Addiction experts have warned that Republican proposals to dramatically cut Medicaid funding could worsen the nation’s growing opioid crisis. So a pair of GOP senators is pushing for a solution: a massive influx of money for treatment to help stave off those effects.
But that makeshift effort may also fall flat, advocates in the recovery community say.
Republican Sens. Rob Portman of Ohio and Shelley Moore Capito of West Virginia, whose states have been devastated by the nation’s opioid epidemic, have suggested in recent interviews they hope to add into the Republican package to repeal and replace Obamacare as much as $4.5 billion each year for the next 10 years in new funding for addiction treatment.
It’s a substantial sum, even within the mammoth reform package. It dwarfs the $1 billion that legislators included in last year’s 21st Century Cures Act for two years of funding for state efforts to address opioid abuse. One reluctant House moderate was won over with $8 billion in extra funding aimed at helping people with preexisting conditions. The ask from Portman and Capito is more than five times larger.
Behind that sum is a recognition that the rest of the repeal package will ultimately leave many of the Americans who are currently receiving addiction treatment without health insurance coverage. Republican senators are currently negotiating exactly when to phase out Obamacare’s expansion of the Medicaid program that helped more low-income adults get coverage. And they are eyeing a series of longer-term cuts to the broader program’s federal financing that were also included in the House version of the package.
Medicaid currently pays for about 1.2 million adults to receive opioid addiction treatment, according to an analysis from Harvard and New York University researchers. Repealing the expansion, those researchers found, would rescind about $4.5 billion in annual funds that currently cover addiction treatment.
The solution, at least according to Portman and Capito, is to insert that money back into the system, albeit as a grant rather than within the Medicaid system. The number could still shrink, however, as Republicans spend this week hammering out many of the remaining provisions of their repeal plan.
“Rob believes any replacement bill must do something significant to address the substance abuse problems that are gripping this country,” a Portman spokesman told STAT.
Addiction experts fighting the epidemic, however, said the senators’ proposal overlooks the complicated spiral in health issues that can be brought on by addiction.
“Sure, yeah, you know, it sounds wonderful. Here’s billions of dollars to help combat this issue. But the issue is larger than that,” said Mark Drennan, the executive director of the West Virginia Behavioral Healthcare Providers Association.
Individuals with an opioid addiction are much more likely than the general population to suffer from hepatitis C, post-traumatic stress disorder, and anxiety, among other conditions. Even if additional funding made treatment services available, it wouldn’t help those struggling with addiction address those other medical issues.
“One of the things we’ve seen over and over again is that when you give people supplemental services around addiction treatment — you take care of their pain, you take care of their depression, you take care of their unmanaged hepatitis C, they’re more likely to recover,” said Keith Humphreys, a Stanford University psychiatry professor. “It’s sort of like saying we’re going to treat somebody’s pancreas but not touch the rest of them. It’s really hard to do that with people; things tend to be interconnected.”
Said Drennan: “It’s the chicken and the egg — which came first? Does someone have a mental health condition or physical health condition that’s led them toward addiction, or vice versa? It happens both ways.”
Another universal fear for the Washington advocates working to curb the crisis: Congress is far more likely to cut grant funding, which requires an annual appropriation, than to cut Medicaid, which does not. President Trump, for example, included in his 2018 budget request the $500 million for opioid deterrence efforts that was authorized by the Cures Act. But he proposed slashing the budget of the mental health agency that oversees much of the addiction treatment effort by $400 million at the same time.
“What gets cut?” asked Chuck Ingoglia, senior vice president of public policy and practice improvement at the National Council for Behavioral Health. “I also worry, if this is not mandatory spending, where’s that money going to be taken from to help pay for it?”
Not every advocate decried the congressional efforts to overhaul the Medicaid program. Andrew Kolodny, co-director of opioid policy research at Brandeis University, pointed out that even with the coverage gains under the Affordable Care Act, the crisis was growing worse, not better.
“It’s not as if people with Medicaid have good access to this medicine, and if they lose their Medicaid, it’s going to have a big impact — it won’t,” he said. “People losing access to Medicaid will make the opioid crisis worse, but not that much worse. There’s not that much further to fall.”