Trumpcare would result in millions more people going uninsured, but it would be particularly harmful for people who have substance abuse problems and depend on Medicaid expansion for treatment.
The Affordable Care Act (ACA) required that Medicaid cover basic mental health and addiction services, but that requirement would be phased out in 2020. Medicaid expansion in 31 states and the District of Columbia increased access to substance abuse treatment for people addicted to opioids, since medicine to treat people struggling with the addiction is very expensive. Before expansion, Medicaid covered mostly pregnant women, poor children, and people with disabilities, and even those groups had to have very low incomes to be considered eligible.
About 1.3 million people receive treatment for mental health and substance abuse disorders under the expansion, according to a recent estimate from professors at New York University and Harvard Medical School.
Experts on substance abuse and Obamacare explained how the GOP health care plan would affect people seeking treatment for addiction to opioids in a press call on Tuesday. Gary Mendel, founder and CEO of Shatterproof, a national nonprofit focused on helping families living with addiction, who lost his son to substance abuse, said that if Trumpcare becomes law, it “will cause enormous human suffering.”
“This epidemic is bipartisan. The only difference is that Republicans would decimate the ACA to gain political points,” Mendel said.
People suffering from opioid addiction tend to have lower incomes. As of 2011, the rate of overdose deaths from opioid prescription drugs was highest in states with higher poverty levels, according to the Centers for Disease Control. There were 33,000 deaths from opioid-related overdoses in 2015 alone.
The opioid epidemic is partly the result of doctors prescribing patients too freely or without any information on addiction risk. Doctors are uneven in their likelihood to prescribe opioids. Some doctors are three times more likely to prescribe them than other doctors in the same hospital. Opioids used to be reserved for acute pain, but in the 1980s, researchers began to advocate for broader use of opioids. Prescription opioid use in a given month increased from 3.4 percent to 7 percent from 1994 to 2006, and Americans now use six times more opioids per person than they did 20 years ago, according to the CDC.
Opioids are highly addictive, and often drive younger users who recreationally use prescription pain medication to the black market where they can get access to cheap heroin. Older people who have greater access to pain medication are also vulnerable to opioid addiction. The rate of drug overdose involving synthetic opioids nearly doubled between 2013 and 2014.
Mendel gave the example of a lower middle class woman who goes to a community college and succeeds academically but gets hurt in a soccer game and goes to the doctor.
“She gets medication from her doctor and gets addicted. She can’t get a job but she has Medicaid, and maybe she starts to do OK. If this law happens, she will slide backward and may turn to a life of crime. And the only way she can get back on Medicaid is to get pregnant,” Mendel said.
The highest rates of drug overdose deaths were in West Virginia, New Mexico, New Hampshire, Kentucky, and Ohio. Florida, Maryland, Maine, Ohio, and Pennsylvania reported sharp increases in illicit fentanyl seizures and people who died from a suspected fentanyl overdose. Illicit fentanyl is sold as or combined with heroin.
West Virginia and Kentucky may be particularly suspectible to a repeal of the ACA because both states are struggling with major opioid epidemics and are likely to see some of the biggest job losses as a result of a repeal. A recent Economic Policy Institute report projected that job growth could fall by almost 1.2 million in 2019 as the result of an ACA repeal, because low-income and middle-income Americans would have to spend more on health care. If there were an economic slowdown as a result of the ACA, there would be more economic insecurity, which would likely leave more people without treatment.
Treatment providers will also suffer under the Republican health care plan, because they would no longer have a stable base of funding, said Michael Botticelli, former director of the White House Office of National Drug Control Policy. This would hit rural parts of the United States the hardest, since the ACA allowed treatment providers to expand services in those areas.
“There will be no safety net [under the Republican plan] … You’re going to see treatment providers go out of business. It would endanger the treatment provider infrastructure in the U.S,” Botticelli said.
The Republican health care plan would be particularly harmful to older and low-income Americans suffering from substance abuse, said Dr. Richard Frank, professor of health economics at Harvard Medical School and former assistant secretary for planning and evaluation at U.S. Department of Health and Human Services. Since older Americans can be charged up to five times more than younger Americans under the health care plan, Frank said he is concerned.
“In recent years, rates of opioid abuse have gone up in the 35 to 50 category, and costs are going up for older Americans [under the plan],” Frank said.
Frank added that the population the ACA targeted with Medicaid expansion — poor Americans — are the same population where treatment rates for opioid addiction were going up.
Republicans in states particularly affected by opioid abuse have said Medicaid expansion has helped them combat drug abuse, like Ohio Gov. John Kasich (R) and New Hampshire Gov. Chris Sununu (R).
“Thank God we expanded Medicaid because that Medicaid money is helping to rehab people,” Kasich said to reporters in January.
“There’s no doubt expanded Medicaid has provided (drug) recovery, treatment options for a lot of folks that otherwise may not have had that option available,” Sununu said when he explained why he is not supporting the Republican health care bill.
Republican senators said they were worried about the phasing out of Medicaid under the Republican health care bill. Four Republican senators wrote in a letter to Senate Majority Leader Mitch McConnell (R-KY). Sen. Shelley Moore Capito (R-WV), Sen. Lisa Murkowski (R-AK), Sen. Rob Portman (R-OH), and Cory Gardner (R-CO) wrote, “As the largest payer of mental health and substance use services in the United States, it is critical that any health care replacement provide states with a stable transition period and the opportunity to gradually phase in their populations to any new Medicaid financing structure.”