Impact of the Young Adult Dependent Coverage Expansion on Opioid Overdoses and Deaths: a Quasi-Experimental Study



Several policymakers have suggested that the Affordable Care Act (ACA) has fueled the opioid epidemic by subsidizing opioid pain medications. These claims have supported numerous efforts to repeal the ACA.


To determine the effect of the ACA’s young adult dependent coverage insurance expansion on emergency department (ED) encounters and out-of-hospital deaths from opioid overdose.


Difference-in-differences analyses comparing ED encounters and out-of-hospital deaths before (2009) and after (2011–2013) the ACA young adult dependent coverage expansion. We further stratified by prescription opioid, non-prescription opioid, and methadone overdoses.


Adults aged 23–25 years old and 27–29 years old who presented to the ED or died prior to reaching the hospital from opioid overdose.

Main Measures

Rate of ED encounters and deaths for opioid overdose per 100,000 U.S. adults.

Key Results

There were 108,253 ED encounters from opioid overdose in total. The expansion was not associated with a significant change in the ED encounter rates for opioid overdoses of all types (2.04 per 100,000 adults [95% CI − 0.75 to 4.82]), prescription opioids (0.60 per 100,000 adults [95% CI − 1.98 to 0.77]), or methadone (0.29 per 100,000 adults [95% CI − 0.78 to 0.21]). There was a slight increase in the rate of non-prescription opioid overdoses (1.91 per 100,000 adults [95% CI 0.13–3.71]). The expansion was not associated with a significant change in the out-of-hospital mortality rates for opioid overdoses of all types (0.49 per 100,000 adults [95% CI − 0.80 to 1.78]).


Our findings do not support claims that the ACA has fueled the prescription opioid epidemic. However, the expansion was associated with an increase in the rate of ED encounters for non-prescription opioid overdoses such as heroin, although almost all were non-fatal. Future research is warranted to understand the role of private insurance in providing access to treatment in this population.

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There are no contributors to the manuscript that did not meet authorship criteria.


Research reported in this manuscript was supported by the National Heart, Lung, and Blood Institute under award number T32HL098054 (EC), the National Institute on Drug Abuse K12DA033312 (EC), and the National Institute of Child Health and Human Development K23HD090272001 (MKD).

Author information




Specific contributions are as follows: EC and MKD conceived the study and conducted the analysis. DK acquired the data. MKD, RMW, and DP provided statistical guidance and supervised the analysis. All authors interpreted the results. EC drafted the manuscript. All authors contributed to the critical revision of the manuscript. EC takes responsibility for the manuscript as a whole.

Corresponding author

Correspondence to Edouard Coupet Jr MD, MS.

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Coupet, E., Werner, R.M., Polsky, D. et al. Impact of the Young Adult Dependent Coverage Expansion on Opioid Overdoses and Deaths: a Quasi-Experimental Study. J GEN INTERN MED 35, 1783–1788 (2020).

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  • opioids
  • health policy
  • substance use