Individuals involved in the criminal justice system have high rates of opioid use disorder (OUD), but frequently have limited options for treatment. The Affordable Care Act’s Medicaid expansion gave states the opportunity to increase coverage for individuals with criminal justice involvement, but whether that translated into increased access to OUD treatment in this population is an open question. In our latest study in Health Affairs, we found that the receipt of medications for OUD increased significantly more for individuals referred by criminal justice agencies in states that expanded Medicaid compared to those states that did not.

Utsha Khatri, MD | LDI
Utsha G. Khatri, MD is an LDI Associate Fellow, a fellow in the National Clinician Scholars Program at the Perelman School of Medicine, and an emergency medicine physician.

Using 2008-17 national data from the Substance Abuse and Mental Health Services Administration, we looked at a sample of over 3 million admissions for OUD. Over the entire study period, individuals referred for treatment by criminal justice agencies were 79% less likely to receive medications for OUD compared to those referred from other sources. This disparity predates the implementation of the Affordable Care Act (2008-2013) and continues beyond that (2015-17).

Despite overall low rates of medications for OUD among individuals with criminal justice involvement, we did find some positive signs. Specifically, for individuals referred by a criminal justice agency, the use of medications for OUD rose by 165% (from a baseline of 5.5%) in states that expanded Medicaid, after adjusting for trends in states that did not expand Medicaid.

Although COVID-19 pandemic has been at the forefront of the nation’s collective attention over the past year, the overdose crisis has not gone away. Deaths due to overdoses increased in 2019 and reached new highs during the pandemic. Many people with OUD are involved in the criminal justice system due to the criminalization of substance use, which has disproportionately impacted communities of color. This contact with the criminal justice system creates substantial barriers to needed treatment and is associated with very high risk of death after release from incarceration. Though our study confirms that barriers to evidence-based treatment exist for this population, we also show that Medicaid may be an effective means to expanding services.

In the remaining non-expansion states, our study suggests that expansion would increase evidence-based and life-saving treatment for individuals with criminal justice-involvement and OUD. However, Medicaid expansion alone will not address the treatment disparities between people with and without justice-involvement. Additional changes to policies, procedures, and culture within criminal justice agencies and treatment centers are needed to expand access to medications for OUD equitably. For example, many states continue to terminate Medicaid upon incarceration rather than suspend it, leaving the burden of reactivation on the individual during reentry, a period of many competing priorities. Additionally, access to Medicaid alone does not change preferences criminal justice agencies may have for treatment plans and facilities that do not include medications for OUD. But it’s a start.

The study, Medicaid Expansion Increased Medications For Opioid Use Disorder Among Adults Referred By Criminal Justice Agencies, was published in in the April 2020 issue of Health Affairs.  Authors include Utsha G. Khatri, Benjamin A. Howell, and Tyler N. A. Winkelman.