HARLESTON, W.Va. — When the Republicans’ first effort to repeal and replace the Affordable Care Act collapsed earlier this spring, Mary Aldred-Crouch, an addiction counselor here, saw that failure as a victory. “It was Snoopy dance time,” she said.
But the Republicans didn’t give up. And when the House passed a more conservative version of the GOP health plan last week, Aldred-Crouch felt her anxiety spike. West Virginia, like other states afflicted by the opioid crisis, lately has seen so many more patients with drug addiction find treatment.
The new bill threatens to destroy that progress, Aldred-Crouch and other counselors say.
“When I heard it passed, I about fell out of my chair,” she said, noting that the three House members from West Virginia — all Republicans — backed the measure. “I am so disappointed in them, I can’t see straight. You just torched the health benefits of 200,000 West Virginians, and in the middle of an [opioid] epidemic.”
Republicans have framed their bill as a way to give patients more freedom in their insurance choices, allowing them to buy plans that fit their needs instead of being mandated to buy coverage for services they would never use. But the bill’s huge cuts to Medicaid could cause millions of low-income people to lose coverage. The bill also gives states the flexibility to redefine which “essential benefits” insurance plans must cover — and some could choose to make mental health and addiction coverage optional.
That’s a harsh blow for the recovery community, which was just starting to feel — at last — as though it had the elements in place to at least start combating the epidemic.
It required the problem to fester into a full-blown crisis, killing more than 30,000 people a year, to grab the public’s attention, but policymakers and even presidential candidates had begun putting forward opioid plans. States were expanding access to medication-assisted treatment, needle exchanges, and overdose antidotes. Under the Affordable Care Act, hundreds of thousands of newly insured people were able to seek help and have it paid for. The law’s Medicaid expansion provided an estimated 1.3 million people with substance abuse or mental health care.
President Trump, both in the campaign and in office, had signaled that the availability of such services would only grow during his administration.
Now, counselors fear that by reducing the number of insured, the GOP health plan could inevitably make it harder for people in need to get help.
“We’ve finally gotten people to want to come in and recognize the need for them to come in, and we’ve made those services available to people and made them affordable, and now we’re going to take them away,” said Gerry Schmidt, the president of the Association for Addiction Professionals, also known as NAADAC.
Senate Republicans have already said they are going to rewrite the House health plan, so the details of a final bill remain to be seen.
But as passed, the House bill would roll back the Medicaid expansion that 31 states, including West Virginia, took advantage of under the ACA and cap federal contributions to the Medicaid program beyond the expansion. Millions of people would be expected to lose their coverage, and those who maintain some sort of plan might find it more expensive to get substance abuse treatment.
Those were the possibilities that alarmed Aldred-Crouch as she briefed the West Virginia Association of Alcoholism and Drug Abuse Counselors at the statehouse back in March, when the first version of the GOP bill was circulating. As she spoke, earning nods of approval, others passed around papers with contact information for the West Virginia congressional delegation and suggestions for what to tell lawmakers.
Aldred-Crouch’s key message: get involved. Call your representatives and senators. Tell them about yourself — and that you vote.
“The biggest issue we face today is the feds,” she said at the counselors’ annual advocacy day. “If that passes, we’re in deep doo-doo.”
Then the advocates spread through the massive marble rotunda on the second floor of the Capitol, hoping to snag a few minutes with state lawmakers.
“If they defund it, addicts are not going to stop being addicts,” Aldred-Crouch said about possible Medicaid cuts. She argued that restricting access to treatment would only lead to more expenses for criminal justice, family services, and round after round of emergency department visits.
“If nothing else, you’re going to be paying for public funerals,” she said.
The bill’s possible impact on substance abuse treatment has a particular significance here in West Virginia and in places like neighboring Kentucky and Ohio. All three states have been walloped by the opioid crisis, expanded Medicaid under Obamacare, and threw their support to Trump in the election.
Now, counselors say, some people in treatment, many of whom were drawn to Trump for his economic message and pledge to reinvigorate the coal industry, are starting to ask if they could really lose their coverage. As a candidate, Trump had promised to provide care for everyone and pledged not to cut Medicaid. What’s more, voters figured if Trump brought better jobs, then they wouldn’t have to worry about affording health care.
More moderate Republicans have been voicing concerns about the Medicaid cuts and access to addiction treatment for months. Among them: Ohio Governor John Kasich and Senators Rob Portman of Ohio and Shelley Moore Capito of West Virginia.
That’s not to say Republicans in this region are uniformly anxious. In Kentucky, Senate Majority Leader Mitch McConnell, whose state has seen the biggest drop in its rate of uninsured residents since Obamacare was enacted, has campaigned in support of the bill, and will be leading the Senate’s efforts to pass a replacement measure.
And even among the public, the threat of losing insurance is not on everyone’s radar here, many counselors pointed out. Many people on Medicaid have too many other things to worry about than the latest back-and-forth in Congress.
“Their focus is on their family, their focus is on their day-to-day life,” said Heather Sharp-Spinks, a social worker and addiction counselor in rural Pocahontas County.
Even with Obamacare, the current system is by no means providing everyone with the treatment they want, the counselors acknowledged. People who have private insurance are paralyzed by their high deductibles. Waiting lists are still the norm for recovery programs. There aren’t enough clinics or providers, and the ones that are out there are already strapped.
Patty Deutsch, a counselor in private practice in Charleston, said she knows doctors who offer medication-assisted treatment who won’t see Medicaid patients because the program reimburses clinicians at such low rates. She works out sliding-scale payments for people on Medicaid — they pay what they can, when they can — so she doesn’t have to deal with the hassle of being reimbursed.
“We are dealing with people who are on the edge of death,” she said. “The people we treat, many of them, most of them, want to get better. They just don’t have the tools to do it.”
She added: “I don’t know how we right this.”
The answer was not to cut funding and coverage further, the counselors said. They are not only worried about people trying to find treatment in the future, but also those who are in recovery now, in the midst of months- or years-long medication-assisted treatment and counseling programs.
“They are remaining clean and sober because of the treatment they get,” said Joan Englund, the executive director of the Mental Health and Addiction Advocacy Coalition, an Ohio group. “If that’s taken away, their recovery is in peril.”
Before the Medicaid expansion, Aldred-Crouch used to have someone else listen to her voicemail messages because she couldn’t handle hearing more people telling her they were going to die with a needle in their arm if they couldn’t get help, only to have to add them to waiting lists that could take several years to climb.
The expansion hasn’t solved that problem, she said, but it has at least helped somewhat.
“In early recovery, these folks are like a country music song,” she said. “The house is gone, the wife is gone, the job is gone, even the dog is gone. Medicaid is the only option, as long as the expansion remains in place.”