Learned it from watching you

In an excellent article last month in the Wall Street Journal about the Obamacare-opioid connection, Allyssia Finley links to data on opioid related hospital stays (rather than overdoses) by insurer/payer. In 2014 there was a large, roughly 40% increase in the number of stays for Medicaid patients, which more than made up for the decrease among uninsured patients. Moreover, there was essentially no large increase in opioid-related hospital use for privately insured (or Medicare) patients from 2013 to 2015.


This is certainly in line with the argument this blog has made, that the 2014 Medicaid expansion facilitated access to drugs for a population that was particularly at risk for abuse.

A more subtle issue exposed by this graph is a divergence that started in late 2008 between Medicaid and privately insured patients, who previously (or at least earlier in 2008) had identical rates of hospital stays, but who were, by 2013 very far away from each other:


Well, what started in late 2008? A large recession and increase in unemployment that put a lot of people onto Medicaid, pretty obviously, and who evidently were more susceptible to opioid abuse than the people who were on Medicaid before. This seems to tell a pretty coherent story: as more people are newly put on Medicaid and discover that they can use the cards to get drugs, the next group of people to get insurance are, through faster information transmission and expanded social networks of users, even more susceptible to abuse. This is what makes opioids an epidemic in a literal sense: not merely that abuse has grown rapidly, but that each user is a potential vector of transmission, both by exposing social contacts to the drug and by passing on knowledge about how to score. In this way, concentrations of people with access to funding for drugs and a propensity to abuse- as happens when almost all young people are insured and an increasing number of young adults have nothing to do- accelerates transmission much more than steady diffusion would predict, allowing for the truly frightening numbers of overdoses and hospitalizations that are occurring in 2017 in the counties where the problem is worst:


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