One of the key proposals of the American Healthcare Act, the GOP leadership’s plan to repeal and replace Obamacare, is a
massive spending cut to Medicaid, the government-run health program that provides insurance primarily to pregnant women, single parents, people with disabilities, and seniors with low incomes.
The move has been criticised by both Republicans and Democrats for the effects it could have on people suffering from substance-use disorders, particularly disorders related to heroin and prescription opioids.
A study published this week in the journal Medical Care lends further credence to those concerns.
The study found that the Medicaid expansion has led to a massive increase in the number of Medicaid prescriptions for buprenorphine, a medication considered by many experts to be the “gold standard” for overcoming opioid addiction.
Chemically similar to opioids, buprenorphine works by attaching to the same brain receptors as opioids, preventing users from using heroin or other opioids to get high while reducing cravings and withdrawal symptoms. The most commonly prescribed version is called suboxone and includes naloxone, an anti-overdose drug, to prevent misuse. A study conducted by the National Institute on Drug Abuse, among others, has shown considerable success for suboxone treatment.
Eligibility for Medicaid was expanded under the ACA to include any adult living under 138% of the federal poverty level — an income of $US27,821 for a family of three in 2016. Thirty-two states, including the District of Columbia, have chosen to participate, leading to more than 11 million people nationwide gaining coverage.
The 26 states that opted to expanded Medicaid in 2014 saw Medicaid-covered buprenorphine prescriptions rise 70% over the course of one year. Meanwhile, Medicaid spending on buprenorphine rose in those states by 50%. Prescriptions and spending in non-expansion states remained more or less flat.
Given buprenorphine’s increasing acceptance in the medical community, it is highly likely prescriptions have continued or accelerated the upward trend in expansion states in the years since.
“Our findings suggest that Medicaid expansion has the potential to reduce the financial barriers to buprenorphine utilization and improve access to medication-assisted treatment [MAT] of opioid use disorder,” the study concluded.
Those findings will be a moot point if the AHCA passed.
The bill proposes rolling back the expansion by ending the government’s commitment to provide funding for the expansion population and preventing states from enrolling additional people under the expansion rules after 2020. Roughly $US880 billion would be cut from federal Medicaid spending and 14 million people would be likely be taken off the Medicaid rolls by 2026 under the proposed legislation, according to the CBO report.
Bradley Stein, a senior natural scientist at the RAND Corp. who studies substance-use disorders, told Business Insider that he has observed states increasingly using Medicaid to expand access to buprenorphine, particularly in rural communities in states like Pennsylvania that have been hit hard hit by the opioid epidemic.
Over the last 5 years, the number of physicians certified to prescribe buprenorphine has doubled, according to Stein. While part of that has to do with the increased attention on the opioid epidemic in recent years, much of the increase has been driven simply by the fact that more addicts have insurance to pay for the treatment, encouraging doctors to get trained and certified.
Approximately 30% of the patients in the MAT program at the Center for Addiction Treatment in Cincinnati, the only nonprofit treatment facility in the region, receive care through Medicaid, according to CEO Sandi Kuehn.
Access is still a major issue. As The Huffington Post’s Jason Cherkis reported in 2015, many addicts have been forced to go on months-long waiting lists or travel hours every week to obtain suboxone treatment. The Obama Administration took steps last year to open up access by allowing doctors to prescribe to more patients — doctors were previously limited to 100 patients at a time — but access and affordability remain large issues.
The Medicaid rollback would affect both those issues.
“If there’s no longer insurance to pay for the treatment, doctors are going to treat other patients with other problems,” said Stein, who added that a Medicaid rollback could discourage doctors from seeking buprenorphine certification.
Medicaid patients trying to get medication-assisted treatment are only a small part of those affected by the AHCA rollback. About 1.29 million people in the US are receiving treatment for substance-use disorders or mental illnesses thanks to the Medicaid expansion, according to research conducted by Frank and Sherry Glied, a dean at New York University.
The AHCA Medicaid plan wouldn’t likely be popular with the public. A Morning Consult/Politico poll released last week found that only 48% of Americans said they supported the current proposal to change Medicaid.