From opioids to coronavirus — Medicaid is a crisis response program

Ten years ago this week, one of America’s most vital crisis response programs — the Affordable Care Act — was signed into law. Since 2010, the ACA has provided billions in federal assistance to ensure that low-income people get health care when they need it the most.

This is especially true for the ACA’s Medicaid expansion, which provides states with substantial federal funds to allow them to expand their Medicaid programs to cover adults with incomes up to 138 percent of the federal poverty line. Since the passage of the ACA, 36 states and the District of Columbia have expanded Medicaid and more than 15 million people have gained coverage under Medicaid expansion.

With the novel coronavirus rapidly spreading across the country, Medicaid will help some of our poorest and most vulnerable citizens pay for testing, treatment, and rehabilitation.

We know this because Medicaid has already played a similarly vital role in a very different public health crisis — the drug overdose epidemic. Between 2009 and 2018, half a million Americans died of a drug overdose — which is more American deaths than occurred in all 20th-century wars. Experts project that coronavirus could reap an even more grim toll in the course of a single year.

Faced with daunting public health challenges, it is critical that the most vulnerable have access to the care that they need. In a new study published in the journal "Health Affairs," we analyze a national database of admissions to drug rehabilitation facilities, comparing changes in admissions in Medicaid expansion states to the states that did not expand Medicaid.

We find that admissions to treatment increased steadily since the beginning of the Medicaid expansion. After four years after expansion, there were 35 percent more admissions to treatment programs in expansion states. This works out to nearly four hundred thousand additional admissions to treatment per year by 2017.

The increase in treatment utilization has occurred across all demographic groups — men and women and all racial and ethnic groups. Scaling up access to drug treatment would save thousands of lives every year, and at least one study suggests that the ACA Medicaid expansion may already be preventing overdose deaths.

People with opioid addiction — many of whom inject drugs — are an especially high-risk group for both drug overdose and coronavirus complications. Because opioids suppress respiratory function, they can increase overdose risk and also make respiratory infections more lethal. Our study found that under Medicaid expansion, admissions to treatment have increased most rapidly for opioid addiction.

Many people entering treatment for opioid addiction are receiving life-saving medications such as buprenorphine and methadone. As the National Academies concluded in 2019, these medications should be considered the ‘gold standard’ for opioid addiction treatment. Our study shows that treatment with these medications more than doubled in expansion states, with the greatest surge occurring three years after expansion.

As states grapple with how to respond to the coronavirus, they will need to pay particular attention to the needs of people with addiction issues. Medicaid expansion makes this task more manageable in two ways.

First, increasing access to addiction treatment reduces unmet medical need, criminal justice involvement, and homelessness — increasing the resilience of people with a history of substance use and reducing vulnerability to conditions that spread coronavirus.

Second, Medicaid expansion provides more flexibility in how states develop services to help people with addiction issues. This can include paying for new outreach strategies, providing coronavirus testing at addiction treatment facilities, and ensuring that people who do contract coronavirus are able to access rehabilitation and long-term care facilities.

Conversely, the challenges of helping people with addiction will be much harder in the 14 states that have not expanded Medicaid. There are five million people living in these states — which include — Florida and Texas — who would be eligible for Medicaid if their states expanded. Even with the emergency relief offered by the federal government, states that have not expanded Medicaid are confronting coronavirus without a cohesive health care program to serve low-income people.

Medicaid expansion on its own cannot prevent public health emergencies. It will not cure coronavirus and it cannot singlehandedly stop the drug overdose crisis. But Medicaid expansion provides a key resource that states need in a time of crisis: funding. We need to ensure that when the most vulnerable are sick, there is an open door to provide life-saving treatment and a path to better days ahead.

Dr. Brendan Saloner is an associate professor in the department of health policy and management at the Johns Hopkins Bloomberg School of Public Health. His research focuses on the intersection between health and social policy, particularly on the role of health insurance in promoting access to care, financial protection, and wellness. Dr. Catherine Maclean is an associate professor in the department of economics at Temple University, a research associate in the Health Economics Program at the National Bureau of Economic Research, and a research affiliate at the Institute of Labor Economics.