About 1.9 million nonelderly adults in the United States are believed to be living with opioid addiction, and those with Medicaid were twice as likely as those with private insurance or no health insurance to receive treatment for the disease in 2016, according to a new report from the Kaiser Family Foundation.
The analysis raises serious questions for the Trump administration, which has declared the opioid crisis a major priority while working simultaneously to undermine Medicaid and its expansion under the Affordable Care Act. As the nation grapples with high rates of fatal opioid overdoses, President Trump has promoted punitive responses, such as putting drug dealers to death and building a wall on the southern US border -- responses that have nothing to do with public health.
Among Medicaid recipients living with an opioid use disorder, 43 percent received inpatient and/or outpatient addiction treatment in 2016. In comparison, only 21 percent of those with private insurance and 23 percent of those who were uninsured received treatment, according to Kaiser's analysis of data from the National Survey on Drug Use and Health.
Kevin Fiscella, an opioid addiction specialist and professor of public health at the University of Rochester, said the data does not explain why Medicaid recipients are more likely to receive opioid addiction treatment. One possible explanation is that Medicaid recipients tend to pay fewer out-of-pocket costs for medications, counseling and inpatient treatment than people with private insurance plans.
Medicaid paid more for addiction treatment than all the private insurers combined in 2014.
"Financial barriers are among the leading reasons [why] people with substance use disorders report that they did not obtain treatment," Fiscella said in an email. "Engaging more people in treatment will require reducing cost-related barriers to treatment. I don't think current policy has yet come to grips with this simple fact."
The majority of people living with opioid addiction are employed, but many have lower incomes and jobs that do not provide health benefits, according to the Kaiser report. About 13 percent are unable to work due to a disability, reflecting the complex health needs associated with opioid use disorders, which can result from using prescription opioids to treat chronic pain.
This is where Medicaid comes in, particularly now that the Affordable Care Act has expanded eligibility for millions of Americans despite efforts by Republicans to repeal and weaken the law.
Medicaid has a history of filling critical gaps during public health crises, such as the HIV/AIDS epidemic or natural disasters, by providing access to health care for lower-income people, according to Kaiser's analysis. Medicaid covers several inpatient and outpatient treatment services for opioid addiction, as well as drugs like Suboxone and methadone, which treat addiction and are known collectively as Medication Assisted Treatment, or MAT.
Medicaid work requirements will create red tape for vulnerable people seeking health care.
As the opioid overdose epidemic has unfolded, states began applying for federal waivers allowing them to promote and expand opioid treatment and behavioral health services. Thirty-three states also expanded their Medicaid programs to include more people under the Affordable Care Act, and Medicaid paid more for addiction treatment than all the private insurers combined in 2014.
"As a central payer for opioid use disorder, the Trump Administration must commit to protecting and strengthening Medicaid, instead of promoting work requirements, drug testing, and cuts that will jeopardize states' abilities to provide treatment to all in need," said Daniel Raymond, a spokesperson for the Harm Reduction Coalition, in an email to Truthout.
Last year, President Trump loudly supported efforts by the Republican majority in Congress to "repeal and replace" the Affordable Care Act and roll back the Medicaid expansion. Polls showed that voters did not like the idea of millions of people losing their health insurance coverage -- particularly during a public health crisis like the opioid epidemic -- and the GOP's efforts to undo President Obama's landmark health care achievement ultimately failed.
This hasn't stopped the Trump administration from finding other ways to undermine Medicaid, most recently by allowing several states to impose work requirements on Medicaid eligibility. The requirements will create red tape for vulnerable people seeking health care, and advocates say people with disabilities and other problems that make keeping a job difficult are bound to fall through the cracks and become uninsured.
Living with a severe opioid use disorder can make it difficult to find and keep work. Drug use is still stigmatized in our society, and many employers test their workers for drugs. Opioid use is also criminalized, making it more likely that people living with addiction will miss work after being arrested or forced to apply for jobs with a criminal record.
If a patient treating their opioid addiction with MAT therapies can no longer afford the drugs because they lost their job and their Medicaid coverage along with it, they would be at a serious risk of a relapse that could cause a fatal overdose.
"Existing data suggest that imposing work requirements reduces insurance coverage through Medicaid," Fiscella said. "This will create a major, often insurmountable financial [barrier] to initiating or continuing treatment, resulting in more overdoses and opioid-related deaths."
Medical experts and health advocates have long implored policymakers to approach the nation's opioid problems as public health challenges rather than a criminal issue so that people end up in helpful treatment programs rather than prison cells. However, Trump has responded with the tough-on-crime rhetoric of the war on drugs and used the opioid epidemic to promote his anti-immigrant agenda.
"Whether you're a Republican or Democrat, we need a wall," Trump said during a cabinet meeting on Monday, referring to his proposal to build a wall on the border with Mexico. "And it will stop your drug flow. It will knock the hell out of the drug flow. And it will stop a lot of people that we don't want in this country from coming into our country."
Experts say building a border wall would not be as effective in preventing illegal opioids from entering the country as Trump thinks. The Drug Enforcement Agency reports that it's much more common for traffickers to bring drugs across the border in vehicles and airplanes at valid points of entry than haul them through remote areas of the southwestern desert.
The Trump administration also wants to beef up surveillance of international shipments and increase penalties for drug trafficking -- even telling federal prosecutors to seek the death penalty for certain traffickers. The White House also wants to cut opioid prescriptions by one-third over three years, an effort that some argue could punish patients in need of pain relief.
The White House's opioid response plan does include initiatives to expand access to MAT, an effort Congress began funding with landmark legislation in 2016. However, the plan does not expand access to a full range of MAT therapies in jails and prisons. As Truthout has reported, the ongoing criminalization of drug use and the lack of MAT options behind bars has severely exacerbated the opioid crisis.
"The president has spoken much more passionately about law enforcement and interdiction efforts than on the vital role of Medicaid in financing a system of care for our most vulnerable," Raymond said. "His Administration will be judged on whether they end the overdose crisis by preserving and expanding Medicaid or prolong the crisis by chipping away at it."
The president's tough talk could also reinforce longstanding social stigma around drug use that can prevent people living with opioid addiction from seeking medical help in the first place.