Unexpectedly Intriguing!
March 8, 2017

Nicholas Eberstadt recently raised an interesting question regarding the role of Medicaid, the United States' welfare program that provides free health insurance for Americans with low incomes, when he commented on how it may very well have directly contributed to the nation's rising problem with opioid addiction.

The opioid epidemic of pain pills and heroin that has been ravaging and shortening lives from coast to coast is a new plague for our new century. The terrifying novelty of this particular drug epidemic, of course, is that it has gone (so to speak) "mainstream" this time, effecting breakout from disadvantaged minority communities to Main Street White America. By 2013, according to a 2015 report by the Drug Enforcement Administration, more Americans died from drug overdoses (largely but not wholly opioid abuse) than from either traffic fatalities or guns. The dimensions of the opioid epidemic in the real America are still not fully appreciated within the bubble, where drug use tends to be more carefully limited and recreational. In Dreamland, his harrowing and magisterial account of modern America’s opioid explosion, the journalist Sam Quinones notes in passing that "in one three-month period" just a few years ago, according to the Ohio Department of Health, "fully 11 percent of all Ohioans were prescribed opiates." And of course many Americans self-medicate with licit or illicit painkillers without doctors' orders....

How did so many millions of un-working men, whose incomes are limited, manage en masse to afford a constant supply of pain medication? Oxycontin is not cheap. As Dreamland carefully explains, one main mechanism today has been the welfare state: more specifically, Medicaid, Uncle Sam's means-tested health-benefits program. Here is how it works (we are with Quinones in Portsmouth, Ohio):

[The Medicaid card] pays for medicine—whatever pills a doctor deems that the insured patient needs. Among those who receive Medicaid cards are people on state welfare or on a federal disability program known as SSI.... If you could get a prescription from a willing doctor—and Portsmouth had plenty of them—Medicaid health-insurance cards paid for that prescription every month. For a three-dollar Medicaid co-pay, therefore, addicts got pills priced at thousands of dollars, with the difference paid for by U.S. and state taxpayers. A user could turn around and sell those pills, obtained for that three-dollar co-pay, for as much as ten thousand dollars on the street.

In 21st-century America, "dependence on government" has thus come to take on an entirely new meaning.

It occurred to us that we have the ability to determine whether Medicaid is contributing to the nation's growing opioid epidemic by taking advantage of a natural experiment made possible by the Affordable Care Act. More popularly known as "Obamacare", the primary means by which the ACA has expanded health insurance coverage in the U.S. has been through the expansion of eligibility in the U.S.' Medicaid welfare program, where the threshold for eligibility was raised from 100% of the federal poverty limit to 138% of the federal poverty limit in states that agreed to expand their Medicaid programs.

But, not all states agreed to expand their Medicaid program when the Affordable Care Act went into effect on 1 January 2014. From that time through 2015, 28 states and the District of Columbia had chosen to participate in the Affordable Care Act's expansion of eligibility for Medicaid, while 22 others opted to not do so during those years.

That state-by-state division then provides for the basis of a natural experiment, where we can get a sense of how well correlated the expansion of enrollment in Medicaid is with the incidence of deaths from drug overdoses, which have been increasing as part of the U.S.' growing problem with opioid drug addiction.

The image below shows what we found for the age-adjusted death rate per 100,000 Americans from drug overdoses for the years from 2010 through 2015, which covers the years in which the individual U.S. states that chose to expand their Medicaid enrollment did so. We've ranked the states in order from the greatest increase in the rate of deaths from drug overdoses between 2013 and 2015, which for all but six states, marks the difference between "before" and "after" for the expansion of their Medicaid programs.

Age-Adjusted Deaths from Drug Overdoses Per 100,000 Population, 2010-2015

Overall, the biggest increase in the age-adjusted death rate from drug overdoses by state from 2013 to 2015 was an increase of 19.2 deaths per 100,000 (New Hampshire), and the biggest recorded decrease was 1.6 deaths per 100,000 (Oklahoma).

Looking just at the change from 2013 to 2015, the median change in the number of deaths from drug overdoses is 2.0 per 100,000 of the state's population. For the 28 states that acted to expand the eligibility of their state's Medicaid programs, 19 have seen the number of deaths from drug overdoses increase by 2.0 per 100,000 or higher per year, accounting for 68% of all Medicaid expansion states. The change in each of these states' age-adjusted death rates ranged from New Hampshire's biggest increase of 19.2 deaths per 100,000, to Nevada's decrease of 0.7 deaths per 100,000, where the median change was an increase of 2.7 drug overdose deaths per 100,000 population.

Median Change in Deaths from Drug Overdoses per 100,000 Population Since 2010, Medicaid Expansion States vs Non-Expansion States

For non-Medicaid expansion states, only 7 of 22 states saw their age-adjusted death rates from drug overdoses increase by 2.0 per 100,000 or more per year, representing 32% of the states whose increase in death rates exceeded the median for all states. In the non-Medicaid expansion states, the change in each of these states' age-adjusted death rates ranged from the biggest increase of 8.0 deaths per 100,000 population for Main, to a Oklahoma's decrease of 1.6 deaths per 100,000 population. The median change for the non-Medicaid expansion states was an increase of 1.5 deaths per 100,000 population.

We also looked at the change in the age-adjusted death rates for each state from 2010 through 2013. Here, we saw the change in death rates per 100,000 for each state range between a decline of 3.8 deaths per 100,000 (Florida) and a high of 6.9 deaths per 100,000 (Rhode Island), with a median increase of 1.6 deaths per 100,000 for all 50 states and the District of Columbia. The median change in age-adjusted deaths from drug overdoses in the states that would act to expand their Medicaid programs was an increase of 2.2 deaths per 100,000 from 2010 through 2013, while the median change for states that did not expand their Medicaid programs was 1.2 deaths per 100,000 during this period.

Those figures are significant because 2010 marked the year in which the use of opioid street drugs like heroin and synthetic versions like fentanyl and tramodol began to take off, along with deaths from drug overdoses as they were increasingly substituted for prescription medications like OxyContin by addicts, which came about because of the introduction of abuse-resistant forms of the opioid-based medication.

To put that increase in perspective, in 2010, heroin alone was responsible for 8% of drug overdose deaths in 2010. Five years later, heroin alone was responsible for 25% of all drug overdose deaths in the U.S. Deaths caused by overdoses of synthetic opioids have increased similarly.

That change would account for a portion of the increased drug overdose deaths across the entire nation from 2010 onward, but the state-by-state mortality data suggests those deaths accelerated after 2013, which means that something else changed after 2013 to drive the number of drug overdose deaths to increase at a rate so much faster than they had before the Affordable Care Act was implemented.

As we've shown, that acceleration took place predominantly in the states that had expanded their Medicaid programs, where in accordance with the policies and practices advocated from the top down by a federal government bureaucracy that saw prescribing painkillers as a less costly option when compared with more expensive medical treatments, many newly covered patients were prescribed the painkilling medications to which they would become addicted, at nearly no out-of-pocket costs to themselves.

Until the prescriptions ran out. That's when the newly addicted turned to the opioid substitutes available in the U.S.' black market, driving up the nation's opioid addiction rates to new highs in portions of the population that had not previously been at such elevated risk.

If access to health care through Medicaid really improved health care outcomes, these are outcomes that we would not observe. That the expanded access to Medicaid would appear to be making that problem worse indicates that the Medicaid welfare program is in dire need of major reform.

References

U.S. Centers for Disease Control and Prevention. National Vital Statistics System, Mortality. CDC WONDER. [Online Database]. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. [Note: Deaths were classified using the International Classification of Diseases, Tenth Revision (ICD–10). Drug overdose deaths were identified using underlying cause-of-death codes X40–X44, X60–X64, X85, and Y10–Y14.]

Eberstadt, Nicholas N. Our Miserable 21st Century. Commentary. [Online Article]. 15 February 2017.

Kaiser Family Foundation. States Getting a Jump Shart on Health Reform's Medicaid Expansion. [Online Article]. 2 April 2012.

Center on Budget and Policy Priorities. Status of State Medicaid Expansion in 2015. [PNG Image]. 28 April 2015.

Bloom, Josh. Have Opioid Restrictions Made Things Better or Worse? American Council on Science and Health. [Online Article]. 3 November 2016.

Rettner, Rachel. US Drug Overdose Deaths Continue to Rise: Here Are the Numbers to Know. LiveScience. [Online Article]. 24 February 2017.

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