Vox has an article arguing that repealing or limiting Obamacare would worsen the opioid crisis, since you would be taking away insurance (mostly Medicaid) from people who desperately need it to handle their addiction.

Look, it may be that whatever health care bill the Republican Congress passes will make the opioid epidemic even worse, but it is highly unlikely that Obamacare did anything to help, and it probably dug us deeper in the hole. This is because, as Sam Quinones’s recounts in his excellent investigative history of the opioid crisis, Dreamland, Medicaid is one of the main mechanisms by which addicts became hooked, and public insurance is the main funder of prescription opiates. Medicaid paid for the Oxycontin, and the desire for a Medicaid card was a big driver of the increase in SSI applicants during the decade ending in 2008, when the opioid crisis first took off:

Given that we haven’t addressed the two fundamental issues driving the opioid crisis- the ease with which people are prescribed addictive narcotics and the ease and low cost with which Mexican black tar heroin is entering the country and being distributed to addicts- I find it highly unlikely that the expansion of Medicaid in 2014 and 2015 did anything to help.

We can also look at this question more directly. Here is the change in drug overdose death rates from 2013 to 2015 from the CDC, comparing the 26 states and DC who had expanded Medicaid by 2015 (most expanded on January 1, 2014) to the 22 states that did not expand Medicaid by the end of 2015 and to the two states (Indiana and Alaska) who expanded Medicaid during 2015.

Obviously this is hardly an open-and-shut case- it’s likely that the states which expanded Medicaid already had a more quickly worsening problem than those who didn’t. But again, we’re talking about an additional increase of over 1.5 per 100,000 in the death rate from drug overdoses in states that expanded Medicaid versus the ones that didn’t. This translates to about 2600 additional deaths in 2015.

Update: I changed the graphs and the calculation above to weight by the population of states in 2015 and by the 2013 death rates respectively. There’s an argument against weighting here (you’re discussing a state-level policy, so in some ways weighting states equally makes sense), but given that I’m interested in how this affected the country as a whole and given that I didn’t want to feel like I was choosing my assumptions to make my case (using population weights reduced the estimated effect from 2.5 per 100,000 to 1.5 per 100,000), it seems like the better choice. Here are the unweighted graphs:

And here are the state-level changes. Only one state (Maine) that did not expand Medicaid had an increase in drug overdose death rates of over 5 per 100,000 in the two years from 2013 to 2015. Ten states that expanded Medicaid had a change of 5 per 100,000 or larger:

Gabriel Rossman developed a graph showing the full time course by using mortality data from CDC Wonder:, suggesting that there may have been a divergence in 2010 that was more important than ACA implementation after 2013 (when there was only an apparently small “kink” upward in the expanding states.)

And when I reproduced this without weighting it looks very similar, although with a more dramatic divergence in 2009-2010:

Were Medicaid expanders in states which were more likely to be hardest hit by the financial crisis? Perhaps, though this wouldn’t explain to me why states like Connecticut and New Hampshire and Massachusetts have had among the most rapid increases in opioid deaths in recent years:

Were the conservative governors who came into office in 2010 who turned down the Medicaid expansion able to slow down Medicaid or other public insurance enrollments even before the Affordable Care Act came into full effect, with some slowing of the opioid crisis as a result? Or, to put the shoe on the other foot, were liberal state governments that accepted the expansion also deliberately speeding public insurance enrollment in the years leading up to full ACA rollout, with the knock-on effect of even faster increases in overdoses? This seems pretty plausible to me.

Second Update:

Apparently Gabriel and I contributed to a showdown between German Lopez and Dylan Matthews of Vox and Senator Mike Lee’s communication director last night. That’s funny.

What’s not funny is that yesterday, after I wrote this post, I ran into the uncle of two former students. I asked how they were doing. When I taught them in high school, they were both nice, polite, reasonably bright underachievers who smoked too much pot. I figured they’d be working or in community college, muddling along like a lot of young guys.

Their uncle told me yesterday that they both had near-fatal overdoses in the last year. Both had started with prescription pills and moved on to heroin, with the predicted utter destruction of the rest of their lives. One seems to have moved back from the brink and is starting to get clean. The other is still in free fall.

Here’s a still image from a Slate animation of the age of overdose victims:

The average age at death of an opiate overdose is between 20 and 25.

Now, do I think that the Medicaid expansion was itself the biggest driver of why ACA expansion states had larger growth in overdoses than non-ACA states? No.

I think that a full-court press to increase insurance rates across the society and particularly for the young had as an additional effect that a lot of young people decided to use that insurance for something that appealed to them: drugs. The fire had already been lit in the 2000s, and as suddenly everyone had a way to get drugs cheap, the fire could spread faster. This didn’t need to be just about Medicaid expansion. The level of enrollment in Medicaid during 2014 ACA rollout is slightly associated with state-level changes in OD rates, but not enough to explain the divergence between ACA and non-ACA states:

Nor did the growth in SSI receipt diverge between expansion and non-expansion states:

But the rate of uninsured, particularly among the young, did diverge, and contra Dylan Matthews and German Lopez, this didn’t need to wait until full ACA rollout to take effect. Thanks to the provision of the Affordable Care Act that required parents’ employer-based health insurance to cover children through age 26, there were significant changes in the percentage of young adults with health insurance just from 2009 to 2011:

If you just look at pre-ACA variables, it’s pretty hard to predict which states will take off in overdose rates. Even taking the baseline 2010 overdose rate, the percentage of the population receiving SSI in 2010, and the percentage of Medicaid recipients who were white together doesn’t do all that much to explain the states that really exploded in drug use since 2010:

The best single predictor I’ve found for the change in overdose rates by state from 2010 to 2015 is the percent of white uninsured in the state in 2015, with lower percentages uninsured having much larger increases in overdose rates.

If you put this variable- that the Affordable Care Act did affect, together with the baseline variables (2010 OD Rates, SSI receipt, and percent of Medicaid recipients white)- suddenly those outliers don’t look like outliers any more.

That’s what I think caused at least part of the divergence between blue (ACA expansion) and red (no ACA expansion) states in the overdose rates. Not the Medicaid expansion in of itself, but the dominant political party in these states taking reducing the percentage of uninsured as a principal goal, without realizing that a new population of younger insured carried huge new risks of abuse.