Drug-related epidemics among impoverished people who inject drugs (PWID) may be attenuated by increasing health insurance coverage and reducing unmet need for care through US Medicaid expansion, according to study findings published in Addiction. However, nonfinancial barriers may continue to subvert the impact of medical expansion.
While drug-related epidemics are a major crisis in the United States (US), the potential impact of Medicaid expansion on health care use, substance use disorder (SUD) treatment, and insurance coverage has been significantly under-examined among PWID. Previous research has demonstrated that health insurance coverage increases among working-age adults with Medicaid expansion, and has been associated with greater preventive health care use in the general population, reducing unmet need for medical care. Therefore, investigators sought to explore the potential of Medicaid expansion to mitigate drug-related epidemics among PWID subsisting at or below 138% of the US federal poverty line.
The investigators conducted a cross-sectional observational study using data from the Center for Disease Control and Prevention’s National HIV Behavioral Surveillance (NHBS) that included 19,946 impoverished PWID who were less than 65 years of age across 13 states. The Kaiser Family Foundation data was used to measure state-level Medicaid expansion.
Among the PWID included in analyses, 65.2% were homeless in the past year and 41.6% reported annual household incomes below $5000. By reported race/ethnicity, (36.6% were non-Hispanic White, 40.0% were non-Hispanic Black, 21.7% were Hispanic/Latinx, and 1.7% reported Other.
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Expanding Medicaid to all US states will be an essential step to help curb drug-related harms among this structurally marginalized population.
With Medicaid expansion, the investigators observed that the probability of insurance coverage increased by 19.0 percentage points (95% CI, 9.0%-30.0%; P =.006), and insurance coverage in expansion states increased from 63.9% in 2012 to 87.1% in 2018. Meanwhile, insurance coverage was relatively unchanged (38.7% to 37.2%) in nonexpansion states during the same period. Given that health insurance is commonly tied to employment in the US, the investigators suggest that PWID may particularly benefit from Medicaid expansion if previous drug-related offenses prevented these individuals from employment. Additionally, Medicaid expansion was associated with a 9.0 percentage-point reduction in the probability of unmet need (95% CI, -15% to -0.2%).
Among participants with daily drug use (n=17,584), Medicaid expansion was not associated with the probability of SUD treatment, though the percentage of PWID who participated in SUD treatment increased 9.1 percentage points from 2012 to 2018 in expansion states, and increased 8.1 percentage points in the same period in nonexpansion states. The investigators suggest that it may be necessary to induce practice- and policy-level reforms to ensure health insurance coverage gains combined with enhanced medical care engagement result in increased SUD treatment participation. These may include resources to effectively link impoverished PWID to SUD treatment and increasing the availability and accessibility of SUD treatment programs to this patient population.
These findings suggest that there is a potential for Medicaid expansion to attenuate drug-related epidemics among impoverished PWID by improving access to health care and reducing unmet need. Study authors concluded, “Expanding Medicaid to all US states will be an essential step to help curb drug-related harms among this structurally marginalized population.”
Study limitations include a lack of 2021 NHBS data (pandemic disruption), recall bias in survey responses, and reduced data of PWID in rural areas.
Reference
Cooper H, Beane S, Yarbrough C, et al.; NHBS Study Group. Association of Medicaid expansion with health insurance, unmet need for medical care and substance use disorder treatment among people who inject drugs in 13 US states. Addiction. Published online December 5, 2023. doi:10.1111/add.16383
This article originally appeared on Psychiatry Advisor
