The Affordable Care Act of 2010 expanded access to health insurance and preventative healthcare services for millions of Americans. Two of the bill’s most popular and most utilized aspects include extending healthcare coverage to dependent children (through the age of 26) and complete coverage of 22 key preventative healthcare services without copayment or deductible.
Key Preventative Health Services Covered by the ACA
The list of free preventative health treatments includes statin medications to prevent heart disease, aspirin to prevent stroke, and pre-exposure prophylaxis (PrEP) HIV medication to reduce the spread of HIV. There are a few clinical requirements, and prescriptions must be dispensed by an in-network provider. Even so, these are significant benefits that have the potential to substantially reduce morbidity and mortality and increase the overall lifespan for millions of Americans.
The Overlooked Crisis: Addiction and Substance Use Disorders
That’s the good news. The bad news is that there are a few glaring omissions. Most notably, even though unintentional overdose is now the number one cause of death in 37 out of the 50 states for Americans under the age of 40, there are no free preventative services covered for addiction and substance use disorders. This, even though you are now more likely to die of an overdose than in a car crash. (The lifetime odds of an overdose are 1 in 96 compared with 1 in 103 for vehicular death.)
The Case for Including Addiction Treatment in Preventative Services
For the first time in many years, the CDC recently reported that life expectancy in the U.S. declined due to an uptick in drug overdoses and suicides. Shouldn’t we cover some very basic preventative services for the number one cause of death in America? When car crashes were the number one cause of death in the 1960s, we mandated that the auto industry install seatbelts. Subsequent deaths from car crashes dropped dramatically.
The Need for Free Narcan and Other Essential Treatments
Similarly, in an ideal world, free preventative addiction health services would include complete coverage of naloxone (Narcan), fentanyl, and xylazine test strips, free safe-use supplies, and medication-assisted treatment (MAT). Having these services available without co-pays and deductibles would finally make addiction treatment truly accessible to those who need it most. It would also save countless numbers of lives each year.
But if bureaucracy, complexity, and a lack of consensus building prevented the ideal—as it often does in Washington—and we could only pick the most meaningful of these services to add, my vote would go to free Narcan, fully covered by all payors, without any cost sharing to patients.
A limited amount of free Narcan is currently available at select state community health centers. However, this supply remains variable from state to state, and supply can vary daily. After seeing patients who did not fill their Narcan scripts due to cost, I visited three local community health centers in Virginia last year and requested free Narcan. At all three facilities, I was told they had run out and to come back “at some later date.” For the average person suffering from opioid use disorder, that “later date” might very well never come… due to lack of access to Narcan.
To reach the most people, we need readily available, no-strings-attached Narcan. This means Narcan being readily available for pickup without any co-pay or deductible for patients with both commercial and Medicare/Medicaid funding.
Disturbingly, the average co-pay for Narcan is going up, not down. According to a recent JAMA article published last week, in 2021, the mean “cost-sharing” or out-of-pocket payment required per Narcan claim increased by $15.0 for commercially insured patients. It increased by $12.3 for Medicare patients. When this happened, the probability of not picking up the prescription increased by 4.7 percentage points and 2.8 percentage points, respectively. With this data, the authors predicted that a decision by commercial and Medicare plans to increase naloxone cost sharing by $10 would result in a 2.3-3.1 percent increase in patients not picking up critical medication due to cost.
With an estimated 1.2 million doses of Narcan dispensed by retail pharmacies in 2021, a $10 cost increase would result in a whopping 37,200 Americans not picking up the life-saving medication due to cost. Two Narcan dispensers are included with each prescription, so double that number to 74,400. That’s 74,400 preventable deaths that will occur each year with current annual Narcan price increase rates- or the equivalent of 186 jumbo jet plane crashes each year. That makes me nauseous just thinking about it.
Narcan is just one of several essential preventative medications for substance use disorders that remain out of financial reach for many Americans. The rising prices of medication-assisted treatments like Suboxone contribute to reduced access to prescribed Suboxone while fueling an unregulated and often tainted black market supply.
Grassroots Efforts and Innovative Solutions
We have taken some small positive steps to increase Narcan access. Many harm reduction-focused, state-level grassroots coalitions like the Kentucky Harm Reduction Coalition led by Henry Lucas strive to improve education about and access to free Narcan. Harm Reduction Therapeutics is a non-profit drug maker that recently released one of the least expensive over-the-counter generic naloxone products. The Alliance Health Pharmacy – Remedy’sRx is an innovative grassroots drugmaker specifically focused on supplying at-cost generic naloxone for community distribution efforts.
While these are good strides, they do not address the problem’s magnitude. Remember, the Federal Aviation Administration immediately grounded all 737 MAX jets after the 2018 and 2018 crashes that killed 346 people. They then launched an immediate, comprehensive, nationwide investigation into Boeing that is still ongoing. That was two crashes. We are talking about the equivalent of 186 preventable plane crashes each year.
To be fair, the FDA did not approve the first over-the-counter naloxone spray product until March 2023- a full 13 years after the passage of the Affordable Care Act. First responders did not begin to routinely carry Narcan until just a few years ago. But now, Narcan is the new seatbelt. It is the new airplane oxygen mask. Its large-scale, lifesaving potential is irrefutable. As a society, we can and should do better.
The Urgent Need for Comprehensive Policy Change
Access to the seatbelts of addiction treatment should not be income-dependent. Our tax dollars spent here are indisputably worth every penny of the investment.
Aware Recovery Care Is Here to Help
If you or a loved one is struggling with an addiction to opioids, other drugs, and/or alcohol and need help in Maine, New Hampshire, Massachusetts, Connecticut, Rhode Island, Virginia, Georgia, Florida, Ohio, Kentucky, or Indiana, the recovery teams at Aware Recovery Care are here to help. And we come to you, regardless of where you live. Our unique in-home treatment model of care gives clients a significantly better chance of recovery than traditional inpatient rehab care. We are now offering Virtual Detox and Medication Assisted Treatment in New Hampshire, Connecticut, Virginia, Georgia, Indiana, Kentucky, and Ohio as well. Please get in touch with one of our Recovery Specialists to learn more.
About the author…Dr. Lauren Grawert MD.
Dr. Grawert is a double board-certified Addiction Psychiatrist. She completed her medical school training in 2009 and a General Psychiatry Residency in 2013 at the Medical University of South Carolina (MUSC). She then went on to complete an Addiction Psychiatry fellowship at MUSC, which she completed in 2014. After fellowship training, Dr. Grawert served as the Chief of Psychiatry and Addiction at Kaiser Permanente of the Mid-Atlantic. She has also worked in private practice specializing in general psychiatry, substance use disorders, and medically assisted treatment (MAT). Dr. Grawert has served as an expert for the San Diego Community Response to Drug Overdose Task Force, the Addiction Committee Leader for Kaiser Permanente National Mental Health & Addiction Leadership Organization, and a Professor of Psychiatry at Penn State College of Medicine. She likes to write, travel, and spend time with her two young children in her spare time.
