Association of Medicaid expansion and 1115 waivers for substance use disorders with hospital provision of opioid use disorder services: a cross sectional study

Abstract

Introduction Opioid-related hospitalizations have risen dramatically, placing hospitals at the frontlines of the opioid epidemic. Medicaid expansion and 1115 waivers for substance use disorders (SUDs) are two key policies aimed at expanding access to care, including opioid use disorder (OUD) services. Yet, little is known about the relationship between these policies and the availability of hospital based OUD programs. The aim of this study is to determine whether state Medicaid expansion and adoption of 1115 waivers for SUDs are associated with hospital provision of OUD programs. Methods We conducted a cross-sectional study of a random sample of hospitals (n = 457) from the American Hospital Association’s 2015 American Hospital Directory, compiled with the most recent publicly available community health needs assessment (2015–2018). Results Controlling for hospital characteristics, overdose burden, and socio-demographic characteristics, both Medicaid policies were associated with hospital adoption of several OUD programs. Hospitals in Medicaid expansion states had significantly higher odds of implementing any program related to SUDs (OR: 1.740; 95% CI: 1.032–2.934) as well as some specific activities such as programs for OUD treatment (OR: 1.955; 95% CI: 1.245–3.070) and efforts to address social determinants of health (OR: 6.787; 95% CI: 1.308–35.20). State 1115 waivers for SUDs were not significantly associated with any hospital-based SUD activities. Conclusions Medicaid expansion was associated with several hospital programs for addressing OUD. The differential availability of hospital-based OUD programs may indicate an added layer of disadvantage for low-income patients with SUD living in non-expansion states.

Examining the relationship between social determinants of health, measures of structural racism and county-level overdose deaths from 2017–2020

“…First, because the Census of Governments data used in our analysis includes years in which there was a limited census conducted (2018–2020), the counties included may be subject to selection bias; however, we do include on year of data (2017) in which a full survey was conducted, which is a strength to this analysis. Second, while the GEE model accounts for time and intra-unit correlation effects, we do not include data on the implementation of state policies (i.e., Medicaid 1115 waivers for substance use disorders or Good Samaritan laws) [ 38 ] which may affect overdose risk in communities. Third, the fines and forfeitures data taken from the Census of Governments do not include other court costs, such as fees for jail time, and is likely an underestimation of the effect.…”

Does Medicaid Institutions for Mental Diseases Exclusion Waiver Crowd Out the Access to Treatment Among Commercially Insured Substance Use Disorder Patients? An Empirical Study Using Commercial Insurance Claims Data

“…A recent study showed that the acceptance of Medicaid increased at residential and intensive outpatient facilities, and the delivery of medications increased with the adoption of the IMD exclusion waivers (13). It was also found that hospitals in states that have adopted Medicaid 1115 waivers for SUDs were more likely to provide opioid use disorder (OUD) treatment programs (14). By the end of 2020, there were 28 states with these SUD IMD Exclusion waivers (15).…”