“Studies Show”: Marijuana Legalization and Opioid Deaths

In his NY Times column today, Ross Douthat argues that legalizing marijuana is a big mistake. Douthat makes a number of arguments, but let me focus on one point he makes in the column: that recent research suggests legalizing marijuana increases opioid deaths. This point is made in just one sentence of the essay, so let me quote it in full:

There was hope, and some early evidence, that legal pot might substitute for opioid use, but some of the more recent data cuts the other way: A new paper published in the Journal of Health Economics finds that “legal medical marijuana, particularly when available through retail dispensaries, is associated with higher opioid mortality.”

Kudos to Mr. Douthat for actually linking to the paper. That’s what the internet is for! Yet so many writers in traditional news sources fail to do this.

Now, on to the paper itself. There is nothing untrue in what Douthat writes. First, there was plenty of “early evidence” that legalizing marijuana reduced opioid deaths. More on this in a moment. And the study he cites by Mathur and Ruhm is particularly well done. It is published in the top health economics journal. But the main point of the paper is to say “we think the rest of the literature is wrong, and we’re going to try really hard to convince you that we are right.”

What does the rest of this literature say? Here’s a brief tour (all of these are cited in Mathur and Ruhm). The variable in question is opioid deaths.

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Why Many Substance Use Treatment Facilities Don’t Take Insurance

According to the latest data, about one in four facilities doesn’t accept private insurance or Medicaid, and more than half don’t accept Medicare. This makes substance use treatment something of an outlier, since 91% of all US health spending is paid for through insurance. Still, there are many reasons to prefer being paid in cash: insurance might reimburse at low rates, impose administrative hassles, and generally try to tell you how to run things.

Providers generally put up with the hassles of insurance because they see the alternative as not getting paid. But if demand for their services gets high enough that they can stay busy with patients paying cash, they will often try going cash-only. Some try to generate high demand by providing excellent service. Sometimes high demand comes from a growing health crisis, as with opioids.

Demand can also be high relative to supply because supply is restricted. US health care is full of supply restrictions, but in this case I wondered if Certificate of Need laws were playing a role. As we’ve written about previously, CON laws require health care providers in 34 states to get the permission of a government board to certify their “economic necessity” before they can open or expand. But there’s a lot of variation from state to state in what types of services are covered by this requirement; acute hospital beds and long-term care beds are most common. 23 states require substance use treatment facilities to obtain a CON before opening or expanding.

States with Substance Use–Treatment CON Laws in 2020. Created using data from Mitchell, Philpot, and McBirney

How do these laws affect substance use treatment? We didn’t really know- only one academic article had studied substance use CON, finding it led to fewer facilities in CON states. But I’ve studied other types of CON, so I joined forces with Cornell substance use researcher Thanh Lu and my student Patrick Vogt to investigate. The resulting article, “Certificate-of-need laws and substance use treatment“, was just published at Substance Abuse Treatment, Prevention, and Policy. Here’s the quick summary:

We find that CON laws have no statistically significant effect on the number of facilities, beds, or clients and no significant effect on the acceptance of Medicare. However, they reduce the acceptance of private insurance by a statistically significant 6.0%.

Overall I was surprised that CON didn’t significantly affect most of the outcomes we looked at, and appears to be far from the main reason that treatment facilities don’t take insurance. Still, repealing substance use CON would be a simple way to improve access to substance use treatment, particularly since CON doesn’t appear to bring much in the way of offsetting benefits.

Going forward I aim to investigate how these laws affect health outcomes like overdose rates, and to dig more into the text of state laws and regulations to determine exactly what is covered by substance use CON in different states. As the article explains, we identified several errors in the official data sources we were using. This makes me worry there are more errors we didn’t catch, and there are certainly things the sources just don’t specify, like in which states the laws apply to outpatient facilities. So I hope we (or someone else) will have even better work to share in the future, but for now this article is as good as it gets, and we share our data here.