ASHINGTON — As Republicans plan to overhaul Medicaid, the opioid crisis looms large.

More than 30,000 Americans are dying from heroin and painkiller overdoses every year. Hundreds of thousands of people covered by Obamacare’s expansion of Medicaid — more than a million, by at least one estimate — have mental health and substance abuse issues.

The GOP plan could impact the program in two ways. First, it would eliminate in 2020 the requirement that states, which administer Medicaid and jointly fund it with the federal government, offer robust coverage of mental health and substance abuse services for people who enrolled in Medicaid under the Obamacare expansion. According to the Kaiser Family Foundation, traditional Medicaid coverage of these services is often less generous than the expansion coverage. So the fear is that coverage for those people would be rolled back under the GOP’s plan.


Second, it would fundamentally change how the entire program, which covers more than 70 million people, is funded. Instead of an open-ended federal commitment to pay whatever is necessary, states would receive a set dollar amount from the feds for each person. In exchange, states are supposed to receive more flexibility — even if the Republican bill doesn’t do much to provide it. The Heath and Human Services secretary, Tom Price, has pledged, however, to use his administrative authority to give states that leeway.

The concern, however, is that a spending cap and state flexibility could lead to enrollment cuts and fewer benefits — particularly for high-cost populations like people in addiction recovery.

It’s hard to know for sure what will happen. But the stakes are high. Medicaid pays for 1 out of every 4 prescriptions for the addiction treatment medication buprenorphine, according to data from IMS Health. But there is a lot of variation across states, because they already have a lot of latitude to decide how the program works within their borders.

In some states, like Ohio, Medicaid pays for nearly half of those prescriptions. In other states, the program’s share is much smaller. So some states have much more to lose, depending on how the GOP’s plan ultimately changes things.

The map below should help give you an idea of the stakes.

MAP: Percent of addiction treatment medication that Medicaid pays for, by state

Natalia Bronshtein/STAT Source: Use of Opioid Recovery Medications. Report by the IMS Institute for Healthcare Informatics

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