Medicaid Expansion Has Not Helped the Drug Crisis. It May Be Making It Worse.
KEY FINDINGS
- 14 of the 15 states with the highest overdose rate are Medicaid expansion states.
- Half of the states with the lowest overdose rate have not expanded Medicaid and another two had only expanded during the data year.
- The 10 states with the highest Medicaid usage more than doubled their overdose rate from 2014 to 2020 and this rate was more than twice that of the 10 states with the lowest Medicaid usage.
- Mothers enrolled in Medicaid gave birth to babies with Neonatal Abstinence Syndrome (NAS) at a higher rate than mothers with any other coverage, including those who were uninsured.
- In West Virginia, more than 85 percent of mothers who gave birth to NAS babies were on Medicaid, in Arizona, that figure stood at more than 92 percent.
Overview
The drug crisis crushing the nation arose largely because of the overuse of prescription opioids.1 The epidemic cuts across demographics, affecting people throughout the country.2 In 2021, the national age-adjusted drug overdose rate was 32.4 per 100,000 people, an increase from 6.8 in 2001.3 Drug overdoses claimed more than 106,000 lives in 2021.4
Both politicians and policy experts hyped Medicaid expansion as an answer to rising overdose deaths.5 Others warned that any cuts to Medicaid would surely make the crisis even worse.6-7 However, seven years of data has not born this out.
In 2017, FGA experts posed the question of whether Medicaid expansion actually makes the problem worse.8 The data answers that question with a resounding, “yes.”9 As a report by the Committee on Homeland Security and Governmental Affairs under Senator Ron Johnson (R-WI) highlighted in 2018, “if Medicaid is helping to drive the epidemic, it stands to reason that expanding the program—particularly to people most susceptible to abuse—could worsen the problem.”10 He was right.
Medicaid expansion states and those with higher Medicaid usage continue to show higher rates of overdose deaths and other tragedies like NAS births. But this really should not be surprising based on what is known about the Medicaid program. It increases access to prescription painkillers, is full of fraud, and keeps able-bodied adults out of the workforce. These are all major contributors to the drug crisis, and as a result, Medicaid is more likely to contribute to the problem, not solve it.
To truly address the drug crisis, instead of enrolling more individuals in Medicaid, states and the federal government should reform the program to make sure it prioritizes the truly needy. This includes adding work requirements that will move able-bodied adults off Medicaid and back into the workforce.11
Medicaid expansion was wrongly sold as an answer to the opioid epidemic
After the passage of ObamaCare, liberals argued that Medicaid expansion was key to fighting back against the opioid epidemic.12-13 When the Supreme Court ruled that the federal government could not coerce states into expanding Medicaid in NFIB v. Sebelius, this argument became even more important to encourage costly expansion.14 The White House continues to claim that all the states that have not expanded Medicaid fail to provide adequate treatment to their citizens.15
Maine illustrates how a governor tried to use the opioid epidemic to make the case for expanding Medicaid. Governor Janet Mills’s first executive order required “expeditious implementation” of Medicaid expansion.16 Expanding Medicaid remains on the governor’s website as one of the actions that is saving lives and preventing substance use disorders.17 This step was also heralded as “effectively addressing the opioid epidemic.”18 Despite all this hype, Maine set a record for drug overdose deaths for the third straight year in 2022.19
The belief in Medicaid as a tool to combat drug overdoses was echoed by other governors and senators. In response to a proposal to phase out Medicaid expansion, Governor Roy Cooper (D-NC) declared, “we cannot have millions of Americans lose their health coverage and still effectively attack this crisis. We can’t significantly reduce Medicaid spending and still be successful in fighting opioid addiction.”20 Senator Bob Casey (D-PA), speaking along with Senator Joe Manchin (D-WV) addressed the same proposal, “this is a critical time for the opioid epidemic and a critical time for Medicaid because of the connection between the two.”21
However, data fails to show that people in states that have not expanded Medicaid or that have low Medicaid usage have suffered disproportionately from drug overdoses or related tragedies. If anything, the opposite is true.
Increasing Medicaid coverage does not reduce overdoses
Comparing age-adjusted overdose death rates using the latest data from the Centers for Disease Control and Prevention reveals a stark difference between states that had expanded Medicaid and those that had not. At the time the data comes from, 36 states and Washington, D.C. had implemented Medicaid expansion and 14 states had not. Of the 15 states with the highest age-adjusted overdose rates all but one, Tennessee, had expanded Medicaid.22 While a majority of the country did expand Medicaid, these states represented an incredibly outsized 93 percent of the jurisdictions with the highest overdose rate.
On the flip side, of the 10 states with the lowest age-adjusted overdose rates, five states had yet to expand, and two others had only expanded during that year.23 These non-expansion states represent a small fraction of the total states but were vastly overrepresented in states with lower overdose rates.
This shows that simply expanding Medicaid did not help states turn the tide on the drug epidemic. A recent study also found that Medicaid expansion states saw a greater increase in drug overdose deaths during the first year of COVID-19 than non-expansion states.24 Overall, expansion states had an age-adjusted overdose rate of 31.47 people per 100,000 and non-expansion states had a lower rate of 24.73 people per 100,000.25
But if Medicaid expansion was not a key to reducing overdose deaths, maybe simply enrolling more individuals in Medicaid, and having them utilize more Medicaid services, could be the answer. This also fails to be supported by the data.
From 2014 to 2020, the 10 states with the highest Medicaid usage rate more than doubled their overdose rate to 39.69 deaths per 100,000 people.26 Over the same timeframe, the 10 states with the lowest Medicaid usage rate increased their overdose rate by less than a third, settling at 19.13 deaths per 100,000 people.27
It is not just overdose deaths, emergency department visits also fail to show the benefits of Medicaid in the drug crisis. A six-state study showed a higher rate of emergency department visits for suspected overdose in expansion states versus non-expansion states.28 This should not be surprising since Medicaid and Medicare are responsible for two-thirds of all charges for opioid-related visits to the emergency department.29
Medicaid is linked to other harmful effects of drug use
While Medicaid fails to show improvement in outcomes for drug overdoses, the program also fails to prevent another harmful effect of drug use, NAS births. Medicaid mothers gave birth to NAS babies at nearly twice the overall rate and more than eight times the rate of mothers with private insurance.30 Medicaid even exceeded the uninsured in the rate of NAS births, showing that moving uninsured expecting mothers to Medicaid may not even be beneficial in this aspect.31
Two recent studies from expansion states show how stark the differences between Medicaid and private insurance in covering NAS births can be.
A study of all newborns in West Virginia from 2017 to 2019 revealed that for every 1,000 births, there were 85.8 incidences of NAS covered by Medicaid but only 12.7 for private insurance.32 Medicaid covered just a little more than half of all births in the state but a full 86 percent of NAS births.33
Likewise, a study covering births in Arizona from 2017 to 2021 showed that Medicaid covered just a little more than half of all births but more than 92 percent of NAS births.34 This is an astounding number and national data hints that Medicaid covers a disproportionate share of NAS births across the country.
The 10 states with the lowest Medicaid usage averaged fewer than four NAS births per 1,000 births.35 But the rate for the 10 states with the highest Medicaid usage was almost three times as high at 11.49 NAS births per 1,000 births.36 The same divergence is seen when comparing states that had expanded Medicaid, 9.18 NAS births, with states that had not expanded Medicaid, 5.12 NAS births.37 This data should not come as a surprise as even the Centers for Medicare & Medicaid Services admit that “studies show a higher risk of opioid use during pregnancy among Medicaid beneficiaries.”38
Medicaid is fraught with fraud that drives improper usage of services
It makes sense that states that increase Medicaid coverage would not see a reduction in the harmful effects of drug use when you look at the results from a Medicaid and CHIP Payment and Access Commission study.
The study found that adults enrolled in Medicaid were more likely to report being dependent on or abusing pain relievers in the past year than both those covered by private insurance and uninsured.39 The study also showed that while adults enrolled in Medicaid reported misusing pain relievers in the past 30 days at the same rate as the uninsured, this rate was twice that of those covered by private insurance.40
This in large part because Medicaid is fraught with fraud that drives improper usage of Medicaid benefits and services. The report from Senator Johnson’s Senate committee highlighted 100 cases of Medicaid fraud related to opioids.41 FGA’s research highlights the serious problems with welfare fraud and the massive improper payment rates in the Medicaid program.42-43 A program rife with fraud is only adding fuel to the fire in the drug crisis as millions more individuals are added to the program with little oversight.
The answer is to expand work, not Medicaid
If expanding Medicaid is not the magic formula to solve the drug crisis, what is? It turns out that the unemployed are nearly twice as likely as full-time workers to report non-medical use of prescription opioids and more than twice as likely to report non-medical use of prescription stimulants.44
This makes Medicaid especially dangerous, as most able-bodied adults on Medicaid do not work at all.45 Unfettered access to prescription painkillers or other opioids like Suboxone, combined with the lack of work among able-bodied Medicaid recipients is a killer—not just for state budgets, but for thousands of Americans.
To reduce this type of drug use and ultimately overdoses and deaths, able-bodied adults need to move off Medicaid and back into the workforce. The best way to do this is by implementing work requirements in programs like Medicaid and food stamps.46-47 Some states have sought permission from the federal government to do this, but the Biden administration continues to block their path forward.48-49 Thankfully, some leaders in Congress who care about solving the problem, like Rep. Jake LaTurner (R-KS), have introduced a bill that would implement work requirements in Medicaid.50
THE BOTTOM LINE: During Medicaid expansion battles, the program was touted as an answer to the drug crisis, but evidence fails to support that claim.
REFERENCES
1 Centers for Disease Control and Prevention, “Opioids,” U.S. Department of Health and Human Services (2023), https://www.cdc.gov/opioids/basics/epidemic.html.
2 David Powell, “Understanding the demographics of the opioid overdose death crisis,” RAND Corporation (2021), https://www.rand.org/content/dam/rand/pubs/working_papers/WRA1400/WRA1484-2/RAND_WRA1484-2.pdf.
3 Centers for Disease Control and Prevention, “Drug overdose deaths in the United States, 2001-2021,” U.S. Department of Health and Human Services (2023), https://www.cdc.gov/nchs/products/databriefs/db457.htm.
4 Ibid.
5 Erin Schumaker, “New Governor Janet Mills makes fighting opioid deaths a priority in Maine – finally,” HuffPost (2019), https://www.huffpost.com/entry/maine-governor-janet-mills-opioids.medicaid_n_5c2f7883e4b08aaf7a98c078.
6 Scott Malone, “Cuts to Medicaid could worsen U.S. opioid crisis, governors warn,” Reuters (2017),
7 Jess Mancini, “Sens. Joe Manchin, Bob Casey: Loss of Medicaid funds for addiction would be disastrous,” The Intelligencer (2017), https://www.theintelligencer.net/news/top-headlines/2017/06/sens-joe-manchin-bob-casey.loss-of-medicaid-funds-for-addiction-would-be-disastrous/.
8 Sam Adolphsen, “Has Medicaid made the opioid epidemic worse?” National Review (2017), https://www.nationalreview.com/2017/07/medicaid-opioid-problem-has-it-made-epidemic-worse/.
9 Ibid.
10 Majority Staff Report of the Committee on Homeland Security and Government Affairs, “Drugs for dollars: Howe Medicaid helps fuel the opioid epidemic,” United States Senate (2018), https://www.hsgac.senate.gov/wp.content/uploads/imo/media/doc/Statement%20for%20Record-HSGAC%20Majority%20Staff%20Report-2018-01.17.pdf.
11 Michael Greibrok, “Congress could boost economy by allowing Medicaid work requirements without bureaucratic intervention,” Foundation for Government Accountability (2023), https://thefga.org/research/congress-boost-economy-allowing-medicaid-work-requirements/.
12 Christine Vestal, “States gear up to help Medicaid enrollees beat addictions,” Pew Charitable Trusts (2015), https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/1/13/states-gear-up-to-help.medicaid-enrollees-beat-addictions.
13 German Lopez, “A big Obamacare policy could help fight the heroin epidemic. Politics is holding it back.” Vox (2016), https://www.vox.com/2016/5/12/11640508/medicaid-expansion-opioid-epidemic.
14 SCOTUSblog, “National Federation of Independent Business v. Sebelius,” (2023), https://www.scotusblog.com/case-files/cases/national-federation-of-independent-business-v-sebelius/.
15 Office of National Drug Control Policy, “National drug control strategy,” Executive Office of the President (2022), https://www.whitehouse.gov/wp-content/uploads/2022/04/National-Drug-Control-2022Strategy.pdf.
16 Executive Order, “An order to require expeditious implementation of the MaineCare expansion,” Office of the Governor of Maine (2017), https://www.maine.gov/governor/mills/sites/maine.gov.governor.mills/files/inline.files/Executive%20Order%201_0.pdf.
17 Office of Governor Janet T. Mills, “Opioid epidemic,” State of Maine (2023), https://www.maine.gov/governor/mills/issues/opioid-epidemic.
18 Lisa Clemans-Cope, et al., “Leveraging Medicaid to address opioid and substance use disorders in Maine,” Urban Institute (2019), https://www.urban.org/sites/default/files/publication/100443/2019.06.20_mainecare_report_final_6.pdf.
19 Eric Russell, “Maine overdose deaths set record for 3rd straight year in 2022,” Central Maine (2023), https://www.centralmaine.com/2023/02/02/2022-set-another-record-for-drug-overdose-deaths-in-maine/.
20 Scott Malone, “Cuts to Medicaid could worsen U.S. opioid crisis, governors warn,” Reuters (2017),
21 Jess Mancini, “Sens. Joe Manchin, Bob Casey: Loss of Medicaid funds for addiction would be disastrous,” The Intelligencer (2017), https://www.theintelligencer.net/news/top-headlines/2017/06/sens-joe-manchin-bob-casey.loss-of-medicaid-funds-for-addiction-would-be-disastrous/.
22 Authors’ calculation comparing expansion and non-expansion states with 2020 drug overdose death rates from the Centers for Disease Control and Prevention, https://www.cdc.gov/drugoverdose/deaths/2020.html.
23 Ibid.
24 Samantha G. Auty and Kevin N. Griffith, “Medicaid expansion and drug overdose mortality during the COVID-19 pandemic in the United States,” Drug Alcohol Dependence (2022), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8809643/.
25 Authors’ calculation comparing expansion and non-expansion states with 2020 drug overdose death rates from the Centers for Disease Control and Prevention, https://www.cdc.gov/drugoverdose/deaths/2020.html.
26 Authors’ calculation using 2014 and 2020 drug overdose death rates from the Centers for Disease Control and Prevention, https://www.cdc.gov/drugoverdose/deaths/2014.html and https://www.cdc.gov/drugoverdose/deaths/2020.html.
27 Ibid.
28 William E. Soares III MD, MS, et al., “Emergency department visits for nonfatal opioid overdose during the COVID-19 pandemic across six US health care systems,” Anals of Emergency Medicine (2022), https://www.sciencedirect.com/science/article/pii/S0196064421002262.
29 James R. Langabeer, et al., “Prevalence and charges of opioid-related visits to U.S. emergency departments,” Drug and Alcohol Dependence (2021), https://www.sciencedirect.com/science/article/abs/pii/S0376871621000636?via%3Dihub.
30 Andrea E. Strahan, PhD, et al., “Neonatal abstinence syndrome incidence and health care costs in the United States, 2016,” JAMA Network (2019), https://jamanetwork.com/journals/jamapediatrics/fullarticle/2756325.
31 Ibid.
32 Amna Umer, et al., “Disparities in neonatal abstinence syndrome and health insurance status: A statewide study using non—claims real-time surveillance data,” Paediatric and Perinatal Epidemiology (2021), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8386694/.
33 Ibid.
34 Department of Health Services, “Neonatal abstinence syndrome surveillance report, 2017-2021,” State of Arizona (2022), https://www.azdhs.gov/opioid/documents/nas/5year-nas-report.pdf.
35 Authors’ calculation using December 2020 Medicaid enrollment data found at
https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-chip-enrollment.data/monthly-medicaid-chip-application-eligibility-determination-and-enrollment-reports-data/index.html with data from Healthcare Cost and Utilization Project on neonatal abstinence syndrome births found at
36 Ibid.
37 Authors’ calculations comparing expansion and non-expansion states with data from Healthcare Cost and Utilization Project on neonatal abstinence syndrome births found at
38 Centers for Medicare and Medicaid Services, “Guidance to improve care for infants with neonatal abstinence syndrome and their families,” U.S. Department of Health and Human Services (2020), https://www.medicaid.gov/federal-policy-guidance/downloads/cib090420.pdf.
39 Medicaid and CHIP Payment and Access Commission, “Medicaid and the opioid epidemic,” (2017), https://www.macpac.gov/wp-content/uploads/2017/06/Medicaid-and-the-Opioid-Epidemic.pdf.
40 Ibid.
41 Majority Staff Report of the Committee on Homeland Security and Governmental Affairs, “Drugs for dollars: How Medicaid helps fuel the opioid epidemic,” United States Senate (2018), https://www.hsgac.senate.gov/wp.content/uploads/imo/media/doc/Statement%20for%20Record-HSGAC%20Majority%20Staff%20Report-2018-01.17.pdf.
42 Sam Adolphsen, “Testimony on unintended consequences: Medicaid and the opioid epidemic,” Foundation for Government Accountability (2018), https://www.hsgac.senate.gov/wp.content/uploads/imo/media/doc/Testimony-Adolphsen-2018-01-17.pdf.
43 Hayden Dublois and Jonathan Ingram, “Ineligible Medicaid enrollees are costing taxpayers billions,” Foundation for Government Accountability (2022), https://thefga.org/research/ineligible-medicaid-enrollees-costing.taxpayers-billions/.
44 Alexander S. Perlmutter, et al., “Is employment status in adults over 25 years old associated with nonmedical prescription opioid and stimulant use?” Social Psychiatry and Psychiatric Epidemiology (2016), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5673257/.
45 Frequently Asked Questions, “Work requirements for Medicaid,” Foundation for Government Accountability (2023), https://thefga.org/wp-content/uploads/2018/01/Work-Requirements-for-Medicaid-FAQ.pdf.
46 Michael Greibrok, “Congress could boost economy by allowing Medicaid work requirements without bureaucratic intervention,” Foundation for Government Accountability (2023), https://thefga.org/research/congress-boost-economy-allowing-medicaid-work-requirements/.
47 Hayden Dublois, et al., “Food stamp work requirements worked for Missourians,” Foundation for Government Accountability (2020), https://thefga.org/research/missouri-food-stamp-work-requirements/.
48 Sarah Kliff and Margot Sanger-Katz, “Biden Administration moves to end work requirements in Medicaid,” The New York Times (2021), https://www.nytimes.com/2021/02/12/upshot/biden-medicaid-reversing-trump.html.
49 Michael Greibrok, “Congress could boost economy by allowing Medicaid work requirements without bureaucratic intervention,” Foundation for Government Accountability (2023), https://thefga.org/research/congress-boost-economy-allowing-medicaid-work-requirements/.
50 Representative Jake LaTurner, “Rep. LaTurner introduces Medicaid & SNAP work requirements legislation,” United States Congressman (2023), https://laturner.house.gov/media/press-releases/rep-laturner-introduces.medicaid-snap-work-requirements-legislation.
51 Jon Styf, “Report: Soon 100 million U.S. residents will be on Medicaid,” The Center Square (2023), https://www.thecentersquare.com/national/report-soon-100-million-u-s-residents-will-be-on.medicaid/article_1fa5daee-8a9d-11ed-9907.6f093b7d56f8.html#:~:text=(The%20Center%20Square)%20%E2%80%93%20The,the%20program%20for%20healt h%20care.
52 National Institute on Drug Abuse, “Drug overdose death rates,” National Institutes of Health (2023), https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates.
