No clear link found between increased opioid deaths and Affordable Care Act Medicaid expansion

October 9, 2019

No clear link found between increased opioid deaths and Affordable Care Act Medicaid expansion


  • IGPA Staff

Note: This article was produced by the Institute of Government and Public Affairs as part of IGPA’s efforts to connect relevant, nonpartisan research and expertise from the University of Illinois System to the public policy discussion in Illinois.

University of Illinois researchers found that expanded Medicaid coverage is likely not directly to blame for increased deaths from opioid overdoses.

A broad expansion of Medicaid, a state and federally funded program that provides health care coverage to low-income patients, is a key component of the Patient Protection and Affordable Care Act (ACA). Under the expansion, the income threshold to qualify for the program was increased to 138 percent of the federal poverty level, and childless adults without disabilities became eligible for the program.

A U.S. Supreme Court ruling allowed states to decide whether to participate in the Medicaid expansion. As of February 2019, 36 states and the District of Columbia were participating, providing an estimated additional 17.4 million individuals access to health care coverage.

Some critics of the ACA say that the expanded access to health care has had a deadly downside. They claim that the increased Medicaid coverage gave more people access to prescription opioids, and that led to more overdose deaths in the states that opted for the expansion.   

However, U of I researchers did not find a direct link between the Medicaid expansion and increased opioid deaths. A new paper titled “Prescription Opioid Availability and Opioid Overdose-Related Mortality Rates in Medicaid Expansion and Non-Expansion States,” published in the journal Addiction, compares opioid-availability and overdose-fatality data from states that participated in the Medicaid expansion with states that did not.

States that opted for the Medicaid expansion do have more prescription opioids available, but the largest relative increases in availability occurred years before full implementation of the Medicaid expansion occurred for most states in 2014.

 “What I expected was to see Medicaid-expansion states and non-expansion states pretty much overlapping in terms of opioid availability prior to the expansion and then, after the expansion, see a divergence,” said James Swartz, lead author of the paper and a professor at the University of Illinois at Chicago’s Jane Addams College of Social Work. “What we saw was that divergence happened much earlier. That surprised us. That wasn’t anything we expected.”

A report released by U.S. Senate’s Committee on Homeland Security and Governmental Affairs last year claimed that the expansion gave more people easy access to low-cost, prescription opioids, which flooded the black-market and caused an increase in fatal overdoses.

The report provided some anecdotes of Medicaid patients selling prescription opioids on the black market, but, Swartz said: “the data that are there don’t support the report’s central contention that some kind of widespread drug diversion fueled by the Medicaid expansion led to increases in fatality rates. A relatively small percentage of drugs were actually diverted.”

He said an earlier study found that prescription rates in Medicaid-expansion states and states that opted out were similar, meaning that Medicaid patients, newly eligible under the expansion, were likely not getting opioid prescriptions at higher rates.

Swartz noted that while the expansion states continued to have more opioid overdose-related fatalities over the period examined by his team, non-expansion states also saw increases in fatalities after 2014.

The largest increases in opioid overdose-related deaths for Medicaid-expansion states compared with non-expansion states were after 2015. These numbers include deaths related to street drugs, like heroin and illicit fentanyl. “We think that availability and use of those substances might underly much of the increase in fatality rates, rather than Medicaid expansion,” Swartz said.

Swartz said that it is also possible the increase in fatalities could be a delayed, indirect effect of the increased access to prescription opioids that came with the Medicaid expansion. “We can’t rule out that greater access to prescription drugs eventually transitioned to use of heroin or fentanyl among those in the expanded pool of Medicaid participants. But we have no direct data to assess the extent to which this delayed effect might have occurred and contributed to the increased fatality rates,” he said.

Research Area: Substance Use Disorders and Behavioral Health

Policy Initiative: none