implemented as part of the Affordable Care Act, promote rises in drug overdose mortality."

In the study, Venkataramani and co-author Paula Chatterjee, MD, MPH, a post-doctoral researcher in Penn's department of General Internal Medicine, examined state-level data on drug overdose mortality from the Centers for Disease Control and Prevention from 1999 through 2008. They compared the overdose mortality trends in the three Medicaid-expansion states to those in other states.

"We focused on all drug overdose deaths, given the well-known underreporting of opioid-attributable deaths and the fact that over 60 percent of drug overdose deaths are likely due to opioids," said Venkataramani, who is also a member of Penn's Center for Health Incentives and Behavioral Economics.

The researchers observed that, prior to the Medicaid expansions in Arizona, Maine, and New York, the gaps between these and other states' overdose mortality rates were relatively stable. After the Medicaid expansions, the gaps generally widened as the mortality rates in Medicaid-expansion states rose more slowly, on average, than those in non-expansion states.

In 2001, immediately prior to the Medicaid expansions, the expansion states had about 2 fewer overdose deaths per 100,000 people, compared to all non-expansion states, whereas in 2008 the expansion states had about 7 fewer overdose deaths per 100,000 people.

Similarly, in 2001 the expansion states had about 8 fewer deaths per 100,000 people compared to adjacent non-expansion states, but by 2008 the expansion states had 17 fewer deaths per 100,000 people.

Overall, the study suggests that drug overdose deaths were nearly 20 percent lower in early expansion states than they otherwise would have been in the absence of Medicaid expansions.

While the study wasn't designed to determine how Medicaid expansions might have reined in overdose mortality, researchers suggest that the Medicaid expansions may have reduced the abuse of opioids and other drugs by improving people's financial security and mental health, and by increasing access to treatment for substance use disorders.