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    1 Comment for this article
    Michael Ball, MD |
    Please open the paper clip above and look at eFigure.

    Since 2013, in every category, including total opioid death rate, the non-expansion counties have a lower death rate than the expansion counties!

    Michael Ball, MD
    Views 14,574
    Citations 0
    Original Investigation
    Health Policy
    January 10, 2020

    Association of Medicaid Expansion With Opioid Overdose Mortality in the United States

    Author Affiliations
    • 1Violence Prevention Research Program, Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento
    • 2Network for Public Health Law, Los Angeles, California
    • 3Prevention Research Center, Pacific Institute for Research and Evaluation, Berkeley, California
    • 4Center for Opioid Epidemiology and Policy, Department of Population Health, New York University School of Medicine, New York
    • 5Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
    • 6Mailman School of Public Health, Department of Epidemiology, Columbia University, New York, New York
    JAMA Netw Open. 2020;3(1):e1919066. doi:10.1001/jamanetworkopen.2019.19066
    Key Points español 中文 (chinese)

    Question  Is state Medicaid expansion associated with county-level opioid-involved overdose deaths in the United States?

    Findings  In this serial cross-sectional study of 3109 counties within 49 states and the District of Columbia from 2001 to 2017, Medicaid expansion was associated with reductions in total opioid overdose deaths and deaths involving heroin and synthetic opioids other than methadone. Expansion was associated with increased mortality involving methadone.

    Meaning  The findings suggest that expanding eligibility for Medicaid may help to mitigate the opioid overdose epidemic.


    Importance  The Patient Protection and Affordable Care Act (ACA) permits states to expand Medicaid coverage for most low-income adults to 138% of the federal poverty level and requires the provision of mental health and substance use disorder services on parity with other medical and surgical services. Uptake of substance use disorder services with medications for opioid use disorder has increased more in Medicaid expansion states than in nonexpansion states, but whether ACA-related Medicaid expansion is associated with county-level opioid overdose mortality has not been examined.

    Objective  To examine whether Medicaid expansion is associated with county × year counts of opioid overdose deaths overall and by class of opioid.

    Design, Setting, and Participants  This serial cross-sectional study used data from 3109 counties within 49 states and the District of Columbia from January 1, 2001, to December 31, 2017 (N = 3109 counties × 17 years = 52 853 county-years). Overdose deaths were modeled using hierarchical Bayesian Poisson models. Analyses were performed from April 1, 2018, to July 31, 2019.

    Exposures  The primary exposure was state adoption of Medicaid expansion under the ACA, measured as the proportion of each calendar year during which a given state had Medicaid expansion in effect. By the end of study observation in 2017, a total of 32 states and the District of Columbia had expanded Medicaid eligibility.

    Main Outcomes and Measures  The outcomes of interest were annual county-level mortality from overdoses involving any opioid, natural and semisynthetic opioids, methadone, heroin, and synthetic opioids other than methadone, derived from the National Vital Statistics System multiple-cause-of-death files. A secondary analysis examined fatal overdoses involving all drugs.

    Results  There were 383 091 opioid overdose fatalities across observed US counties during the study period, with a mean (SD) of 7.25 (27.45) deaths per county (range, 0-1145 deaths per county). Adoption of Medicaid expansion was associated with a 6% lower rate of total opioid overdose deaths compared with the rate in nonexpansion states (relative rate [RR], 0.94; 95% credible interval [CrI], 0.91-0.98). Counties in expansion states had an 11% lower rate of death involving heroin (RR, 0.89; 95% CrI, 0.84-0.94) and a 10% lower rate of death involving synthetic opioids other than methadone (RR, 0.90; 95% CrI, 0.84-0.96) compared with counties in nonexpansion states. An 11% increase was observed in methadone-related overdose mortality in expansion states (RR, 1.11; 95% CrI, 1.04-1.19). An association between Medicaid expansion and deaths involving natural and semisynthetic opioids was not well supported (RR, 1.03; 95% CrI, 0.98-1.08).

    Conclusions and Relevance  Medicaid expansion was associated with reductions in total opioid overdose deaths, particularly deaths involving heroin and synthetic opioids other than methadone, but increases in methadone-related mortality. As states invest more resources in addressing the opioid overdose epidemic, attention should be paid to the role that Medicaid expansion may play in reducing opioid overdose mortality, in part through greater access to medications for opioid use disorder.