Trends in Access to Medications for Opioid Use Disorder

Importance Medicaid, the largest payer for medications for opioid use disorder (MOUD), disenrolled more than 19.1 million individuals by March 2024 after the continuous coverage requirement ended in April 2023—a process termed Medicaid unwinding —but the impact on buprenorphine receipt remains unknown. Objective To assess the association between Medicaid unwinding and dispensing of prescription buprenorphine, overall and by payment sources nationally and by state. Design, Setting, and Participants Cross-sectional study of buprenorphine dispensing (age ≥18 years) from April 2020 to March 2024 using the IQVIA Longitudinal Prescription (LRx) database containing more than 90% of US retail pharmacy claims. Interrupted time-series estimated levels and trends of buprenorphine prescription dispensation before and after Medicaid unwinding. Main Outcomes and Measures The number of patients with filled buprenorphine prescriptions each month was analyzed by payer type (Medicaid, Medicare, commercial, or self-pay) and by state. Stratified analyses assessed state factors, including automated (ex parte) Medicaid renewal rates (higher or lower than the median), income verification sources used for automated renewals (≤3, 4-5, or 6-7), and Affordable Care Act Medicaid expansion status. Results Of the 2 405 970 adults who filled buprenorphine prescriptions between April 2020 and March 2024, 1 154 866 (48%) had at least 1 fill covered by Medicaid, 288 716 (12%) by Medicare, 1 106 746 (46%) by commercial insurance, and 264 657 (11%) by self-pay. Medicaid unwinding was associated with reversal of previously increasing trends in buprenorphine prescriptions, with 2.9% fewer patients (−23 855 [95% CI, −32 661 to −15 054]) receiving buprenorphine each month by 8 months after unwinding vs the month before unwinding began. This decline was driven by a 12.7% drop in patients with Medicaid-paid fills (−46 545 [95% CI, −51 362 to −41 730]), partially offset by increases in patients with commercial (6.12%, 19 809 [95% CI, 12 109 to 27 509]) and self-paid (7.24%, 2525 [95% CI, 1246 to 3805]) fills. Sixteen states saw overall declines in buprenorphine use after unwinding, with reductions among patients with Medicaid-covered prescriptions in 36 states, partially offset by increases in patients with commercial insurance covered fills (32 states) and self-paid fills (23 states). Buprenorphine prescriptions remained stable in states with above-median automated Medicaid renewal rates and more income verification sources, whereas states with below-median automated renewal rates, fewer verification sources, and nonexpansion state status experienced smaller offsets for Medicaid-related losses, highlighting importance of state-specific policies. Conclusions and Relevance This cross-sectional study of Medicaid unwinding and filled buprenorphine prescriptions found that although shifts to commercial and self-pay sources mitigated some losses, rising self-pay reliance poses affordability barriers that threaten treatment continuity. Addressing access disparities is critical amid persistently high US overdose rates.