Medication and Acute Care Use in Young Adults With Opioid Use Subject to Medicaid Prescription Caps

Christopher M Santostefano; Jaclyn M W Hughto; Landon D Hughes; Theresa I Shireman; Christina Andrews; Rachel Rosales; Julie M Donohue; Lisa Peterson; Patience M Dow

doi:10.1001/jamahealthforum.2026.1187

. 2026 May 22;7(5):e261187. doi: 10.1001/jamahealthforum.2026.1187

Medication and Acute Care Use in Young Adults With Opioid Use Subject to Medicaid Prescription Caps

Christopher M Santostefano ^1,^✉, Jaclyn M W Hughto ^2,³, Landon D Hughes ^4,⁵, Theresa I Shireman ^1,², Christina Andrews ⁶, Rachel Rosales ¹, Julie M Donohue ^7,⁸, Lisa Peterson ⁹, Patience M Dow ¹

¹Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island

²Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island

³Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island

⁴Department of Population Medicine, Harvard Medical School, Boston, Massachusetts

⁵Harvard Pilgrim Health Care Institute, Boston, Massachusetts

⁶Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia

⁷Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pennsylvania

⁸Deputy Editor, JAMA Health Forum

⁹VICTA, Providence, Rhode Island

Accepted for Publication: March 22, 2026.

Published: May 22, 2026. doi:10.1001/jamahealthforum.2026.1187

Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License, which does not permit alteration or commercial use, including those for text and data mining, AI training, and similar technologies. © 2026 Santostefano CM et al. JAMA Health Forum.

^✉

Corresponding Author: Christopher M. Santostefano, MPH, RN, Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 S Main St, Box G-S121-6, Providence, RI 02912 (christopher_santostefano@brown.edu).

Author Contributions: Mr Santostefano had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Hughto, Hughes, Shireman, Rosales, Dow.

Acquisition, analysis, or interpretation of data: Santostefano, Hughto, Hughes, Shireman, Andrews, Donohue, Peterson, Dow.

Drafting of the manuscript: Santostefano, Hughto, Hughes, Shireman, Dow.

Critical review of the manuscript for important intellectual content: Santostefano, Hughto, Hughes, Andrews, Rosales, Donohue, Peterson, Dow.

Statistical analysis: Santostefano, Hughes.

Obtained funding: Hughto, Shireman, Dow.

Administrative, technical, or material support: Santostefano, Hughto, Hughes, Shireman, Rosales, Peterson.

Supervision: Hughto, Hughes, Dow.

Conflict of Interest Disclosures: Mr Santostefano reported grants from the National Institutes of Health (NIH) during the conduct of the study. Dr Hughto reported grants from NIH during the conduct of the study. Dr Shireman reported grants from the National Institute on Drug Abuse (NIDA) during the conduct of the study and grants from the National Institute on Aging, Fox Chase Cancer Center/National Cancer Institute, Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Foundation Physical Therapy, National Institute of Mental Health, National Institute of Child Health and Human Development, and from the Department of Veterans Affairs Health Services Research and Development outside the submitted work. Dr Andrews reported grants from NIDA during the conduct of the study and grants from the National Institute on Alcohol Abuse and Alcoholism outside the submitted work. Dr Donohue reported grants from NIDA during the conduct of the study. Dr Dow reported grants from NIH awarded to Brown University during the conduct of the study. No other disclosures were reported.

Funding/Support: National Institute on Drug Abuse (R01DA057979).

Role of the Funder/Sponsor: The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.

Disclaimer: Dr Donohue is Deputy Editor of JAMA Health Forum but was not involved in any of the decisions regarding review of the manuscript or its acceptance.

^✉

Corresponding author.

PMCID: PMC13197877 PMID: 42172006

This cohort study reports on the association of Medicaid prescription cap policies with medication and acute care use in young adults with opioid use disorder.

Key Points

Question

Is becoming newly exposed to Medicaid prescription cap policies associated with medication and acute care use among young adults with opioid use disorder (OUD)?

Findings

This cohort study in 15 526 individuals from 26 non–prescription cap states and 1769 from 8 states with prescription cap policies found reductions in the prevalence of any prescription receipt and the monthly total number of prescriptions filled after turning age 21 years in states with prescription caps; buprenorphine use for OUD did not change. Increases in the monthly number of emergency department visits and hospitalizations were observed, although only after adjustment for baseline trends.

Meaning

Results of this study suggest that state Medicaid prescription caps were associated with lower overall use of prescription medications and more frequent acute care use.

Abstract

Importance

State Medicaid prescription cap policies (ie, limiting the monthly number of covered prescriptions) may impede access to medications for opioid use disorder (OUD) and other chronic conditions. Yet, these policies remain understudied among those who become subject to caps at age 21 years.

Objective

To evaluate the association of prescription cap policies with medication and acute care use among young adults with OUD.

Design, Setting, and Participants

This study identified a cohort of young adults diagnosed with OUD using T-MSIS Analytic Files from January 1, 2016, to December 31, 2021. Data analysis was conducted from July 2025 to December 2025. The study compared outcomes between prescription cap and noncap states using a difference-in-differences analysis where a 2-month policy phase-in window was applied before and after age 21 years and effects estimated across the full follow-up period and the early (months 3-6), mid (months 7-9), and late (months 10-12) periods since the 21st birthday.

Exposures

Becoming exposed to prescription caps at age 21 years.

Main Outcomes and Measures

Monthly use (any and count) of buprenorphine, overall prescriptions, inpatient hospitalizations, and emergency department (ED) visits 12 months before vs after participant reached the age of 21.

Results

This study analyzed 15 526 individuals from 26 non–prescription cap states and 1769 from 8 states with prescription cap policies. Most individuals were female (noncap states, 8156 [52.5%]; cap states, 1033 [58.4%]) and White (noncap states, 9512 [61.3%]; cap states, 705 [39.9%]). The baseline monthly prevalence for noncap and cap states was 39.3% vs 40.2% for any prescription receipt, 7.5% vs 3.1% for buprenorphine receipt, 3.2% vs 4.8% for hospitalizations, and 14.1% vs 18.7% for ED visits. After adjustment, cap policies were associated with a 4.7% (95% confidence limit [CL], −9.9% to −0.2%) lower prevalence of any prescription receipt and 12.7% (95% CL, −18.7%, −6.7%) fewer total monthly prescriptions 10 to 12 months after participants reached the age of 21. Cap states had more hospitalizations during postperiod months 10 to 12 (6.0%; 95% CL, 0.3%-10.0%) and more ED visits in postperiod months 3 to 6 (4.7%; 95% CL, 1.0%-10.0%) and months 7 to 9 (8.3%; 95% CL, 3.3%-13.3%). Buprenorphine use did not significantly change after cap implementation.

Conclusions and Relevance

In this cohort study, Medicaid prescription caps were associated with lower overall use of prescription medications and greater frequency of acute care use among young adults with OUD.

Introduction

The increase in synthetic opioids has been a major factor in fatal drug overdoses among young adults in the US and was exacerbated by the COVID-19 pandemic.^1,2,3,4 Increases in opioid-involved deaths among young adults highlight opioid use disorder (OUD) morbidity⁵ and the importance of access to OUD treatment, particularly because young adults⁶ who die of an overdose are rarely engaged in treatment.² Although the American Academy of Pediatrics recommends that pediatricians offer medications for OUD (MOUD) to adolescents and young adults,⁷ 1 study found that only 1 in 4 young adults aged 18 to 22 years received any of the 3 US Food and Drug Administration–approved MOUD within 3 months of OUD diagnosis.⁸ MOUD are considered the standard of care for young adults,⁹ and buprenorphine and methadone have been shown to reduce return to substance use, overdose, and mortality.^10,11 Buprenorphine is often well suited for young adults because it is approved for use as early as age 16 and can be prescribed in primary care settings.¹² While various individual, clinician, and structural factors likely contribute to low MOUD uptake among young adults,¹³ financial barriers such as restrictions on health insurance coverage can further restrict access to care.

Individuals with low incomes are at higher risk of opioid use, resulting in a disproportionate prevalence of OUD among Medicaid enrollees.^14,15 Medicaid insures more than 40% of all people in the US with OUD and plays a central role in financing addiction treatment as the single largest payer for MOUD.^11,16,17 Many states define Medicaid eligibility for children through age 20 years, with the 21st birthday marking a transition to adult coverage for which benefits may be more limited.¹⁸ At this transition, individuals must meet adult eligibility criteria and may lose access to certain benefits and exemptions available in childhood coverage. In 12 state Medicaid programs, young adults become newly subject to prescription caps, a cost-containment strategy limiting the monthly number of Medicaid-covered prescriptions for adults aged 21 and older. In Illinois, prescription caps apply even earlier, at age 19 years.¹⁹ While intended to control Medicaid prescription drug spending, these policies also risk restricting access to clinically necessary medications for individuals with chronic conditions such as OUD.²⁰ Furthermore, young adults could be especially sensitive to cap policies because they have less experience navigating health insurance and the health care system on their own and may be less likely to push back on denials and changes in coverage.^21,22

One prior study²³ examined the impact of prescription caps on individual health outcomes and health care use among young adults and found that prescription caps were associated with reductions in monthly fills for mental health medications and increases in inpatient admissions. However, this study focused specifically on individuals with disabilities; to our knowledge, other subgroups of young adults, including those with OUD, have not been assessed until now. Prior studies (not limited to young adults) collectively highlight how prescription caps can affect medication access, health care use, and costs,^{24,25,26,27,28,29} raising concerns about broader implications for vulnerable populations such as young adults with OUD, who are at greater risk of co-occurring mental health conditions and may require multiple medications to comprehensively address their health care needs.³⁰ For example, more than one-half of young adults with OUD have a co-occurring psychiatric disorder,³¹ which frequently requires medication to manage effectively.³² Failure to start or continue MOUD and other medically necessary medications can increase the likelihood of a return to substance use, health complications, and other adverse outcomes.³³

To better understand the effects of prescription cap policies, this study leverages a natural experiment occurring when young adults with OUD become newly subject to Medicaid prescription cap policies at age 21 to assess changes in total prescription fills, receipt of buprenorphine MOUD, and acute care utilization.

Methods

Study Design

This study identified a cohort of young adults diagnosed with OUD using T-MSIS Analytic Files from January 1, 2016, to December 31, 2021. Data analysis was conducted from July 2025 to December 2025. This cohort study used a difference-in-differences approach to compare prescription medication receipt and acute care use among enrollees in the 12 months before vs 12 months after participants reached the age of 21 in states with prescription cap policies (cap states) relative to states without cap policies (noncap states). More information about the methods can be found in the Brown University Digital Repository.³⁴ This study used secondary deidentified data and was deemed exempt from approval and consent by the Brown University Institutional Review Board. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Data Sources

We used 2016-2021 Medicaid T-MSIS Analytic File (TAF) individual claims from 34 states, linking each TAF Annual Demographic and Eligibility File at the person-month level to all inpatient, long-term care, pharmacy, and other service claims for that person. States included 8 with an overall prescription cap policy during the study period (Alabama, Arkansas, California, Kansas, Louisiana, Oklahoma, Tennessee, and Texas) compared with 26 states without any cap policy. eTable 1 in Supplement 1 provides information about TAF data quality checks and reasons for state exclusions.

Cohort

Medicaid claims spanning January 1, 2016, through December 31, 2021, were available. We identified community-dwelling nondual Medicaid enrollees with an International Classification of Diseases, Ninth Revision (ICD-9) or International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code for opioid dependence or opioid use (ie, OUD) before age 21 and who turned 21 between January 1, 2017, and December 31, 2020, as we required continuous Medicaid enrollment in the 12 months before and after reaching age 21.

Exposure

The exposure was becoming subject to a state Medicaid prescription cap on reaching age 21 in 1 of 8 cap states. Two states eliminated or suspended Medicaid prescription caps during our study window: South Carolina in July 2017 and California in March 2020. Considering the 2-year continuous enrollment criteria and the extent of our available data (2016 to 2021), we categorized South Carolina as a noncap state by excluding person-months for South Carolina enrollees prior to July 2017. Conversely, we categorized California as a cap state by excluding person-months for California enrollees after March 2020. This yielded a balanced panel of individuals enrolled for 25 continuous months: 12 months before and 12 months after age 21. The month of the 21st birthday was designated as month 0.

Outcomes

We had 4 outcomes: overall prescription receipt, buprenorphine prescription receipt for OUD treatment, inpatient hospitalization, and emergency department (ED) use, including the latter 2 outcomes as potential indicators of poorly managed OUD and other chronic conditions. We examined all-cause rather than substance use–specific utilization because prescription caps are broad constraints that can disrupt treatment of various co-occurring conditions. Although important, opioid overdoses are poorly detected using claims and were less than 1% prevalent in our sample, precluding inclusion of this outcome. We analyzed each outcome both as a binary (any vs none) and as a continuous count variable.

Covariates

We captured covariates in the 12 months before reaching age 21 (ie, preperiod). Time-invariant demographic characteristics included sex, race, and ethnicity. Race and ethnicity were obtained from the TAF Annual Demographic and Eligibility File. The Centers for Medicare & Medicaid Services requires state Medicaid agencies to collect and report race and ethnicity to T-MSIS. All individuals were the same age at the time of observation. Regression models controlled for the following time-varying characteristics at the person-month level: pregnancy,³⁵ comprehensive managed care enrollment, any surgical procedure, any evaluation and management office visit, county rurality,³⁶ county Social Deprivation Index,³⁷ the raw count of comorbid Elixhauser conditions,³⁸ and binary indicators of ICD-9 or ICD-10 diagnosis codes for serious mental illness, chronic pain, respiratory disease, or cardiovascular disease. We did not include a covariate for state-specific OUD prevalence because a claims-based measure of disease burden cannot account for individuals with untreated OUD who have not accessed care. State Medicaid expansion was nearly perfectly correlated with the absence of a prescription cap (98.4% of noncap person-months), precluding our ability to directly control for Medicaid expansion due to a lack of statistical variation.

Statistical Analysis

We performed separate difference-in-differences regression models with person and time fixed effects for each outcome, adjusting for time-varying preperiod covariates. Models included robust SEs to account for state-level clustering. Since policy effects may lag and evolve over time, we allowed for a phase-in exposure window of 2 months before and after age 21 and estimated 3 disaggregated effect estimates³⁹ over the follow-up period: early (months 3-6), mid (months 7-9), and late (months 10-12) relative to turning 21. For comparison, we also estimated traditional 2-group/2-period (2 × 2) point estimates over the full follow-up, without the exposure phase-in window. Analyses were performed using Stata version 18 (StataCorp LLC).

In additional analyses, first, to understand potential changes in prescription use across the transition to prescription caps, we conducted a post hoc descriptive analysis of patterns of prescription receipt before and after age 21 for several classes of medication, including antipsychotics, anxiolytics, hypnotics or sedatives, antidepressants, psychostimulants, opioid analgesics, anti-asthmatic agents, and hormonal contraceptives. These medication classes were identified based on the preperiod prevalence of comorbidities among enrollees with OUD and consideration of prescriptions that are commonly used by young adults.^40,41

Next, we conducted sensitivity analyses to assess the robustness of our findings to alternate model specifications. If the parallel pretrends assumption is violated, our difference-in-differences model may be biased. Therefore, we repeated our covariate-adjusted analysis with further adjustment for differential trends in the preperiod between cap and noncap states. In particular, visual inspection of overall prescription receipt and inpatient hospitalization trends suggests that the parallel pretrends assumption may not hold for these outcomes.

Results

Sample Characteristics

The study sample comprised 15 526 young adults with OUD from 26 noncap states and 1769 from 8 cap states (Table 1). Individuals were predominantly female (noncap states, 52.5%; cap states, 58.4%), White (noncap states, 61.3%; cap states, 39.9%), and enrolled in comprehensive managed care (noncap states, 86.2%; cap states 90.3%). The baseline comorbid condition count was the same in both groups (mean [SD], 1.4 [1.5]). Among all enrollees with OUD, there were high rates of serious mental illness (noncap states, 55.7%; cap states, 50.1%), chronic pain (noncap states, 45.3%; cap states, 47.3%), and respiratory disease (noncap states, 22.8%; cap states, 24.3%). Nearly all individuals had at least 1 evaluation and management office visit in the year before turning 21 (noncap states, 88.5%; cap states, 90.1%).

Table 1. Preperiod Characteristics of Medicaid Enrollees With Opioid Use Disorder in the 12 Months Before Reaching Age 21 Years, 2016-2021^a.

Characteristic	Person-level, No. (%)		Month-level, No. (%)
Characteristic	Noncap states	Cap states	Noncap states	Cap states
No. of individuals/mo	15 526	1769	186 312	21 228
No. of states	26	8	26	8
Sex
Female	8156 (52.5)	1033 (58.4)	97 872 (52.5)	12 396 (58.4)
Male	7370 (47.5)	736 (41.6)	88 440 (47.5)	8832 (41.6)
Race and ethnicity^b
Black	2075 (13.4)	175 (9.9)	24 900 (13.4)	2100 (9.9)
Hispanic	1190 (7.7)	341 (19.3)	14 280 (7.7)	4092 (19.3)
White	9512 (61.3)	705 (39.9)	114 144 (61.3)	8460 (39.9)
Some other race and ethnicity	748 (4.8)	37 (2.1)	8976 (4.8)	444 (2.1)
Unknown race and ethnicity	2001 (12.9)	511 (28.9)	24 012 (12.9)	6132 (28.9)
Pregnant	2464 (15.9)	332 (18.8)	10 249 (5.5)	1424 (6.7)
Comprehensive managed care	13 376 (86.2)	1598 (90.3)	152 584 (81.9)	18 415 (86.7)
Rural-urban continuum code
Metropolitan	12 067 (77.7)	1460 (82.5)	146 677 (78.7)	17 675 (83.3)
Urban	2316 (14.9)	245 (13.8)	26 590 (14.3)	2853 (13.4)
Rural	1143 (7.4)	64 (3.6)	13 045 (7.0)	700 (3.3)
Social Deprivation Index, mean (SD)	49.0 (27.2)	67.3 (22.1)	49.0 (27.4)	67.3 (22.4)
Comorbid condition count, mean (SD)	1.4 (1.4)	1.4 (1.5)	1.4 (1.5)	1.4 (1.5)
Serious mental illness	8643 (55.7)	886 (50.1)	93 081 (50.0)	9394 (44.3)
Chronic pain	7029 (45.3)	836 (47.3)	75 417 (40.5)	8938 (42.1)
Respiratory disease	3536 (22.8)	429 (24.3)	37 560 (20.2)	4560 (21.5)
Cardiovascular disease	1304 (8.4)	193 (10.9)	12 900 (6.9)	1894 (8.9)
Any surgery	1308 (8.4)	210 (11.9)	1335 (0.7)	217 (1.0)
Any E&M office visits	13 743 (88.5)	1594 (90.1)	67 991 (36.5)	7921 (37.3)
Any medications for OUD	4311 (27.8)	380 (21.5)	21 747 (11.7)	2007 (9.5)
Only methadone use	771 (5.0)	170 (9.6)	6126 (3.3)	1282 (6.0)
Only buprenorphine use	2729 (17.6)	164 (9.3)	13 845 (7.4)	655 (3.1)
Only intramuscular naltrexone use	442 (2.8)	27 (1.5)	1682 (0.9)	65 (0.3)
>1 Type of medication	369 (2.4)	19 (1.1)	94 (0.1)	<11

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Abbreviations: E&M, evaluation and management; OUD, opioid use disorder.

^{^a}

Person-level prevalence includes characteristics observed at any point over the 12-month preperiod. Month-level prevalence is averaged over 12 observations per person. Cell values from 1 to 10 have been suppressed per the policy of the Centers for Medicare & Medicaid Services.

^{^b}

Race and ethnicity were obtained from the T-MSIS Analytic File (TAF) Annual Demographic and Eligibility File. The Centers for Medicare & Medicaid Services requires state Medicaid agencies to collect and report race and ethnicity to T-MSIS. Groups included as other are Asian, non-Hispanic; American Indian and Alaska Native, non-Hispanic; Hawaiian/Pacific Islander; and multiracial, non-Hispanic.

Prescription Use

During the 12-month baseline period, 83% of enrollees ever filled any prescription and 19.9% ever received buprenorphine in noncap states (Table 2). In cap states, 84.6% filled any prescription and 10.2% ever received buprenorphine. At the month-level, before age 21, less than one-half of months had any prescription fills (noncap states, 39.3%; cap states, 40.2%) and less than 10% of months had any buprenorphine use, although receipt was over twice as high in noncap states (7.5%) as in cap states (3.1%). In cap and noncap states, the mean (SD) number of monthly prescription fills was 1.4 (2.6). The mean (SD) count of monthly buprenorphine fills was 0.2 (0.7) in noncap states and 0.1 (0.3) in cap states. After turning 21, there was a statistically significant unadjusted decrease in the number of monthly prescription fills in cap states relative to noncap states (−0.173; 95% confidence limit [CL], −0.28 to −0.06; eTable 2 in Supplement 1) but no significant changes in any prescription receipt or buprenorphine use.

Table 2. Unadjusted Preperiod and Postperiod Measures of Prescription Receipt and Acute Care Use Outcomes Among Young Adult Medicaid Enrollees With Opioid Use Disorder, 2016-2021^a.

Outcome measure	Person-level, No. (%)				Month-level, No. (%)
	Noncap states		Cap states		Noncap states		Cap states
	Before age 21 y	After age 21 y	Before age 21 y	After age 21 y	Before age 21 y	After age 21 y	Before age 21 y	After age 21 y
Any prescription fills	12 889 (83.0)	12 151 (78.3)	1496 (84.6)	1377 (77.8)	73 298 (39.3)	72 618 (39.0)	8529 (40.2)	8014 (37.8)
Any buprenorphine use	3086 (19.9)	2914 (18.8)	180 (10.2)	168 (9.5)	13 936 (7.5)	15 462 (8.3)	660 (3.1)	803 (3.8)
Any hospitalizations	3826 (24.6)	3197 (20.6)	547 (30.9)	423 (23.9)	6008 (3.2)	5137 (2.8)	1018 (4.8)	868 (4.1)
Any emergency department visits	10 327 (66.5)	9221 (59.4)	1317 (74.4)	1148 (64.9)	26 338 (14.1)	22 291 (12.0)	3972 (18.7)	3234 (15.2)
No. of prescription fills/mo, mean (SD)	1.4 (1.9)	1.4 (2.1)	1.4 (2.1)	1.3 (1.9)	1.4 (2.6)	1.4 (2.7)	1.4 (2.7)	1.3 (2.5)
No. of buprenorphine fills/mo, mean (SD)	0.2 (0.50)	0.2 (0.5)	0.1 (0.2)	0.1 (0.2)	0.2 (0.7)	0.2 (0.7)	0.1 (0.3)	0.1 (0.3)
No. of hospitalizations/mo, mean (SD)	0.04 (0.1)	0.03 (0.1)	0.1 (0.2)	0.1 (0.2)	0.04 (0.3)	0.03 (0.2)	0.1 (0.3)	0.1 (0.3)
No. of emergency department visits/mo, mean (SD)	0.2 (0.4)	0.2 (0.4)	0.3 (0.6)	0.3 (0.7)	0.2 (0.7)	0.2 (0.6)	0.3 (0.9)	0.3 (0.9)

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^{^a}

Person-level outcomes are observed at any point over the 12-month pre- or 12-month postperiod. Month-level outcomes are used to calculate relative effect estimates.

After covariate adjustment and postperiod disaggregation, we observed a lower proportion of enrollees with any prescription fills, which was significant only in the late post-period (−4.7%; 95% CL, −9.9% to −0.2%). Monthly prescription counts decreased significantly among enrollees with OUD in cap states across early, mid, and late postperiod months and the magnitude of reductions increased over time (Table 3). These decreases correspond to 10.2% (95% CL, −19.3% to −1.3%) fewer prescription fills in the early postperiod, 10.6% (95% CL, −17.3% to −1.3%) fewer prescription fills in the mid postperiod, and 12.7% (95% CL, −18.7% to −6.7%) fewer prescription fills in the late postperiod relative to baseline after reaching age 21 in cap states. These effect estimates were strengthened after trend adjustment (eTable 3 in Supplement 1) to address potentially differential preperiod trends for overall prescription receipt in both unadjusted plots (Figure 1A and Figure 2A) and formal event studies (eFigures 3A and 4A in Supplement 1). The relative reduction in the proportion of enrollees with any prescription fills in cap states was also significant during the mid period (−5.7%; 95% CL, −9.9% to −1.0%) and late postperiod (−6.2%; 95% CL, −9.9% to −2.5%). In both the covariate-only and trend-adjusted models, we did not observe any change in the proportion of enrollees with OUD receiving buprenorphine or the number of buprenorphine fills on turning 21 in cap states.

Table 3. Covariate Adjusted, Disaggregated Difference-in-Differences Estimates of Monthly Prescription Receipt and Acute Care Use Outcomes Among Young Adult Medicaid Enrollees With Opioid Use Disorder, 2016-2021^a.

Outcome measure	Coefficient (95% CL)
Outcome measure	Full postperiod	Early (3-6 mo)	Mid (7-9 mo)	Late (10-12 mo)
Absolute differences
Any prescription fills	−0.011 (−0.03 to 0.005)	−0.007 (−0.03 to 0.01)	−0.018 (−0.04 to 0.001)	−0.019 (−0.04 to −0.001)^b
Any buprenorphine use	0.0002 (−0.01 to 0.01)	−0.003 (−0.01 to 0.01)	0.002 (−0.01 to 0.01)	−0.0001 (−0.01 to 0.01)
Any hospitalizations	0.001 (−0.003 to 0.005)	−0.0004 (−0.01 to 0.004)	−0.0003 (−0.01 to 0.01)	0.003 (−0.002 to 0.01)
Any emergency department visits	−0.002 (−0.01 to 0.002)	−0.002 (−0.01 to 0.004)	−0.001 (−0.01 to 0.01)	−0.003 (−0.01 to 0.003)
No. of prescription fills/mo	−0.143 (−0.24 to −0.04)^b	−0.153 (−0.29 to −0.02)^b	−0.159 (−0.26 to −0.02)^b	−0.191 (−0.28 to −0.10)^b
No. of buprenorphine fills/mo	−0.0001 (−0.02 to 0.02)	−0.005 (−0.02 to 0.01)	0.003 (−0.02 to 0.02)	0.002 (−0.02 to 0.03)
No. of hospitalizations/mo	0.001 (−0.004 to 0.006)	−0.0004 (−0.01 to 0.004)	−0.0003 (−0.01 to 0.01)	0.005 (−0.001 to 0.01)
No. of emergency department visits/mo	0.002 (−0.01 to 0.01)	0.003 (−0.01 to 0.01)	0.014 (−0.01 to 0.03)	0.012 (−0.01 to 0.04)
Relative differences
Any prescription fills	−2.7 (−7.5 to 1.2)	−1.7 (−7.5 to 2.5)	−4.5 (−9.9 to 0.2)	−4.7 (−9.9 to −0.2)^b
Any buprenorphine use	0.7 (−33.3 to 33.3)	−10.0 (−33.3 to 33.3)	6.7 (−33.3 to 33.3)	−0.3 (−33.3 to 33.3)
Any hospitalizations	−2.0 (−6.0 to 10.0)	−0.8 (−20.0 to 8.0)	−0.6 (−20.0 to 20.0)	6.0 (−4.0 to 20.0)
Any emergency department visits	−1.1 (−5.3 to 1.1)	−1.1 (−5.3 to 2.1)	−0.5 (−5.3 to 5.3)	−1.6 (−5.3 to 1.6)
No. of prescription fills/mo	−9.5 (−16.0 to −2.7)^b	−10.2 (−19.3 to −1.3)^b	−10.6 (−17.3 to −1.3)^b	−12.7 (−18.7 to −6.7)^b
No. of buprenorphine fills/mo	−0.2 (−40.0 to 40.0)	−10.0 (−40.0 to 20.0)	6.0 (−40.0 to 40.0)	4.0 (−40.0 to 60.0)
No. of hospitalizations/mo	1.0 (−4.0 to 6.0)	−0.4 (−10.0 to 4.0)	−0.3 (−10.0 to 10.0)	5.0 (−1.0 to 10.0)
No. of emergency department visits/mo	0.7 (−3.3 to 3.3)	1.0 (−3.3 to 3.3)	4.7 (−3.3 to 10.0)	4.0 (−3.3 to 13.3)

Open in a new tab

Abbreviation: CL, confidence limit.

^{^a}

All difference-in-differences models are estimated at the month level, adjusting for time-varying county rurality, county social deprivation index, comorbid condition count, and binary indicators for pregnancy, comprehensive managed care enrollment, serious mental illness, chronic pain, respiratory disease, cardiovascular disease, any surgical procedures, and any evaluation and management office visits and exclude a policy implementation window from 2 months before turning age 21 years to 2 months after turning age 21 years. Relative differences are calculated relative to the preperiod sample mean (before turning 21 years) in cap states.

^{^b}

P < .05.

Acute Care Use

The monthly prevalence estimates were 3.2% for noncap states vs 4.8% for cap states for hospitalization and 14.1% for noncap states vs 18.7% for cap states for ED visits (Table 2). We observed an unadjusted decrease in any acute care use and acute care visit frequency among enrollees with OUD in both cap and noncap states after turning 21. Assuming parallel pretrends, in covariate-only adjusted models, there were no changes for any hospitalization, hospitalization count, any ED visit, or ED visit count between cap and noncap states. Although preperiod trends in inpatient hospitalizations may not appear fully parallel on visual inspection (Figure 1C and Figure 2C), formal event study plots support the parallel trends assumption (eFigures 3C and 4C in Supplement 1). After trend adjustment (eTable 3 in Supplement 1), the difference in the count of hospitalizations in cap states after age 21 increased only in the late postperiod by 6.0% (95% CL, 0.3%-10.0%) relative to the preperiod mean. Compared with noncap states, the trend-adjusted relative difference in the count of ED visits in cap states vs noncap states on turning 21 increased in the early (4.7%; 95% CL, 1.0%-10.0%) and mid (8.3%; 95% CL, 3.3%-13.3%) postperiods but was not statistically significant in the late postperiod.

Other Medications

Before age 21, the most prevalent analyzed medication classes (eTable 4 in Supplement 1) were antidepressants (noncap states, 36.9%; cap states, 35.2%) and opioid analgesics (noncap states, 31.7%; cap states, 43.4%). After participants reached the age of 21, we observed a slight decrease in the prevalence of antipsychotics, anxiolytics, hypnotics/sedatives, antidepressants, psychostimulants, opioid analgesics, anti-asthmatic agents, and hormonal contraceptives in both cap and noncap states, although changes in fill frequency at the month-level were more variable. The monthly fill count within each medication class generally increased or stayed the same on turning 21 among those with existing medication use. Overall, the average days’ supply of dispensed prescriptions was comparable between noncap and cap states (eTable 5 in Supplement 1) and less than 0.5% of fills in our sample were for a 90-day supply. The pre- and postperiod prevalence of each medication class was also comparable by cap status. This is in contrast to buprenorphine use, which was more than twice as common in noncap states (Table 2).

Discussion

In this national cohort study of young adults with OUD, transitioning to Medicaid prescription cap policies at age 21 was associated with sustained reductions in overall prescription medication use and modest changes in patterns of acute care utilization, although there was no relative change in buprenorphine, which had low rates of use in this population. These findings suggest that the effects of prescription caps on medication receipt may be amplified the longer that young adults are exposed to these policies and extend prior research indicating that prescription caps can limit access to medications among Medicaid beneficiaries with chronic and complex health needs.^{24,25,28,42,43} Similar distributions of the duration of dispensed prescriptions by cap status further suggest that clinicians are not systematically utilizing longer days’ supply as a strategy to circumvent cap policies. Collectively, these results suggest that prescription caps may be associated with reduced overall medication access during a critical coverage transition for young adults with OUD, underscoring the need for continued evaluation of how such policies interact with access to care and health service use among this population.

That buprenorphine receipt did not decline may be interpreted as a positive finding given the overall reductions in total prescription fills identified in our analysis. However, it is notable that buprenorphine receipt was low and substantially lower in cap states, with less than 1 in 10 young adults with OUD receiving buprenorphine monthly at baseline, suggesting possible ongoing barriers to evidence-based OUD treatment. Other studies have highlighted low and declining buprenorphine receipt among young adults^44,45 amid generally improving rates nationally. Furthermore, the baseline prevalence of buprenorphine receipt was more than 2-fold higher in noncap states compared with cap states, which may indicate broader system-level disparities in youth receiving MOUD independent of prescription cap policies.⁴⁶

Similar to earlier research that found prescription caps were associated with higher rates of inpatient care use,^23,26 our study found some evidence of more frequent hospitalizations, although this finding emerged in sensitivity analyses and only in the final 3 months of the follow-up period. Since visual inspection suggests that the parallel trends assumption may not hold for hospitalization, it is reasonable for the results with and without adjustment for differential pretrends to differ, with the trend-adjusted results expected to be more accurate. The trend-adjusted finding of more frequent ED visits during the early and mid postperiod months could signify latency, whereby more intensive ED use precedes more frequent hospitalizations observed only late in the postperiod. Further research with a longer follow-up period is warranted to strengthen evidence on the impact of transitioning to prescription caps on acute care use. Nonetheless, our study provides an important signal of potentially more intensive use of costly health services when young adults become subject to Medicaid prescription caps.

Limitations

Our study has limitations. First, TAF data only allow observation of prescriptions covered by Medicaid, not those paid out of pocket or through supplemental insurance. Second, unmeasured confounding cannot be ruled out in this observational study. For example, there could be unmeasured co-occurring policies that differentially influence cap and noncap states in the postperiod. Third, the absence of preperiod parallel trends in hospitalizations challenged the standard difference-in-differences method; therefore, the results for this outcome should be interpreted with caution. To address nonparallel trends, we calculated and interpreted the trend-adjusted effect estimates for the study conclusions, although this assumes that preperiod divergence would have continued linearly into the postperiod. Fourth, our outcomes excluded methadone and injectable naltrexone, thus providing a partial picture of MOUD receipt among young adults. However, neither drug would be much impacted by prescription caps since both are typically billed as a service rather than a prescription. Last, prescription cap policies vary across state Medicaid programs in their design, exemptions, and implementation.¹⁹ Our study does not differentiate among specific policy features, which may affect findings and represents an important area for future research.

Conclusions

In this cohort study among young adults with OUD, the transition to Medicaid prescription caps on reaching age 21 was associated with lower overall receipt of prescription medications and apparent increases in the intensity of acute care use. States should reevaluate the operation of prescription caps, which may limit access to essential medications and contribute to poorer, more costly patient outcomes.

Supplement 1.

eTable 1. State T-MSIS Analytic File (TAF) data quality checks and reasons for exclusion

eTable 2. 2x2 difference-in-differences estimates of monthly prescription receipt and acute care use outcomes among young adult Medicaid enrollees with opioid use disorder, 2016-2021

eTable 3. Covariate- and trend-adjusted, disaggregated difference-in-differences estimates of monthly prescription receipt and acute care use outcomes among young adult Medicaid enrollees with opioid use disorder, 2016-2021

eTable 4. Average prescription receipt by drug class among young adult Medicaid enrollees with opioid use disorder, 2016-2021

eTable 5. Average days’ supply of dispensed prescriptions among young adult Medicaid enrollees with opioid use disorder, 2016-2021

eFigure 1. Time to Medicaid disenrollment after 21st birthday among Medicaid enrollees with opioid use disorder continuously enrolled from age 20 to 21, by cap status, 2017-2020

eFigure 2. Time to Medicaid disenrollment after 19th birthday among Medicaid enrollees with opioid use disorder, by cap status, 2017-2020

eFigure 3. Event study estimates of receipt of any prescription and any acute care use outcomes among young adult Medicaid enrollees with opioid use disorder, 2016-2021

eFigure 4. Event study estimates of receipt of number of prescription fills and number of acute care visits among young adult Medicaid enrollees with opioid use disorder, 2016-2021

jamahealthforum-e261187-s001.pdf^{(558.7KB, pdf)}

Supplement 2.

Data Sharing Statement

jamahealthforum-e261187-s002.pdf^{(15.9KB, pdf)}

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Citations

Santostefano CM, Hughto JMW, Hughes LD, et al. Data documentation for medication and acute care use in young adults with opioid use subject to Medicaid prescription caps. Providence, RI: Brown University Library, Brown Digital Repository. Updated March 24, 2026. doi: 10.26300/tb1v-d502 [DOI] [PMC free article] [PubMed]

Supplementary Materials