Association of Medicaid Expansion With Opioid Overdose Mortality in the United States
Association of Medicaid Expansion With Opioid Overdose Mortality in the United States
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DOI：
10.1001/jamanetworkopen.2019.19066
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发表时间：
2020-01-01
影响因子：
13.8
通讯作者：
Cerda, Magdalena
中科院分区：
文献类型：
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作者：
Kravitz-Wirtz, Nicole;Davis, Corey S.;Cerda, Magdalena
本系列横断面研究探讨了美国州医疗补助的扩张是否与县级阿片类药物过量死亡人数相关。Key PointsPresident州医疗补助的扩张是否与美国县级阿片类药物过量死亡人数相关？在2001年至2017年对49个州和哥伦比亚特区的3109个县进行的一系列横断面研究中，医疗补助的扩大与阿片类药物过量死亡总数以及涉及海洛因和美沙酮以外的合成阿片类药物的死亡减少有关。扩展与美沙酮相关的死亡率增加有关。MeaningThe研究结果表明，扩大医疗补助的资格可能有助于减轻阿片类药物过量的流行。ImportanceThe患者保护和平价医疗法案（ACA）允许各州将大多数低收入成年人的医疗补助覆盖范围扩大到联邦贫困水平的138%，并要求提供与其他医疗和手术服务同等的精神健康和物质使用障碍服务。在医疗补助扩展州，使用阿片类药物治疗药物的物质使用障碍服务的增加比非扩展州更多，但尚未研究ACA相关的医疗补助扩展是否与县级阿片类药物过量死亡率相关。目的研究医疗补助的扩大是否与阿片类药物过量死亡的县数相关。设计、设置和样本本系列横断面研究使用了2001年1月1日至2017年12月31日期间来自49个州和哥伦比亚特区的3109个县的数据（N=3109个县x17年=52853个县年）。使用分层贝叶斯泊松模型对药物过量死亡进行建模。分析时间为2018年4月1日至2019年7月31日。暴露主要暴露是根据ACA州采用医疗补助扩张，衡量为每个日历年的比例，在此期间，一个给定的国家有医疗补助扩张的效果。到2017年研究观察结束时，共有32个州和哥伦比亚特区扩大了医疗补助资格。主要结果和措施感兴趣的结果是每年县级死亡率过量涉及任何阿片类药物，天然和半合成阿片类药物，美沙酮，海洛因和合成阿片类药物以外的美沙酮，来自国家生命统计系统的多种死因文件。二次分析检查了涉及所有药物的致命过量。结果在研究期间，在观察的美国各县有383091例阿片类药物过量死亡，平均（SD）为7.25（27.45）例死亡（范围，0-1145例死亡）。采用医疗补助扩张与总阿片类药物过量死亡率相比，非扩张状态下的死亡率降低了6%（相对率[RR]，0.94; 95%可信区间[CrI]，0.91-0.98）。与非扩张州的县相比，扩张州的县涉及海洛因的死亡率低11%（RR，0.89; 95%CrI，0.84-0.94），涉及美沙酮以外的合成阿片类药物的死亡率低10%（RR，0.90; 95%CrI，0.84-0.96）。在扩张状态下，观察到美沙酮相关过量死亡率增加11%（RR，1.11; 95% CrI，1.04-1.19）。医疗补助扩张与涉及天然和半合成阿片类药物的死亡之间的关联没有得到很好的支持（RR，1.03; 95%CrI，0.98-1.08）。结论和相关性医疗补助的扩大与阿片类药物过量死亡总数的减少有关，特别是涉及海洛因和美沙酮以外的合成阿片类药物的死亡，但美沙酮相关死亡率增加。随着各州投入更多资源解决阿片类药物过量流行病，应注意医疗补助扩大在降低阿片类药物过量死亡率方面可能发挥的作用，部分原因是通过增加阿片类药物使用障碍的药物获得机会。
This serial cross-sectional study examines whether US state Medicaid expansion is associated with county-level counts of opioid overdose deaths.Key PointsQuestionIs state Medicaid expansion associated with county-level opioid-involved overdose deaths in the United States? FindingsIn this serial cross-sectional study of 3109 counties within 49 states and the District of Columbia from 2001 to 2017, Medicaid expansion was associated with reductions in total opioid overdose deaths and deaths involving heroin and synthetic opioids other than methadone. Expansion was associated with increased mortality involving methadone. MeaningThe findings suggest that expanding eligibility for Medicaid may help to mitigate the opioid overdose epidemic.ImportanceThe Patient Protection and Affordable Care Act (ACA) permits states to expand Medicaid coverage for most low-income adults to 138% of the federal poverty level and requires the provision of mental health and substance use disorder services on parity with other medical and surgical services. Uptake of substance use disorder services with medications for opioid use disorder has increased more in Medicaid expansion states than in nonexpansion states, but whether ACA-related Medicaid expansion is associated with county-level opioid overdose mortality has not been examined. ObjectiveTo examine whether Medicaid expansion is associated with countyxyear counts of opioid overdose deaths overall and by class of opioid. Design, Setting, and ParticipantsThis serial cross-sectional study used data from 3109 counties within 49 states and the District of Columbia from January 1, 2001, to December 31, 2017 (N=3109 counties x17 years=52853 county-years). Overdose deaths were modeled using hierarchical Bayesian Poisson models. Analyses were performed from April 1, 2018, to July 31, 2019. ExposuresThe primary exposure was state adoption of Medicaid expansion under the ACA, measured as the proportion of each calendar year during which a given state had Medicaid expansion in effect. By the end of study observation in 2017, a total of 32 states and the District of Columbia had expanded Medicaid eligibility. Main Outcomes and MeasuresThe outcomes of interest were annual county-level mortality from overdoses involving any opioid, natural and semisynthetic opioids, methadone, heroin, and synthetic opioids other than methadone, derived from the National Vital Statistics System multiple-cause-of-death files. A secondary analysis examined fatal overdoses involving all drugs. ResultsThere were 383091 opioid overdose fatalities across observed US counties during the study period, with a mean (SD) of 7.25 (27.45) deaths per county (range, 0-1145 deaths per county). Adoption of Medicaid expansion was associated with a 6% lower rate of total opioid overdose deaths compared with the rate in nonexpansion states (relative rate [RR], 0.94; 95% credible interval [CrI], 0.91-0.98). Counties in expansion states had an 11% lower rate of death involving heroin (RR, 0.89; 95% CrI, 0.84-0.94) and a 10% lower rate of death involving synthetic opioids other than methadone (RR, 0.90; 95% CrI, 0.84-0.96) compared with counties in nonexpansion states. An 11% increase was observed in methadone-related overdose mortality in expansion states (RR, 1.11; 95% CrI, 1.04-1.19). An association between Medicaid expansion and deaths involving natural and semisynthetic opioids was not well supported (RR, 1.03; 95% CrI, 0.98-1.08). Conclusions and RelevanceMedicaid expansion was associated with reductions in total opioid overdose deaths, particularly deaths involving heroin and synthetic opioids other than methadone, but increases in methadone-related mortality. As states invest more resources in addressing the opioid overdose epidemic, attention should be paid to the role that Medicaid expansion may play in reducing opioid overdose mortality, in part through greater access to medications for opioid use disorder.