Health Plan Disenrollment and Mortality After Initiation of Medications for Opioid Use Disorder
*Retrospective cohort study; Level 2b (OCEBM).
Citation
Nguyen AP, Binswanger IA, Narwaney KJ, et al. Health Plan Disenrollment and Mortality After Initiation of Medications for Opioid Use Disorder. JAMA Psychiatry. 2026;83(5):491–498. doi:10.1001/jamapsychiatry.2026.0021
Background
Medications for opioid use disorder lower overdose risk, but treatment and follow-up care can be interrupted when insurance coverage ends. This study examined whether ending health plan enrollment after starting these medications is linked to death.
Patients
20,011 privately or publicly insured patients aged 16 years or older who started buprenorphine or naltrexone (2012–2021) in three integrated health systems in two U.S. states. Excluded: missing/invalid pharmacy or death data and missing address; required continuous enrollment for 90 days before starting medication.
Intervention
Health plan disenrollment (32 days or more without coverage) after starting medication.
Control
Remaining enrolled in the health plan.
Outcome
All-cause death and drug- or alcohol-overdose death (from national death records).
Follow-up Period
Up to 2 years (mean 1.9 years).
Results
| Comparison | All-cause death (hazard ratio, 95% confidence interval) | Overdose death (hazard ratio, 95% confidence interval) |
|---|---|---|
| Ever disenrolled vs remained enrolled | 1.51 (1.23–1.84) | 1.56 (1.17–2.09) |
| Disenrolled vs enrolled and on medication | 4.34 (3.19–5.89) | 4.22 (2.61–6.85) |
| Enrolled but off medication vs enrolled and on medication | 4.19 (3.24–5.43) | 3.88 (2.52–5.98) |
Limitations
Observational design cannot prove cause and effect. The study could not confirm what insurance or medication access patients had after disenrollment, or why disenrollment occurred. Results come from integrated health systems and may differ in other settings.
Funding
National Institutes of Health, National Institute on Drug Abuse (Clinical Trials Network grants).
Clinical Application
When starting opioid-use-disorder medication, proactively plan for insurance gaps (navigation help, bridge prescriptions, overdose-reversal supply) because coverage loss is linked to higher mortality.
Discussion
Sign in to join the discussion.
In this retrospective cohort of patients initiating buprenorphine or naltrexone, health plan disenrollment was associated with higher all-cause mortality (adjusted HR 1.51, 95% CI 1.23–1.84). Given the nonrandomized exposure, how convincing is this association (eg, confounding/reverse causation), and is it strong enough to change how you plan MOUD follow-up around insurance transitions? The study reports an adjusted hazard ratio (HR) of 1.51 (95% CI 1.23–1.84) for all-cause mortality comparing patients who ever disenrolled vs remained enrolled. What is the best interpretation of this HR?