Medicaid Expansion Reduces Disparities in Treatment Access and Retention in Addiction Health Services

Background and Purpose: The extant literature has established that Latinx and African Americans are most likely to experience barriers to access and engagement in addiction health services (AHS). Drawing from a treatment capacity framewok to reduce disparities, the main objective of this study was to examine to what the extent the expansion of Medicaid reduced disparities in treatment access and retention in one of the largest treatment systems in the United States. We also sought to identify the mechanisms that contribute to reduced disparities.

Methods: We analyzed unique multi-year data from clients and programs at four points. We analyzed two waves during pre-expansion in 2011 (N=115 programs, n= 11,526 clients) and 2013 (N=111 programs, n= 18,789 clients), and two waves during post-expansion in 2015 (N=106 programs, n= 17,339 clients) and 2017 (N=94 programs, n= 16,191 clients). We relied on path analyses to test difference between pre and post expansion on days to enter treatment (wait time) and days in treatment (retention), as well as mechanisms of change. We used multiple group multilevel negative binomial regression models to test race/ethnicity as moderators and coordinated care (mental health and HIV testing) as mediating mechanisms.

Results: Compared to pre-Medicaid expansion and white clients, Latinx and African Americans reported shorter wait times to enter care in high-capacity programs post-expansion. African Americans’ retention was longer than whites in high-capacity programs. Additionally, receipt of HIV testing and coordination of mental health services played an indirect role in the relationship between high program capacity and shorter wait time.

Conclusions and Implications: Medicaid expansion played a significant role in eliminating disparities in access and retention in AHS. Wait time decreased for all, while retention improved for African Americans. Coordinated care may contribute to improve access to care. Findings have implications for system redesign to improve treatment engagement among Latinx and African Americans. Our unique large data from underserved Latinx, rigorous statistical modeling and positive findings have significant implications for advancing disparities research and for improving healthcare policy implementation.