Overcoming Opioids Cures Act

This Tuesday, Aug. 15, 2017 photo shows an arrangement of pills of the opioid oxycodone-acetaminophen in New York. (AP Photo/Patrick Sison)

Attorney General Jeff Landry believes Louisiana's expansion of Medicaid has fueled an opioid black market in this state – pushing pills onto the streets and into the hands of vulnerable addicts through schemes that begin with coached patients and faux illnesses.

"A Medicaid card to a drug pusher is like a credit card," Landry, a Republican who took office in January 2016, said in a recent interview. "It costs them nothing, then on the street it's 100 percent profit."

The idea may seem overly conspiratorial, and the Louisiana Department of Health categorically denies that there is any proof of the widespread scheming that Landry describes and cites a decrease in prescriptions as proof. The agency also argues access to drug treatment through Medicaid as one of the ways that expansion is helping address the problem.

But Landry isn't alone in believing – insisting – that there is some link. It's a common argument made by prominent Republicans nationally.

"It's common sense," Landry said, arguing that more access to free health care equals more access to prescription drugs and more opportunity for unscrupulous endeavors to thrive.

"It's impacting the epidemic in a negative way," Landry said. "To fix a problem, you have to admit you have a problem."

Louisiana Department of Health deputy secretary Michelle Alletto said the agency has already taken steps to discourage opioid use and abuse that Landry isn't accounting for.

"We know for a fact that the number of pills and prescriptions has gone down," she said.

Prescription monitoring efforts show the number of opioid prescriptions and the number of opioid pills prescribed in the state have dropped below pre-expansion levels, both in the Medicaid population and non-Medicaid patients, after new opioid discouraging laws were implemented and the state adopted new Medicaid prescription policies.

The amount of opioids dispensed for average Medicaid claims fell 40 percent from the first month of expansion to August 2017, according to LDH.

"We've been working very hard to address the opioid epidemic," Alletto said.

Opioids are a commonly-prescribed category of narcotic pain medication.

They include OxyContin, Percocet, Vicodin and codine. In a 2016 report, the Centers for Disease Control and Prevention found that about 20 percent of patients who saw doctors for non-cancer pain symptoms or pain-related diagnoses received an opioid prescription.

And Louisiana has traditionally been a high risk state for opioids, with the sixth-highest opioid pain reliever-prescribing rate in the country, according to IMS Institute for Healthcare Informatics' analysis of a year-long period through June 30, 2016, which preceded Medicaid expansion. That pre-expansion report found that there were 102.3 opioid prescriptions for every 100 people, when counting new prescriptions and prescribed refills. The national average was 69.5 prescriptions for every 100 people during that period.

The state's drug overdose rate also outpaces the national average, fueled by the rise in prescription opioid abuse and the use of illicit opioids, like heroin, and synthetic black-market opioids, like fentanyl. The Centers for Disease Control and Prevention have not yet released opioid overdose death statistics for the period since Medicaid expansion took effect in Louisiana.

Landry's issues with the Department of Health and Edwards' administration, in general, run much deeper.

"I believe they have no credibility," said Landry, who has frequently sparred with the governor over lawsuits on issues ranging from executive authority to coastal protection.

But Landry said it isn't personal.

"This is not something that I'm attacking the governor individually on," he said. "It's a problem with Medicaid expansion."

Medicaid expansion, which Democratic Gov. John Bel Edwards achieved through an executive order, is the most substantive policy change of the governor's administration to date, and Edwards frequently cites it as his proudest achievement in office.

Under the expansion, Medicaid is now available to households that have incomes below 138 percent of the federal poverty level. That's about $33,950 for a family of four or $16,640 for a single adult.

Nearly 465,000 people, mostly the working poor, have received health care coverage under the expanded program in Louisiana.

Because Louisiana was late to expansion, waiting years as Edwards' predecessor refused to embrace the growth of the health care program under the federal Affordable Care Act, many of the statistics used to argue against expansion pre-date Louisiana's statistics. 

Landry said he has relied on statistics that he says are evidence of issues that emerged in other expansion states, including CDC figures that show the five states with the highest overdose death rates in 2015 were all expansion states: West Virginia, New Hampshire, Kentucky, Ohio and Rhode Island.

To Landry's theory on the black market pill proliferation, Republicans who agree with Landry frequently cite an anecdote from Portsmouth, Ohio that appears in the 2017 book Dreamland by former L.A. Times reporter Sam Quinones.

“If you could get a prescription from a willing doctor – and Portsmouth had plenty of them – Medicaid health-insurance cards paid for that prescription every month,” Quinones writes in a paragraph that has been repeated in conservative media outlets and cited in a recent congressional report. “For a three-dollar Medicaid co-pay, therefore, addicts got pills priced at thousands of dollars, with the difference paid for by U.S. and state taxpayers. A user could turn around and sell those pills, obtained for that three-dollar co-pay, for as much as ten thousand dollars on the street.”

"More access to medical care means more access to pills," Quinones testified during a January congressional hearing on the opioid crisis.

The 164-page “Drugs for Dollars: How Medicaid Helps Fuel the Opioid Epidemic” congressional report details 10 cases in which the authors conclude Medicaid access helped get opioids into the wrong hands, though at least one of those cases was entirely unrelated to Medicaid expansion – a case out of Louisiana.

A Metairie doctor who pleaded guilty to unlawfully prescribed pain killers and threatening to murder federal agents had been under investigation for months before Louisiana's Medicaid expansion took effect in July 2016. His arrest came about three weeks into the expansion.

Asked about the fear that opioids make it onto a black market, Alletto said she would need more than anecdotal evidence.

"I've never seen any evidence to that," she said. "I think I have a lot more trust in our Medicaid patients and our providers."

Landry has been an advocate of more aggressively pursuing Medicaid recipient fraud. His office investigates provider fraud, while it's left to LDH to focus on rooting out dishonest recipients.

"You could actually do something impactful with regard to stemming the opioid epidemic," Landry said, arguing it would also save taxpayer dollars.

LDH has highlighted that Medicaid recipients can receive drug addiction treatment. Nearly 17,000 new Medicaid expansion enrollees have sought in patient or out patient treatment for substance abuse.

LDH has been assessing access to addiction treatment in particularly vulnerable parts of the state, such as New Orleans, she said, and efforts have been boosted by more than $23 million in federal grants to put toward fighting the opioid epidemic.

And more efforts are underway, Alleto said. The state will soon launch a website to track real-time opioid statistics in the state.

"Aside from the politics, we have an epidemic and we care about saving lives," she said.

Follow Elizabeth Crisp on Twitter, @elizabethcrisp.