Opioid Use Disorder among Medicaid Enrollees: Snapshot of the Epidemic and State Responses

As the largest payer of substance use disorder services in the United States, Medicaid plays a central role in state efforts to address the opioid epidemic. In addition to increasing access to addiction treatment services through the expansion of Medicaid under the Affordable Care Act (ACA), states are expanding Medicaid addiction treatment services, increasing provider reimbursements, restricting opioid prescribing, and implementing delivery system reforms to improve the quality of treatment services. While many states have been tracking progress and challenges in these efforts, uniqueness of state systems can make it difficult to compare or benchmark across states. This brief draws on analyses provided by the Medicaid Outcomes Distributed Research Network (MODRN), a collaborative effort to analyze data across multiple states to facilitate learning among Medicaid agencies. It profiles the opioid epidemic among the Medicaid population in six states participating in MODRN that also have been hard hit by the opioid epidemic: Kentucky, Maryland, Ohio, Pennsylvania, Virginia, and West Virginia. The brief also draws on interviews with officials from the state Medicaid and other health agencies. Key findings include following:

• The prevalence of opioid use disorder (OUD) among Medicaid enrollees in the study states (5% in 2016) is higher than the national average, reflecting regional concentration of the opioid epidemic within the country. In states that expanded Medicaid under the ACA, more than half of Medicaid enrollees with opioid use disorder (56%) qualified through the expansion. However, prevalence of OUD among the expansion population (6.9%) is similar to other Medicaid eligibility groups.
• State officials indicated that the ACA Medicaid expansion allowed previously uninsured people with undiagnosed or untreated substance use disorders to receive treatment. To prevent opioid addiction among Medicaid enrollees, states are reducing opioid prescribing to Medicaid enrollees through greater monitoring, use of prior authorization, and other limits on opioid prescribing. In addition, all six states have taken steps to cover the full continuum of treatment services, and five of the six states have received Section 1115 IMD waivers to help provide the full continuum of treatment services.
• All six states cover evidence-based medication-assisted treatment (MAT). Despite these efforts, less than half of Medicaid enrollees with opioid use disorder in the six states receive any MAT. Among those receiving pharmacotherapy, 52% received at least six months of treatment.

The six states are taking other actions to improve access to and quality of addiction treatment services, such as recruiting and training more providers to prescribe buprenorphine, eliminating prior authorization requirements for buprenorphine, improving transitions between hospital settings and community-based care, and adopting new models of care delivery that emphasize greater coordination of MAT with other physical and behavioral health services. Most are also leveraging new federal funding through SAMHSA to work in concert with Medicaid reforms.