On November 10, the Supreme Court will hear oral arguments from the Texas attorney general that the Affordable Care Act (ACA) should be found unconstitutional and overturned. The Urban Institute estimated that this would increase the number of uninsured by 21.1 million people, including many who obtained coverage through the ACA’s Medicaid expansion. And for many Americans with opioid use disorder, the loss of Medicaid expansion could be catastrophic.

Amid the COVID-19 pandemic, the crisis of opioid-related deaths has tragically escalated to unprecedented levels. The Centers for Disease Control and Prevention estimates 75,588 overdose deaths in the 12-month period ending March 2020, the highest on record. And between March and May 2020, as the COVID-19 pandemic deepened, evidence from national, state, and local sources shows that overdoses soared—fatal overdoses increased by 11 percent, and nonfatal overdoses increased by 19 percent (PDF).

Repealing the ACA’s Medicaid expansion threatens to take opioid treatment options away from more than a half million low-income Americans (PDF). Research shows that the risk of death is three times higher for people discharged from medication treatment for opioid use disorder compared with those who remain in treatment, and the cost of care related to opioid overdose is likely to spike if more than a half million people are cut off from treatment. In fact, hospitalization costs attributable to opioid-related overdose were more than $700 million annually before the most recent opioid overdose crisis.

If the ACA is repealed, the loss of treatment for hundreds of thousands of Americans could cost many their lives and prompt a surge in these crisis costs, which would put a huge burden on families, state governments, and providers.

Medicaid expansion has increased how many receive treatment for opioid use disorder

Most drug overdose deaths involve opioids despite the existence of life-saving naloxone to reverse opioid overdose, such as Narcan nasal spray or atomizer kits of generic naloxone, and three highly effective medication treatments for opioid use disorder: buprenorphine (Suboxone), methadone, and Vivitrol. Medication treatment has been shown to reduce overdose, serious opioid-related acute care use, and overdose death.

State Medicaid programs that provide health care for millions of low-income people have been at the front lines of an enormous expansion in treatment for opioid use disorder and overdose, and the ACA’s Medicaid expansion has been a critical tool for getting care to people who need it.  Our research shows states that expanded Medicaid under the Affordable Care Act had larger increases in prescriptions and spending for treatment for opioid use disorder and opioid overdose compared with those that did not expand Medicaid under the ACA. 

Between 2013, before the ACA’s Medicaid expansion, and 2018, buprenorphine treatment prescriptions (mostly Suboxone) per Medicaid enrollee increased 3-fold in expansion states versus 2-fold in nonexpansion states, naltrexone treatment prescriptions (Vivitrol) per enrollee increased 5-fold in expansion states versus 3-fold in nonexpansion states, and naloxone per enrollee (mostly Narcan) increased 36-fold in expansion states versus 18-fold in nonexpansion states.

State Medicaid programs provided treatment for 1.2 million people with opioid use disorder in 2017, with more than half a million (532,809) of those treated covered through the Medicaid expansion (PDF). This includes thousands of people in treatment across states who expanded Medicaid, such as Michigan (21,794 adults treated), Minnesota (10,094), Nevada (6,853), New Hampshire (3,118), Ohio (56,253), and Pennsylvania (64,330).

Several states’ data were not included in these counts, meaning the number of people receiving treatment through Medicaid is likely underestimated. Our research also shows very large increases in treatment between 2017 and 2018, following steady increases for nearly a decade, suggesting that the estimated number of people in treatment is now far larger than was estimated in 2017.

The opioid overdose crisis has already pushed communities and health systems to the brink. And the pandemic has slowed or closed many local initiatives to decrease overdose mortality like community-based harm reduction programs, which have cut back life-saving services including distribution of medications to reverse opioid overdose. And in response to predicted budget shortfalls because of COVID-19, state and local governments are slashing funding for public services, including first responders and substance use treatment programs.

These health care providers and first responders are already overwhelmed, especially in resource-poor communities struggling with the dual epidemics of overdose and COVID-19. With the overdose crisis spiking to unprecedented levels, repealing the ACA would further destabilize more than a half million Americans in treatment, likely fueling an acceleration in overdose deaths on a scale we have never seen.