There are 22 Free Covered Health Treatments Under the ACA. Why Isn't Narcan One of Them?

When the Affordable Care Act passed in 2010, it expanded access to health insurance and preventative health care services for millions of Americans. Two of the most popular and most utilized aspects of the bill include extension of healthcare coverage to age 26 for dependents and complete coverage of 22 key preventative healthcare services without any copayment or deductible. Check out the complete list here.

The list of free preventative health treatments includes statin medications to prevent heart disease, aspirin to prevent stroke, and pre-exposure prophylaxis (PrEP) HIV medication to reduce the spread of HIV. There are a few clinical requirements and prescriptions must be dispensed by an in-network provider. Even so, these are major benefits that have the potential to substantially reduce morbidity and mortality and increase overall lifespan for millions of Americans.

That’s the good news. The bad news is that there are a few glaring omissions. Most notably, despite the fact that unintentional overdose is now the number one cause of death in 37 out of the 50 states for Americans under the age of 40, there are no free preventative services covered for addiction and substance use disorders. This, despite the fact that you are now more likely to die of an overdose than in a car crash. (The lifetime odds of an overdose are 1 in 96 compared with 1 in 103 for vehicular death.)

For the first time in many years, the CDC recently reported that life expectancy in the U.S. declined, due to an uptick in drug overdoses and suicides. Shouldn’t we cover some very basic preventative services for the number one cause of death in America? ?When car crashes were the number one cause of death in the 1960s, we mandated that the auto industry install seatbelts. Subsequent deaths from car crashes dropped dramatically.

Similarly, in an ideal world, free preventative addiction health services would include complete coverage of naloxone (Narcan), fentanyl and xylazine test strips, free safe use supplies, and medication assisted treatment (MAT). Having these services available without co-pays and deductibles would finally make addiction treatment truly accessible to those who need it most. It would also save countless numbers of lives each year.

But if bureaucracy, complexity, and lack of consensus building prevented the ideal-as it often does in Washington-and we can only pick the most meaningful of these services to add, my vote would go to free Narcan, fully covered by all payors, without any cost sharing to patients.

There is a very limited amount of free Narcan currently available at select state community health centers. However, this supply remains quite variable from state to state, and supply can vary day by day. After seeing patient after patient not fill their Narcan scripts due to cost, I visited three local community health centers in Virginia last year and requested free Narcan. At all three facilities, I was told they had run out and to come back “at some later date.” ?For the average person suffering from opioid use disorder, that “later date” might very well never come… due to lack of access to Narcan.

To truly reach the most people, we need readily available, no-strings-attached Narcan. This means Narcan being readily available for pick up without any co-pay or deductible for patients with both commercial and Medicare/Medicaid funding.

Disturbingly, the average co-pay for Narcan is going up, not down. According to a recent JAMA article published last week, in 2021 the mean “cost sharing” or out of pocket payment required per Narcan claim increased by $15.0 for commercially insured patients and increased by $12.3 for Medicare patients. When this happened, the probability of not picking up the prescription increased by 4.7 percentage points and 2.8 percentage points, respectively. With this data, the authors predicted that a decision by commercial and Medicare plans to increase naloxone cost sharing by $10 would result in a 2.3-3.1 percent increase of patients not picking up the critical medication due to cost. ?

With an estimated 1.2 million doses of Narcan dispensed by retail pharmacies in 2021, this means that a $10 cost increase would result in a whopping 37,200 Americans not picking up the life saving medication due to cost. There are two Narcan dispensers included with each prescription, so double that number to 74,400. That’s 74,400 preventable deaths that will occur each year with current annual Narcan price increase rates- or the equivalent of 186 jumbo jet plane crashes each year. That makes me nauseous just thinking about it.

Narcan is just one of several essential preventative medications for substance use disorders that remain out of financial reach for many Americans. The rising prices of medication assisted treatments like Suboxone contribute to reduced access to prescribed Suboxone while fueling an unregulated and often tainted black market supply.

We have made some small positive steps towards increasing Narcan access.? Many harm reduction focused, state level grass roots coalitions like the Kentucky Harm Reduction Coalition lead by Henry Lucas strive to increase education about and access to free Narcan.? Harm Reduction Therapeutics is a non-profit drug maker that recently released one of the least expensive over-the-counter generic naloxone products. The Alliance Health Pharmacy - Remedy'sRx is an innovative grassroots drugmaker specifically focused on supplying at-cost generic naloxone for community distribution efforts.?

While these are good strides, they do not begin to address the magnitude of the problem. Remember, the Federal Aviation Administration immediately grounded all 737 MAX jets after the 2018 and 2018 crashes that killed 346 people. They then launched an immediate, comprehensive, nationwide investigation into Boeing that is still ongoing. That was two crashes. We are talking about the equivalent of 186 preventable plane crashes, each year.

To be fair, the FDA did not approve the first over the counter naloxone spray product until March of 2023- a full 13 years after the passage of the Affordable Care Act. First responders did not begin to routinely carry Narcan until just a few years ago. But now, Narcan is the new seatbelt. It is the new airplane oxygen mask. Its large scale, lifesaving potential is irrefutable. ?As a society, we can and should do better.

Access to the seatbelts of addiction treatment should not be income dependent. Our tax dollars spent here are indisputably worth every penny of the investment. ?

-Dr. Grawert is the Chief Medical Officer at Aware Recovery Care