What’s opioid addiction treatment without health insurance? Expensive. Nearly one in 10 people receive treatment, and nearly a third of those people cited high costs and no insurance as a barrier, according to the Substance Abuse and Mental Health Services Administration.
The Trump administration’s health care track record so far — riddled with efforts to weaken insurance access, specifically for lower income people — undermines a White House that says it’s trying to “win” the fight against the opioid epidemic. Against this back drop, President Donald Trump’s opioid commission released its list of recommendations Wednesday on how best to address the opioid crisis, a move that suggested subsequent robust action.
“After we review and evaluate the commission’s findings, I will quickly move to implement, approximate, and appropriate recommendations,” said Trump during his public health emergency declaration last week.
While the Trump administration has recently made some positive steps under declaration authority — action that’s said to expand Medicaid for opioid addiction treatment in two states — elsewhere, it has scaled back the entitlement program. All of this happened this week; and it looks to be a microcosm for an administration that advocates for treatment, but is reluctant to unequivocally back insurance that helps cover this care: Medicaid.
Medicaid covers about three in 10 people who struggle with opioid addiction. The insurance facilitates access to medical care like medication-assisted treatment (MAT), which is medication like buprenorphine coupled with counseling. Expansion of the Medicaid program has improved efforts to combat the opioid crisis by improving access to treatment — just look at Vermont.
Trump’s opioid commission did stress the importance of treatment throughout the 131-page report. Among the 56 recommendations was eliminating barriers to opioid use disorder medication. Specifically, the report advised the federal government and even private insurers to cover a larger range of treatment.
Some public health experts said the report failed to stress the importance of health insurance when talking about treatment. Baltimore City Health Commissioner Leana Wen, a doctor on the front lines of the epidemic, criticized the report for not going far enough, as it doesn’t “advocate for taking all the necessary steps to expand health insurance.” Like protecting Medicaid, she said. (The report minimally mentions Medicaid and commission members didn’t mention the program at all in their pitch to the White House.)
Underpinning this report is Trump’s health care policy decisions thus far. The current administration supported legislation that would repeal the Affordable Care Act (ACA) and shred Medicaid, undermined the ACA’s essential health benefits provision that ensures coverage for substance use disorder, and openly rejects the Medicaid expansion. In fact, Trump’s opioid commission member and former Rhode Island congressman Patrick Kennedy told CBS News that Trump’s health agenda limited the report and added he wished it “made a strong play for insurance coverage for all.”
Similar to the administration’s “Jekyll and Hyde” approach to sabotaging ACA, it did take concrete steps to expand insurance — specifically Medicaid — in two states. The Centers for Medicare and Medicaid Services (CMS), an arm of the Department of Health and Human Services (HHS), approved waivers submitted by state officials in New Jersey and Utah that are intended to improve residents access to opioid addiction treatment.
Specifically New Jersey allowed Medicaid funds to be used for residential treatment facilities and MAT. And Utah partially expanded Medicaid to 6,000 people who are homeless, in jail, or struggle with opioid addiction. CMS announced it was part of a new policy that prioritizes access to addiction treatment by way of giving states flexibility to reshape the Medicaid program.
While activists applauded these policy decisions, CMS also approved an Iowa waiver that is said to compromise Medicaid coverage for roughly 40,000 residents “to save $37 million,” according to Axios. As Brad Wright, an assistant professor at the University of Iowa’s College of Public Health, described to ThinkProgress, a person could walk into a hospital and receive robust service if the person was likely eligible for Medicaid but not enrolled, prior to the waiver. Now with the “retroactive” benefits cut, health care providers will be less incentivized to provide comprehensive services because they no longer expect to be reimbursed.
“In the context of opioids, that means emergency treatment and the administration of Narcan are unlikely to be affected, but longer term substance abuse treatment will be delayed by at least three months,” Wright told ThinkProgress. “That’s a long time in the world of an addict, and involves significant risk of relapse that often proves lethal. Thus, while I can’t give you a number, this move by the state to restrict eligibility is likely to cost some addicts their lives.”
Several other states have applied for waivers that would fundamentally change the Medicaid program, like implementing work requirements or premiums. The question is, will CMS approve them now that the White House says it will be prioritizing the opioid crisis? Judith Solomon, vice president of health policy at the Center on Budget and Policy Priorities, told ThinkProgress she is closely watching Kentucky’s waiver that imposes strict work requirements. Like the rest of the country, Kentucky is battling its own opioid epidemic.
“They can’t meet a work requirement because they need to be in treatment,” Solomon said of people struggling with opioid use disorder.
It’s important to point out that it’s a tall order to effectively address a public health crisis of this magnitude, which kills tens of thousands each year. For all the praise the Obama administration has received for the 21st Century Cures Act, which designated $1 billion for treatment, there were many deficiencies. Even so, there’s nothing redeeming about a cherry-picked approach to the opioid crisis.