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The Republicans’ Jekyll And Hyde approach to denting the opioid crisis

"I think policymakers are running in two different directions at the same time."

Speaker of the House Paul Ryan (R-WI) speaks to reporters during a press conference held to address the rising rate of opioid related deaths in the Capitol Visitor Center HVC Studio A Thursday June 14, 2018. (CREDIT: Sarah Silbiger/CQ Roll Call)
Speaker of the House Paul Ryan (R-WI) speaks to reporters during a press conference held to address the rising rate of opioid related deaths in the Capitol Visitor Center HVC Studio A Thursday June 14, 2018. (CREDIT: Sarah Silbiger/CQ Roll Call)

This week, the House has been voting on dozens of opioid bills ranging from monitoring prescriptions better to money for recovery coaches — a culmination of lawmakers’ work over the last year and a half. But as Congress works to make a dent in a drug epidemic that kills 115 people daily on average, many of these same lawmakers endorse ideas that undermine how people access addiction treatment.

So how far can piecemeal bills go when the Trump administration and Republican lawmakers continue to undermine insurance elsewhere, be it the plans offered on the Obamacare marketplace or Medicaid? It depends on who you ask.

House members have advanced a handful of bills (and considered 39 bills total) this week that could make a sizable difference. One, for example, creates a student loan repayment program for participants willing to work in addiction treatment, thus addressing an existing provider shortage; it passed by voice vote.

While GOP lawmakers have tried to focus attention to these bills in an election year, they’ve also faced reporter questions on whether they support the Trump administration’s decision to no longer defend in the Affordable Care Act (ACA) in court. (The Department of Justice is instead arguing protections for people with pre-existing conditions is unconstitutional after congressional Republicans voted to repeal the individual mandate in December.) Many Republicans have either distanced themselves from the White House position or declined to comment altogether.

“Before the ACA, in the individual market at least, people who had substance use disorder were really left without options for coverage in most states.”

It’s likely because these protections are very popular. Life for people with substance use disorder, for example, was especially difficult before coverage protections like guaranteed issue or community rating that allowed them to enroll in health insurance and pay the same premium as anyone else.

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“Before the ACA, in the individual market at least, people who had substance use disorder were really left without options for coverage in most states,” said Dania Palanker, an assistant research professor with Georgetown University’s Center on Health Insurance Reforms.

A recent study she co-authored found that if people didn’t have public or employer insurance and so tried to buy health plans directly from insurers, 28 states did not require companies to offer mental health services. And when insurers did cover people with mental health or substance use disorder, they charged them 20 to 50 percent more in premiums while also excluding the very services these people likely needed.

While many Republicans take issue with removing protections for people with pre-existing conditions, they support other GOP ideas that effectively do this.

Rep. Greg Walden (R-OR), for example, is the congressman leading the opioid legislation on the House side. He said he doesn’t want to “go back to the days when you can be denied insurance based on a pre-existing condition.”

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But he has also called Trump’s plan to free up short-term insurance “another important step taken by the administration to expand consumer choice, competition, and access to health care.” A recent Kaiser Family Foundation study found 62 percent of these plans do not cover substance use disorder treatment, for both alcohol and other drugs.

“You have a situation where they are trying to solve the problem with some solution but taking away what we know works at the same time, which is access to evidence based medical care,” Palanker told ThinkProgress.”I think policymakers are running in two different directions at the same time.”

Source: Kaiser Family Foundation analysis of the 2016 National Survey on Drug Use and Health
Source: Kaiser Family Foundation analysis of the 2016 National Survey on Drug Use and Health

When the Washington Examiner asked whether Walden thinks the ACA gave people struggling with addiction more access to treatment, he largely agreed.

“While certainly you’ve seen an unprecedented expansion of Medicaid, which puts more money out into the communities. And so of course you’re going to spend more money, you’re going to get more coverage. But there are budgetary issues,” said Walden.

“It’s very tough for me to understand how somebody can say ‘I support ending the opioid epidemic’ but then… throw a wrench into things like Medicaid.”

He added, “not everyone’s on Medicaid ok, so you’ve got Medicare issues, you’ve got Medicaid issues, you’ve got private pay issues but what you really have is an addiction issue.”

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The ACA wasn’t the panacea for addiction treatment coverage. There are still countless testimonies from people who say their provider doesn’t cover their medication. Vox recently shared a story of one woman’s experience where her insurer, Blue Cross and Blue Shield of Illinois, wouldn’t pay for buprenorphine, evidence-based medication that curbs cravings. A similar situation is playing out in North Carolina.

“Addiction is one of those rare diseases that impacts every aspect of public health and calls on every strategy,” said Andrew Kessler, the founder of Slingshot Solutions, a consulting group working closely with Congress, and longtime advocate on addiction treatment.

And that means improving what both public and private insurance cover, and not weakening it, he said.

“It’s very tough for me to understand how somebody can say ‘I support ending the opioid epidemic’ but then if you throw a wrench into things like Medicaid — Medicaid is the connective tissue of all of public health. No public health problem can be solved without it, ” Kessler told ThinkProgress.

While lawmakers are considering bills that can improve Medicaid — for example, one Senate bill aims to remove lifetime limits on medication — many Republicans are simultaneously hoping to bring back ACA repeal. And many of the GOP health bills sunset the ACA’s Medicaid expansion, which allowed states to cover more low-income people.

Various health experts have told ThinkProgress Congress needs a sustained effort to fight this. That means making it easier to get addiction treatment than it is to get fentanyl. And quality insurance makes it easier.

Much of the major legislation currently under consideration just scratches the surface, and some bills might do more harm than good. Specifically, many experts are wary of a bill to free up Medicaid dollars exclusively for opioid addiction treatment in facilities with more than 16 beds. (This bill is also the costliest measure.) Like their shortsighted view on insurance, various experts told ThinkProgress, this bill is an example of some lawmakers focusing too closely on opioids and not enough on the underlying issues of addiction.

“I’m so appreciative of Congress running with this ball, but we want to get it right. The bite of the apple we have with Congress paying this much attention doesn’t come around too often, and who knows how many more bites of the apple we are going to get,” Kessler told ThinkProgress. “Whatever it is — whether it’s crack, methamphetamine, opioids, synthetics — it’s all addiction. And if we don’t take this opportunity with the attention that we have on the issue to really make that stick, we are going to waste a golden opportunity.”