Low-income people with addiction, especially those with addiction to opioids, may find it hard to access the kind of care they need to recover no matter where they live, a new study suggests.

But treatment for opioid problems is especially scarce in states that may drop people from their Medicaid health insurance rolls -- unless they can show that they’re working, in school, have a disability or are medically frail or receiving treatment for substance use disorder.

In addition, the study shows that states with Medicaid work requirements also have higher rates of opioid overdose deaths than other states – suggesting a need for increased overdose prevention efforts.

In a new paper in the Journal of General Internal Medicine, a pair of University of Michigan researchers looks at data from states that have sought or received federal government permission for Medicaid work requirements, and compares it with data from states that haven’t.

They find that work requirement states tend to have fewer substance use disorder treatment facilities that offer care for opioid use disorder. They also have fewer health care providers certified to prescribe the medication buprenorphine, one of the most effective opioid addiction treatments.

High stakes, low availability

The researchers say their findings support a call for more access to substance use disorder treatment, and specifically to evidence-based opioid use disorder care, across the country.

But the stakes for patients are higher in work requirement states, because of the challenges to employment for people with these conditions and the potential for people to lose their Medicaid health coverage if they can’t find a provider to diagnose or treat their substance use disorder.

Some states with work requirements apply their policy to all Medicaid enrollees, others only to the population covered by the Medicaid expansion program.

Starting in 2018, the Centers for Medicare and Medicaid Services invited states to apply for waivers to the Medicaid statute that would allow changes to their programs designed to increase employment and community engagement by enrollees.

Seventeen states have applied, and nine have received approval, though most of them have put their programs on hold because of a federal court case contesting the legal basis of the work requirement waiver.

All of the seventeen states except Alabama allow Medicaid participants to count substance use disorder treatment as a form of community engagement to fulfill their work requirement and keep their coverage, or to be exempt from the requirement if they have a formal substance use disorder diagnosis.

“Work requirement states are largely treating substance use disorder as a disability, but many want evidence of a diagnosis, or proof that they’re taking part in an approved treatment program,” says Paul Christine, M.D., Ph.D., the U-M internal medicine resident who led the analysis of data from several national databases to conduct the study. “If they’re requiring this as a condition of eligibility, then it’s important to know if treatment resources will be available. And it appears that work requirement states have lower addiction treatment availability, especially in states that have approved waivers.”

Renuka Tipirneni, M.D., M.Sc., the assistant professor of internal medicine who worked with Christine on the study, has also studied the effects of Medicaid coverage on enrollees’ mental and physical health, and ability to work.

“We know that gaining coverage is associated with better health and ability to be a productive part of society, and that losing coverage can have the opposite effect,” she says. “States should increase the availability for substance use disorder treatment, and potentially account for the availability of this care when making decisions about Medicaid eligibility and enrollment.”

The prevalence of substance use disorder was similar across states with and without Medicaid work requirements. But states with approved Medicaid work requirement waivers had a higher incidence of both overall overdose-related deaths and opioid-related overdose deaths, compared with states with pending or no work requirements

Increasing the availability of medication-based therapy for opioid use disorder is a priority nationwide, the authors say, and in states with Medicaid work requirements, failing to do so may have health and health insurance repercussions for individuals with substance use disorders.

The research was supported in part by the University of Michigan and the National Institutes of Health (AG056591). It was not conducted as part of the official evaluation of the state of Michigan’s Medicaid expansion program being conducted by a team at the U-M Institute for Healthcare Policy and Innovation of which Tipirneni is part.

Reference: JGIM, January 2020, https://doi.org/10.1007/s11606-019-05623-1

