CE25-149 - The effect of Medicaid expansion on medications for opioid use disorder, mental health care, and overdose mortality among formerly incarcerated people

PROJECT SUMMARY/ABSTRACT People involved in the criminal legal system (CLS) face a disproportionately high burden of substance and opioid use disorders (SUD/OUD), which upon release from jail or prison is compounded by lack of access to care and results in extremely elevated post-release drug overdose mortality. Few interventions have been able to reduce overdose risk among CLS-involved people. A number of ongoing studies are testing strategies for linking CLS-involved people to medications for OUD (MOUD) in the community. However, lack of insurance for many CLS-involved people makes these care linkages unsustainable after study completion. Medicaid expansion provides an avenue to address healthcare needs for many CLS-involved people. Recent studies show that pre-release Medicaid enrollment increases post-release MOUD and reduces overdoses for CLS-involved people. However, benefits appear to accrue to white individuals and not to black individuals – a concerning inequity because overdose deaths are rapidly increasing among racially minoritized people in the US. Research to date, which has been ecological, has not been able to identify the mechanisms by which Medicaid enrollment may improve MOUD and overdose outcomes and why these benefits may differ across racialized groups. Large, longitudinal, individual level data can map the pathways through which Medicaid expansion benefits some groups but not others. While overdose prevention work among CLS-involved people deservedly focuses on MOUD access, the role of mental health treatment is also critical. Two-thirds of people with OUD have co-occurring mental health needs, a burden that is likely even higher among CLS-involved individuals. Hence, MOUD without mental health care may fall short in MOUD engagement and overdose prevention for CLS-involved individuals. In this application, we propose to conduct a quasi-experimental study, by leveraging the 2023 Medicaid expansion in North Carolina (NC), to examine racialized inequities in enrollment in Medicaid among CLS- involved individuals, as well as post-release MOUD and mental health care access. We will further examine the impact of enrollment in Medicaid and MOUD and mental health care access on fatal and non-fatal drug and opioid overdoses. We will use 13 years of Big Data (2013-2025) on all formerly incarcerated people in NC linked with Medicaid and death records, which our team already has access to through two ongoing studies focused on suicide and polydrug overdose prevention. Our study is aligned with RFA-CE-25-149’s Funding Option A. This study will be the first to examine the individual-level impact of Medicaid enrollment, MOUD access, and mental health services on drug and opioid overdoses among CLS-involved people. This study will further identify mechanistic factors that contribute to racialized inequities among CLS-involved people to help enhance and sustain linkage to care for all CLS-involved people, but especially racially minoritized individuals, thereby enhancing the impact of Medicaid expansion for all people.