Association of Medicaid Expansion With Opioid Overdose Mortality in the United States | Addiction Medicine | JAMA Network Open | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Hedegaard  H, Miniño  AM, Warner  M.  Drug overdose deaths in the United States, 1999–2017.  NCHS Data Brief. 2018;(329):1-8.PubMedGoogle Scholar
82 FR § 8831. 2017.
42 CFR § 438, 456, and 457. 2016.
Chapel  JM, Ritchey  MD, Zhang  D, Wang  G.  Prevalence and medical costs of chronic diseases among adult Medicaid beneficiaries.  Am J Prev Med. 2017;53(6S2)(suppl 2):S143-S154. doi:10.1016/j.amepre.2017.07.019PubMedGoogle ScholarCrossref
Sharp  A, Jones  A, Sherwood  J, Kutsa  O, Honermann  B, Millett  G.  Impact of Medicaid expansion on access to opioid analgesic medications and medication-assisted treatment.  Am J Public Health. 2018;108(5):642-648. doi:10.2105/AJPH.2018.304338PubMedGoogle ScholarCrossref
Saloner  B, Levin  J, Chang  HY, Jones  C, Alexander  GC.  Changes in buprenorphine-naloxone and opioid pain reliever prescriptions after the Affordable Care Act Medicaid expansion.  JAMA Netw Open. 2018;1(4):e181588-e181588. doi:10.1001/jamanetworkopen.2018.1588PubMedGoogle ScholarCrossref
Cher  BAY, Morden  NE, Meara  E.  Medicaid expansion and prescription trends: opioids, addiction therapies, and other drugs.  Med Care. 2019;57(3):208-212. doi:10.1097/MLR.0000000000001054PubMedGoogle ScholarCrossref
Meinhofer  A, Witman  AE.  The role of health insurance on treatment for opioid use disorders: evidence from the Affordable Care Act Medicaid expansion.  J Health Econ. 2018;60:177-197. doi:10.1016/j.jhealeco.2018.06.004PubMedGoogle ScholarCrossref
Zur  J, Tolbert  J.  The Opioid Epidemic and Medicaid’s Role in Facilitating Access to Treatment. San Francisco, CA: Henry J. Kaiser Family Foundation; 2018.
Wen  H, Hockenberry  JM, Borders  TF, Druss  BG.  Impact of Medicaid expansion on Medicaid-covered utilization of buprenorphine for opioid use disorder treatment.  Med Care. 2017;55(4):336-341. doi:10.1097/MLR.0000000000000703PubMedGoogle ScholarCrossref
Sordo  L, Barrio  G, Bravo  MJ,  et al.  Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies.  BMJ. 2017;357:j1550. doi:10.1136/bmj.j1550PubMedGoogle ScholarCrossref
Tanum  L, Solli  KK, Latif  ZE,  et al.  Effectiveness of injectable extended-release naltrexone vs daily buprenorphine-naloxone for opioid dependence: a randomized clinical noninferiority trial.  JAMA Psychiatry. 2017;74(12):1197-1205. doi:10.1001/jamapsychiatry.2017.3206PubMedGoogle ScholarCrossref
Frank  RG, Fry  CE.  The impact of expanded Medicaid eligibility on access to naloxone.  Addiction. 2019;114(9):1567-1574. doi:10.1111/add.14634PubMedGoogle ScholarCrossref
Venkataramani  AS, Chatterjee  P.  Early Medicaid expansions and drug overdose mortality in the USA: a quasi-experimental analysis.  J Gen Intern Med. 2019;34(1):23-25. doi:10.1007/s11606-018-4664-7PubMedGoogle ScholarCrossref
Snider  JT, Duncan  ME, Gore  MR,  et al.  Association between state Medicaid eligibility thresholds and deaths due to substance use disorders.  JAMA Netw Open. 2019;2(4):e193056-e193056. doi:10.1001/jamanetworkopen.2019.3056PubMedGoogle ScholarCrossref
Swartz  JA, Beltran  SJ.  Prescription opioid availability and opioid overdose-related mortality rates in Medicaid expansion and non-expansion states.  Addiction. 2019;114(11):2016-2025. doi:10.1111/add.14741PubMedGoogle ScholarCrossref
National Center for Health Statistics.  Mortality—All County, Micro-Data and Compressed, 2001-2017, for All States, as Compiled From Data Provided by the 57 Vital Statistics Jurisdictions Through the Vital Statistics Cooperative Program. Hyattsville, MD: National Center for Health Statistics; 2017.
McClellan  C, Lambdin  BH, Ali  MM,  et al.  Opioid-overdose laws association with opioid use and overdose mortality.  Addict Behav. 2018;86:90-95. doi:10.1016/j.addbeh.2018.03.014PubMedGoogle ScholarCrossref
Bachhuber  MA, Saloner  B, Cunningham  CO, Barry  CL.  Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999-2010.  JAMA Intern Med. 2014;174(10):1668-1673. doi:10.1001/jamainternmed.2014.4005PubMedGoogle ScholarCrossref
Fink  DS, Schleimer  JP, Sarvet  A,  et al.  Association between prescription drug monitoring programs and nonfatal and fatal drug overdoses: a systematic review.  Ann Intern Med. 2018;168(11):783-790. doi:10.7326/M17-3074PubMedGoogle ScholarCrossref
Prescription Drug Abuse Policy System. Accessed January 1, 2017.
Ruhm  CJ.  Geographic variation in opioid and heroin involved drug poisoning mortality rates.  Am J Prev Med. 2017;53(6):745-753. doi:10.1016/j.amepre.2017.06.009PubMedGoogle ScholarCrossref
Blangiardo  M, Cameletti  M.  Spatial and Spatial-Temporal Bayesian Models with R-INLA. Chichester, United Kingdom: Wiley; 2015. doi:10.1002/9781118950203
Beguin  J,  et al.  Hierarchical analysis of spatially autocorrelated ecological data using integrated nested Laplace approximation.  Methods Ecol Evol. 2012;3(5):921-929. doi:10.1111/j.2041-210X.2012.00211.xGoogle ScholarCrossref
Carroll  R, Lawson  AB, Faes  C, Kirby  RS, Aregay  M, Watjou  K.  Comparing INLA and OpenBUGS for hierarchical Poisson modeling in disease mapping.  Spat Spatiotemporal Epidemiol. 2015;14-15:45-54. doi:10.1016/j.sste.2015.08.001PubMedGoogle ScholarCrossref
Khatana  SAM, Bhatla  A, Nathan  AS,  et al.  Association of Medicaid expansion with cardiovascular mortality.  JAMA Cardiol. 2019;4(7):671-679. doi:10.1001/jamacardio.2019.1651PubMedGoogle ScholarCrossref
Feder  KA, Mojtabai  R, Krawczyk  N,  et al.  Trends in insurance coverage and treatment among persons with opioid use disorders following the Affordable Care Act.  Drug Alcohol Depend. 2017;179:271-274. doi:10.1016/j.drugalcdep.2017.07.015PubMedGoogle ScholarCrossref
Antonisse  L.The Effects of Medicaid Expansion Under the ACA: Updated Findings From a Literature Review. San Francisco, CA: Henry J. Kaiser Family Foundation; 2018.
Clemans-Cope  L, Lynch  V, Epstein  M, Kenney  GM.  Medicaid Coverage of Effective Treatment for Opioid Use Disorder. Washington, DC: The Urban Institute; 2017.
Grogan  CM, Andrews  C, Abraham  A,  et al.  Survey highlights differences in medicaid coverage for substance use treatment and opioid use disorder medications.  Health Aff (Millwood). 2016;35(12):2289-2296. doi:10.1377/hlthaff.2016.0623PubMedGoogle ScholarCrossref
Mattick  RP, Breen  C, Kimber  J, Davoli  M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev.2014;(2):CD002207. doi:10.1002/14651858.CD002207.pub4
Faul  M, Bohm  M, Alexander  C.  Methadone prescribing and overdose and the association with medicaid preferred drug list policies—United States, 2007-2014.  MMWR Morb Mortal Wkly Rep. 2017;66(12):320-323. doi:10.15585/mmwr.mm6612a2PubMedGoogle ScholarCrossref
Urahn  SK, Coukell  A.  The Use of Methadone for Pain by Medicaid Patients: an Examination of Prescribing Patterns and Drug Use Policies. Philadelphia, PA: The Pew Charitable Trusts; 2018.
Clemans-Cope  L, Epstein  M, Kenney  G. Rapid Growth in Medicaid Spending on Medications to Treat Opioid Use Disorder and Overdose. Washington, DC: The Urban Institute; 2017.
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    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
    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.