Why it's so hard to break an opioid addiction
Treatment for more than 100,000 heroin and prescription opioid addicts would no longer be covered under Medicaid if the Senate’s latest Obamacare repeal proposal were to become law.
That’s one ancillary effect of the legislation been pushed by Republican Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana.
These opioid-dependent adults gained access to treatment through provisions in Obamacare that allowed states to expand Medicaid coverage to, among others, the working poor, including childless adults.
Thirty-two states did so, although many of the people receiving treatment for their addiction are residents of Ohio, Kentucky, West Virginia and Pennsylvania -- states that voted for Donald Trump in the 2016 election and have been hit hard by the opioid epidemic, said Richard G. Frank, a health economics professor at Harvard Medical School.
The Republican bill, which could get a vote in the Senate this week, would shut out the addicts by repealing the Affordable Care Act’s Medicaid expansions, beginning in 2020.
In 2015, roughly 99,000 Medicaid expansion enrollees had an opioid-use disorder, Frank said.
“But we know the epidemic has been growing. The mortality is growing at 15 percent a year. So that 99,000 is going to be quite a bit bigger now,” Frank said.
In Ohio alone, more than 25,000 people with an opioid use disorder gained coverage through the Medicaid expansion, Frank said.
Eighteen of the 26 states with opioid overdose death rates above the national average have expanded Medicaid eligibility, according to the Kaiser Family Foundation.
In Trumbull County, Ohio, a longtime Democratic stronghold that Trump won in 2016, there were 18 overdoses in one night last week, said Rep. Tim Ryan, an Ohio Democrat who chairs the House Addiction Treatment and Recovery Caucus.
As Trump pushes for passage of Graham-Cassidy, Trumbull residents and other blue-collar Trump voters are being betrayed by the president and congressional Republicans, Ryan said. While they’ve expressed concern about the nation’s opioid problem, they’re working to slash funding for Medicaid, he said — the very program that treats and counsels more than 650,000 of the nation’s estimated 2.2 million adults with a heroin and/or opioid addiction.
“It’s classic Trump,” Ryan said. “Those people voted for him because they thought he was going to help them with issues like this and here they are pushing something that will have a detrimental effect on them.”
Graham-Cassidy would also allow states to weaken or eliminate requirements that individual insurers cover essential health benefits, including substance-use disorder services. And it eliminates subsidies that help people purchase health insurance in the marketplace, thereby making private coverage that includes substance abuse treatment less affordable.
“Opioid addiction is disproportionately an illness of the poor. So what you’re seeing is an assault on the medical care of poor people,” Frank said of the legislation.
Unlike the previous Senate GOP repeal measure that provided $45 billion for opioid treatment, Graham-Cassidy provides no such funding.
At Monday's Senate Finance Committee hearing on the legislation, Theresa Miller, Pennsylvania's Health and Human Services Secretary, was asked if she thought more people would die from opioid addiction under the legislation.
"I'm afraid they will," she replied.
Republican Sen. Ron Johnson of Wisconsin, a co-sponsor of the legislation along with Sen. Dean Heller of Nevada, recently acknowledged the bill is far from perfect. But he said time is of the essence with a Sept. 30 deadline to pass the bill on a simple majority vote that prevents a Democratic filibuster.
"This our last shot," Johnson recently told reporters. "I will never let perfect be the enemy of the good…Graham-Cassidy-Heller-Johnson is a vast improvement. Not perfect. We've still got a ways to go. There'll still be fixes we've got to initiate. But this is far better than Obamacare."
But besides key senators, a host of physician, hospital, addiction and patient advocacy groups have come out against the bill. The board of directors of the National Association of Medicaid Directors last week said the legislation fails “to deliver on our collective goal of an improved health care system.”
Funding for marketplace subsidies and states Medicaid expansions under Obamacare would, under Graham-Cassidy, be converted into lump-sum block grants that states could use to help bolster coverage through high-risk pools, premium assistance, cost sharing and other efforts.
But most experts say the funding under the bill won’t make up for the loss of private and Medicaid coverage.
As people lose their coverage, which provides treatment, counseling, medication and other services to fight addiction, many “will retreat to using opioids as a means for managing their lives, which feeds the addiction,” said Kenneth Rogers, a Sacramento psychologist who treats opioid addicts.
“I’ve had patients tell me, ‘Look, Dr. Rogers, I know you don’t want me to go on the street and get something, but I’ve got nothing else…And I need to get by. I need to live my life, to somehow manage things.’ And they’re going to do that. They’re going to find whatever means they can.”
While the opioid problem crosses all racial and ethnic groups, research suggests that non-Hispanic white males would feel an outsized impact with the loss of Medicaid coverage.
Of an estimated 441,000 uninsured opioid addicts in 2015, more than 291,000, or 57 percent, were non-Hispanic white males, according to an analysis of government survey data by Julia Zur, a senior policy analyst at the Kaiser Family Foundation.
Among these white male addicts, an estimated 60 percent had a high school diploma or less, almost all were low-income – with 37 percent living in poverty. And 88 percent were childless, with neither sole nor shared custody of a minor.
Zur said many of them would have qualified for Medicaid if their states had opted for the expansion.
“Not only would these people likely remain uninsured under the Graham/Cassidy bill, but many more people who currently have Medicaid would likely lose their coverage. So the number of nonelderly adults with opioid addiction who are uninsured would likely become substantially larger,” Zur said.
In Ohio, 95 percent of people who gained coverage through the Medicaid expansion previously had been uninsured, “so they don’t have a private option to go back to,” said Eric Seiber, a health services professor at Ohio State University.
Seiber, who studied Ohio’s Medicaid expansion population, said demographically they’re “much more white and male than old Medicaid was.”
If Graham/Cassidy becomes law, Seiber said many of the expansion enrollees who lose coverage will seek assistance at county health clinics.
“But they don’t have the money to treat the scope of the epidemic,” he said.