Background and Aims: Deaths from opioid-related overdoses continue to grow, in part due to the increasing lethality of substances being consumed (e.g., fentanyl).  Federal, state, and local governments have sought public policy interventions to reduce the number of deaths due to opioids, including increasing the availability of naloxone. The Affordable Care Act (ACA) expanded Medicaid coverage to low-income, childless adults, potentially giving this group financial access to naloxone.

Methods: We use data from the Medicaid Drug Rebate Program to estimate the impact of Medicaid expansion and Medicaid-covered naloxone. We use difference-in-differences regression analysis to compare states that did not expand to states that did expand before and after Medicaid expansion.

Results: Prior to Medicaid expansion, the number of Medicaid-covered naloxone prescriptions was very similar in expansion and non-expansion states. We find that, on average, states that expanded Medicaid have 78.2 (95%CI: 16.0-140.3;p=0.02) more prescriptions per year for naloxone compared to states that did not expand after expansion, a nearly 10-fold increase over the pre-expansion years. We also find Medicaid expansion contributed to this growth in Medicaid-covered naloxone more than other state-level naloxone policies.

Conclusions: Medicaid expansion has likely put naloxone into the hands of some of the people best positioned to prevent death from an overdose – individuals without opioid use disorder and their friends and members. The difference in difference results imply that the Medicaid expansion accounted for about 8.3% of the growth in take-home naloxone units from 2009 to 2016 holding other factors constant. Additionally, Medicaid is responsible for approximately 13% of the growth in naloxone prescriptions between 2009-2016. However, Medicaid expansion is not a silver bullet for expanding the use of naloxone and curbing the opioid epidemic. Policy makers must consider other ways to improve prevention, harm reduction, and treatment for opioid use disorder.

As the magnitude of the opioid epidemic grew in recent years, individual states across the United States of America enacted myriad policies to address its complications. We conducted a qualitative examination of the structure, successes, and challenges of enacted state laws and policies aimed at the opioid epidemic, with an in-depth focus on prescription drug monitoring programs (PDMPs) and naloxone access efforts.

A set of 10 states (Florida, Kentucky, Massachusetts, Michigan, Missouri, New York, North Carolina, Tennessee, Washington, and West Virginia) was chosen a priori to achieve a varied sample of state policies and timing, as well as population opioid complications. Archival research was conducted to identify state-level policies aimed at the opioid epidemic and semi-structured interviews were conducted with 31 key stakeholders between March and September 2016.

The most frequently mentioned key to success was an identifiable champion instrumental in leading the passage of these policies. The lack of a unified legislature and physician pushback were challenges many states faced in implementing policies.

Champion-led task forces, stakeholders' personal stories garnering buy-in, ongoing education and feedback to PDMP users, and inclusive stakeholder engagement are critical aspects of passing and implementing state policies aimed at combating the opioid epidemic. Engaging all interested stakeholders and providing continuing feedback are ongoing challenges in all states. Leveraging stakeholders' personal stories of how opioids affected their lives helped propel state efforts.

Alternative approaches in Medicaid are proliferating under the Trump administration. Using a novel telephone survey, we assessed views on health savings accounts, work requirements, and Medicaid expansion. Our sample consisted of 2,739 low-income nonelderly adults in three Midwestern states: Ohio, which expanded eligibility for traditional Medicaid; Indiana, which expanded Medicaid using health savings accounts called POWER accounts; and Kansas, which has not expanded Medicaid. We found that coverage rates in 2017 were significantly higher in the two expansion states than in Kansas. However, cost-related barriers were more common in Indiana than in Ohio. Among Medicaid beneficiaries eligible for Indiana’s waiver program, 39 percent had not heard of POWER accounts, and only 36 percent were making required payments, which means that nearly two-thirds were potentially subject to loss of benefits or coverage. In Kansas, 77 percent of respondents supported expanding Medicaid. With regard to work requirements, 49 percent of potential Medicaid enrollees in Kansas were already employed, 34 percent were disabled, and only 11 percent were not working but would be more likely to look for a job if required by Medicaid. These findings suggest that current Medicaid innovations may lead to unintended consequences for coverage and access.