A team of researchers at Oregon Health & Science University (OHSU) has published the results of an analysis of the impact of Medicaid section 1115 waivers. Beginning in 2015, Medicaid provided reimbursement for the treatment of opioid use disorders (OUD) through waivers. Getting a waiver required states to upgrade OUD treatment to meet Medicaid standards.

Researchers compared the results between a pool of 18 states that had not received waivers and 17 states that received waivers between 2017 and 2019. The researchers found that waivers had no measurable impact on the rates of nonfatal overdose. However, it’s not clear that the study lasted long enough to catch the current decline in overdose deaths. Also, recent research in Scotland has shown a substantial decline in the number of fatal overdoses for people enrolled in medically-assisted therapy (MAT).

The Oregon researchers found only a slight increase of 2.3% in methadone prescriptions in waiver states. There was no increase in buprenorphine prescriptions or naloxone use in waiver states. This would appear to indicate the failure to lower nonfatal overdoses in the brief period covered by the research may be due to a lack of implementation. The researchers conclude, rather harshly:

Our findings suggest that such waivers adopted by states during 2017–19 were not associated with significant improvements in medication treatment or reductions in nonfatal opioid-related overdoses among Medicaid enrollees with OUD. However, they may have moderately improved the use of medication treatment for those with severe OUD.

I have a few problems with this analysis:

• The time frame is too short. Two years (2017-2019) failed to capture the slow pace of rollout and adoption.

• The study indicates no “increased treatment” in waiver states. It goes against all logic that switching from not reimbursing for OUD treatment to reimbursing would not lead to an increase in prescriptions.

• No change in nonfatal overdoses. First, not a surprise if treatment did not increase. Second, what about fatal overdoses? The point is to keep people alive long enough for treatment to have an impact.

In an interview, lead researcher Dr. Stephen Lindner with the OHSU Center for Health Systems Effectiveness put what I believe is the correct spin on the surprising results:

[T]he waivers may be necessary but are clearly insufficient to bring the nation’s overdose epidemic under control.

Without clinics, healthcare professionals, training, and ongoing support, how is liberalizing reimbursement for opioid agonist medications going to bend the curve on addiction, hospitalizations, and overdose deaths?

OHSU’s own research “recommends easing access to methadone,” Dr. Lindner says, noting that “80% of people in France with OUD receive [MAT] compared with less than 20% in the United States.” Similarly, OHSU recommends “increasing access to buprenorphine.” 

My concern is that the current study will be misinterpreted to imply that liberalizing access to opioid agonist therapy does not lead to a reduction in nonfatal overdose. The research is clear: increasing the use of MAT decreases overdose fatalities and nonfatal overdoses. What the OHSU study shows is that changing the law does nothing if the realities on the street remain unchanged.

Written by Steve O’Keefe. First published November 12, 2024.

Sources:

“Effects Of Medicaid Waivers On Use Of Medications For Opioid Use Disorder And Nonfatal Overdoses In 17 States,” Health Affairs, November 2024.

“Medicaid funding for addiction treatment hasn’t curbed overdose deaths, study finds,” MedicalXpress, November 4, 2024.

Image Copyright: Bloomington Salvation Army, used under Creative Commons license.