Association for Public Policy Analysis & Management

West Virginia expanded Medicaid in 2014 under the Affordable Care Act (ACA). Following expansion, West Virginia experienced one of the greatest relative increases in Medicaid enrollment in the U.S. The population that gained coverage in West Virginia was likely to have substantial burden of opioid use disorder, as West Virginia also leads the nation in its fatal drug overdose rate. Medicaid under the ACA allowed states to offer medications that help to manage symptoms of opioid use disorder. Medicaid expansion, particularly in West Virginia, could thus provide a link to addiction treatment for previously uninsured low-income adults. This treatment is often intensive, as opioid use disorder is a chronic and relapsing illness and clinical guidelines support medication treatment that is indefinite in duration. While West Virginia’s Medicaid program does not cover methadone maintenance, a highly effective and low-cost medication, it does cover buprenorphine, another effective medication, which can be prescribed by office-based physicians.

We examine 2014-2015 Medicaid claims for individuals enrolling under the ACA. Data are provided under a data partnership with the West Virginia Department of Health and Human Resources. We examine diagnosis rates for opioid use disorder, rates of drug overdoses, and illnesses closely related to injection drug use (including incident diagnoses of HIV and hepatitis C). For those individuals who initiate treatment, we examine patterns of service use, including the duration of buprenorphine pharmacotherapy, receipt of mental health counseling, and the presence of urine drug screens. We compare differences overall between rural and urban areas (West Virginia is one of the most rural states in the U.S.). Given concerns that treatment may be limited in high need areas or areas where there are few treatment providers, we also merge the data with indicators of county drug overdose death rates and measures of treatment system capacity (e.g., the availability of physicians prescribing buprenorphine). We then compare treatment patterns among patients in higher versus lower need areas and higher versus lower capacity areas.

Preliminary analysis, conducted in early 2017, indicate that opioid use disorder was one of the most commonly diagnosed conditions in West Virginia Medicaid during this period. Despite the chronic nature of opioid use disorder, most people who received treatment in each year had few visits or only filled a single prescription for buprenorphine, indicating very low continuity of treatment. However, we do find that counseling and urinalysis were extensively provided to a subset of newly enrolled individuals. Analysis currently underway, which will be completed prior to the APPAM meeting, will include a detailed examination of area-level predictors and additional development of measures related to treatment quality (such as use of care following an overdose hospitalization).

This study should provide important evidence about the specific pathways through which Medicaid expansion altered treatment for opioid use disorder among newly enrolled individuals, and can indicate potential gaps in treatment relevant to researchers and policymakers. I will also discuss plans for a comparison of West Virginia Medicaid data with other expansion states.