State Subsidies for Naloxone Purchase Through Insurance

Research SummaryPublished Dec 19, 2023

Involves states providing co-pay assistance to individuals purchasing naloxone through health insurance plans that include prescription coverage, including Medicaid, Medicare, and commercial insurance.

A panel of experts rated how they expect this type of policy to affect four outcomes: naloxone distribution through pharmacies, opioid use disorder (OUD) prevalence, rates of nonfatal opioid overdose, and opioid overdose mortality. Another panel of experts rated the policy on four implementation criteria: acceptability to the public, feasibility of implementation, affordability from a societal perspective, and equitability in health effects.

Policy Recommendations According to Expert Ratings

Oppose Uncertain Support
No
Yes
No

Summary of Expert Ratings

Outcomes Effect Rating
Harmful Little-to-no Beneficial
Naloxone Pharmacy Distribution
No
No
Yes
OUD Prevalence
No
Yes
No
Nonfatal Opioid Overdose
No
Yes
No
Opioid Overdose Mortality
No
Yes
No
Criteria Implementation Rating
Low Moderate High
Acceptability
No
No
Yes
Feasibility
No
Yes
No
Affordability
No
Yes
No
Equitability
No
Yes
No

Summary of Expert Comments

  • Experts expect this policy to increase pharmacy distribution because it addresses the barrier of out-of-pocket costs to individuals, but it would not impact naloxone distribution sufficiently to impact fatal overdoses.
  • Experts believe the public supports decreasing out-of-pocket costs for obtaining medications.
  • Experts believe the policy is only moderately feasible due to concerns about the logistics of applying for subsidies, obtaining subsidies, and monitoring appropriate subsidization.
  • Experts rated the policy as only moderately affordable because it would provide assistance only with co-pays (rather than full coverage) and costs would fall on the state (rather than on insurance companies).
  • Experts believe the policy to be equitable because it would improve equity among those with insurance, but it would not help those without insurance.

Outcome Summaries

Naloxone Pharmacy Distribution

Amount of naloxone dispensed through retail pharmacies (e.g., chain pharmacy stores, independent community pharmacies).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial
(selected)
 Could lower the financial threshold to obtain naloxone, thereby increasing distribution. "Public health interventions that reduce costs to zero or near zero will increase naloxone distribution"
Little-to-no Indirect mechanism would be less effective than directly providing insurance coverage. Also depends on the extent of subsidy utilization. "Anything to lower cost of accessing naloxone should help — though this less direct way is expected to have smaller effect than straight up insurance coverage for naloxone"
Harmful N/A N/A

Opioid Use Disorder Prevalence

Percentage of the general population with a pattern of opioid use leading to clinically and functionally significant impairment, health problems, or failure to meet major responsibilities.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial N/A N/A
Little-to-no
(selected)
 No credible mechanism linking state subsidies for naloxone purchase through insurance and OUD prevalence. "Naloxone access is not about OUD prevalence"
Harmful N/A N/A

Nonfatal Opioid Overdose

Per capita rates of nonfatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial N/A N/A
Little-to-no
(selected)
 No credible mechanism linking state subsidies for naloxone purchase through insurance and nonfatal overdoses. "I don't think naloxone access has much if any impact on the prevalence of nonfatal opioid overdose"
Harmful Potential for revival from overdose could (1) have a small, indirect, and mechanistic impact on nonfatal overdoses due to increased survivorship and (2) lead to continued opioid misuse. "Slight shift from fatal overdoses to nonfatal, as this financial barrier affects those who cannot afford co-pays the most"

Opioid Overdose Mortality

Per capita rates of fatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Increase in naloxone pharmacy distribution will yield meaningful decreases in fatal overdoses. "More distribution to the right people (e.g., individuals with least amount of money) may make the distribution more effective and lower fatal [overdose]"
Little-to-no
(selected)
 Does not impact naloxone distribution sufficiently to impact fatal overdoses. "Shifts (slight) from fatal to nonfatal, since the denominator of those at risk only changes due to treatment access/availability"
Harmful N/A N/A

Implementation Criteria Summaries

Acceptability

The extent to which the policy is acceptable to the general public in the state or community where the policy has been enacted.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
 Public supports decreasing out-of-pocket costs for obtaining medications. "Decreasing out-of-pocket health care costs is generally viewed positively by the public"
Moderate Concerns about public pushback on using public funds to directly subsidize naloxone due to stigma and moral hazard concerns. "Some people might not be supportive of public funds being used to support people who use drugs"
Low N/A N/A

Feasibility

The extent to which it is feasible for a state or community to implement the policy as intended.

Implementation Rating Summary of Expert Opinion Representative Quotations
High N/A N/A
Moderate
(selected)
Concerns about the logistics of applying for subsidies, obtaining subsidies, and monitoring appropriate subsidization. "Implementation of this program may be messy and, even if efficient, may result in lags between someone needing naloxone and getting government help to pay for it, depending on how the program is run . . . asking patients to seek funds when they cannot afford the naloxone prescription co-pay seems challenging for many average patients, and especially for people who use drugs"
Low Concerns about pushback from the state and insurance companies. "You'd probably be fighting both the insurers and the legislators in charge of spending on this one"

Affordability

The extent to which the resources (costs) required to implement the policy are affordable from a societal perspective.

Implementation Rating Summary of Expert Opinion Representative Quotations
High Cost-effective because the state would not cover the entire cost of purchasing naloxone. "This should be affordable and cost-effective especially since the state is not taking the entire cost"
Moderate
(selected)
Only provides assistance with co-pays (rather than full coverage) and costs fall on the state (rather than on insurance companies). "The benefits of expanding access to naloxone will likely outweigh the costs of the program, but depending on how the program is run, it may be very costly just in terms of administrative effort to implement it. Requiring insurers to cover the full cost seems less costly on a societal level than government trying to cover co-pays among a diverse set of patients (insured by public and private insurers)"
Low N/A N/A

Equitability

The extent to which the policy is equitable in its impact on health outcomes across populations of people who use opioids.

Implementation Rating Summary of Expert Opinion Representative Quotations
High Reduces inequities among those who are insured and prescribed naloxone by reducing bureaucratic red tape with insurers. "If this could be implemented, I think this would be a very equitable policy as it would allow basically anyone the ability to access naloxone despite any financial hardships or barriers with having money for co-pays, etc."
Moderate
(selected)
Improves equity among those with insurance, although it would not help those without insurance. "Only helps those who have insurance that already covers the type of naloxone they need"
Low Does not assist vulnerable populations without insurance. "While it includes Medicaid patients it excludes all of those who are uninsured. This is still worthwhile, but it will exacerbate inequities, especially in states that have not expanded Medicaid"
Cover: State Subsidies for Naloxone Purchase Through Insurance

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State Subsidies for Naloxone Purchase Through Insurance. Santa Monica, CA: RAND Corporation, 2023. https://www.rand.org/pubs/research_briefs/RBA3054-13.html.
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