The impact of expanded Medicaid eligibility on access to naloxone

Abstract

Background and aims: Federal, state and local US governments have sought interventions to reduce deaths due to opioid overdoses by increasing the availability of naloxone. The Affordable Care Act (ACA) expanded Medicaid coverage to low-income, childless adults, potentially giving this group financial access to naloxone. The aims of this paper are: (1) to describe the changes in the amount of Medicaid-covered naloxone used between 2009 and 2016 and (2) to quantify the differential change in the amount of dispensed naloxone between states that expanded their Medicaid programs and states that did not.

Design: A quasi-experimental approach based on states' ongoing choice to expand their Medicaid program to all adults with incomes between 100 and 138% of the federal poverty line (FPL), starting in 2014. As of 2018, 37 states had expanded and 14 states had not. Estimation of the policy impact relies on a difference-in-difference method.

Setting: US state Medicaid programs.

Participants and measurements: Data are from the Medicaid Drug Rebate Program and include all dispensed prescriptions of naloxone through the Medicaid program. State/quarters with fewer than 10 prescriptions are suppressed; n = 1632.

Findings: Prior to Medicaid expansion, the number of Medicaid-covered naloxone prescriptions was very similar in expansion and non-expansion states. On average, states that expanded Medicaid had 78.2 (95% confidence interval = 16.0-140.3, P = 0.02) more prescriptions per year for naloxone compared with states that did not expand Medicaid coverage, a nearly 10 increase over the pre-expansion years. Medicaid expansion contributed to this growth in Medicaid-covered naloxone more than other state-level naloxone policies.

Conclusions: Medicaid accounts for approximately a quarter of naloxone sales. Medicaid expansion generated 8.3% of the growth in naloxone units from 2009 to 2016, holding other factors constant.

Keywords: Health reform; medicaid; naloxone; opioids; overdose prevention; state regulation; substance use disorder.