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A Response to "Unintended Consequences: Medicaid and the Opioid Crisis"

Today, Public Health Law Watch sent a letter (both electronically and on paper) to every member of the U.S. Senate Committee on Homeland Security & Governmental Affairs in response to a January hearing entitled "Unintended Consequences: Medicaid and the Opioid Epidemic." That hearing and its accompanying report presented a slew of misinformation, misleading statistics, and poorly informed conclusions that attempted to blame the current opioid crisis on the expansion of Medicaid. The George Consortium members mobilized to respond with facts and real potential solutions.

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Dear Chairman Johnson and Ranking Member McCaskill:

We, the undersigned, are deeply concerned about a January 17 United States Senate Homeland Security and Governmental Affairs Committee hearing entitled “Unintended Consequences: Medicaid and the Opioid Epidemic,” and its accompanying published report entitled “Drugs for Dollars: How Medicaid Helps Fuel the Opioid Epidemic.” Instead of discussing evidence-based responses to the opioid crisis, both the hearing and report are riddled with inaccurate information, misleading statistics, and poorly informed conclusions. All told, these actions appear aimed at demonizing Medicaid recipients as, at best, interlopers and, at worst, criminals who obtain “free” opioids by fraud and then sell them on the black market for profit. Not only is this blatantly harmful stereotyping of individuals who rely on Medicaid for vital access to health care, but this hearing and report also appear to blame the Medicaid expansion portion of the Affordable Care Act for a very real crisis that kills upwards of 100 people every single day in the United States.

There are numerous failures in empirical analysis and logic in the narrative that links our national overdose emergency with Medicaid expansion. First and foremost, the upward trajectory in opioid deaths accelerated long before the Affordable Care Act Medicaid expansions. The Medicaid expansion did not begin until January 2014. Notably, overdose deaths involving prescription drugs generally slowed and plateaued after 2011 before another rise in 2016.

Second, states with above average opioid overdose death rates include both Medicaid expansion and non-expansion states. While expansion states did have a slightly higher rate of drug deaths than non-expansion states in 2015, that upward trend began in 2010, several years before the expansion itself.  The expansion could not have caused the increase because it did not precede the effects. In fact, it is conceivable that rising opioid-related deaths may have influenced states’ decisions to implement the Medicaid expansion in the first place. Further, the increase in deaths happened across virtually all insurers, not just Medicaid.

Medicaid beneficiaries do have a higher rate of opioid use disorder than privately insured individuals and are prescribed pain relievers at higher rates than those with other sources of insurance.  This is largely because the Medicaid program serves a patient population more vulnerable to higher rates of disability and chronic illnesses compared to the general population. Medicaid recipients have reported daily (or almost daily) pain at rates double that of non-Medicaid recipients. This vulnerable population also faces other life and logistical challenges independent of health care coverage - such as lack of transportation, comorbidities, and inflexible work demands - that make it more difficult to avoid adverse health outcomes. 

Access to opioids is easier with any health insurance coverage, not just Medicaid.  And when access to opioids is restricted, people begin to use more illicit drugs than prescriptions.  For example, Kentucky passed a law imposing strict prescription limits. As intended, this sharply reduced the number of opioid prescriptions written. However, opioid mortality did not drop. Similar laws in Florida and Ohio led to declines in prescription pill overdose deaths but coincided with a massive increase in heroin overdose deaths. Indeed, opioid overdose deaths after Medicaid expansion have spiked largely due to illicit fentanyl and heroin, rather than prescription opioids.

Rather than causing the opioid crisis, Medicaid has been and should remain part of the solution. The Medicaid expansion has greatly improved access to substance use disorder treatment. Medicaid provides coverage for nearly 4 in 10 nonelderly adults with opioid addiction. Expansion created greater access to services such as medication-assisted therapy and case management, with a documented 70% increase in prescriptions of buprenorphine to treat opioid use disorder—treatment that can slash a patient’s overdose risk by half. Medicaid is key in addressing the opioid crisis, not in creating it. Beyond direct treatment services, Medicaid also has the potential to address social risk factors by, for example, reimbursing supportive housing services shown to improve the health of those with substance use disorders.

Finally, medication diversion does occur, but it is driven substantially by unaddressed health needs and structural problems, which also fuel misuse. And such issues are not caused by Medicaid; they occur when people are covered by Medicare and private insurers as well. The response should not be to deny health care to the Medicaid population but to address the underlying drivers of addiction, such as “economic and social upheaval…, physical and psychological trauma, concentrated disadvantage, isolation, and hopelessness.”  Rather than focus on punitive measures such as criminal prosecution and slashing aid to Medicaid and individual recipients, the government should focus on harm reduction strategies such as expanding access to medication-assisted treatment, supporting safe injection sites, increasing awareness of and access to Naloxone, and truly treating this crisis as a serious public health emergency with accompanying funding.

We cannot allow the severe opioid crisis in this country to be highjacked by those who want to demonize Medicaid and its recipients. Medicaid expansion has almost certainly saved thousands of lives. Its rollback will have the opposite effect, restricting vital health care access to those affected by opioid use disorder, as well as millions of others. In 2016, 42,000 people in the United States died from opioid overdoses. Too many lives are at stake to waste time on vilifying Medicaid instead of implementing actual solutions.

Sincerely,

The George Consortium, a network of public health academics, experts, and practitioners around the United States, including:

Marice Ashe, JD, MPH, CEO of ChangeLab Solutions

Leo Beletsky, Professor of Law and Health Sciences, Northeastern University

Micah Berman, Ohio State University

Scott Burris, Professor of Law and Public Health, Temple University

Derek Carr, ChangeLab Solutions

Richard A. Daynard, Northeastern University School of Law

Linda Fentiman, Professor, Elisabeth Haub School of Law, Pace University

Robert I. Field, JD, MPH, PhD, Drexel University Kline School of Law and Dornsife School of Public Health

Lance Gable, Wayne State University School of Law

Rebecca L. Haffajee, JD, PhD, MPH, University of Michigan

Jennifer Lea Huer, Northeastern University School of Law, Center for Health Policy and Law

Peter D. Jacobson, Professor Emeritus of Health Law and Policy, University of Michigan School of Public Health

Nancy J. Kaufman, RN, MS, FAAN, President of Strategic Vision Group

Craig Konnoth, Associate Professor, University of Colorado Law School

Renee M. Landers, Professor of Law, Suffolk University

Wendy E. Parmet, Northeastern University School of Law

Elisabeth J. Ryan, JD, MPH, Northeastern University School of Law, Center for Health Policy and Law

Michael S. Sinha, MD, JD, MPH, Brigham & Women’s Hospital and Harvard Medical School

Cc: Members of the Senate Committee on Homeland Security & Governmental Affairs

 To contact Public Health Law Watch or the George Consortium, please reach out to Elisabeth Ryan at el.ryan@northeastern.edu or 617-373-8493.

Elisabeth Ryan