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GOP health-care bill would drop addiction treatment mandate covering 1.3 million Americans

By Katie Zezima, Christopher Ingraham

March 9, 2017 at 8:48 PM

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Republicans confirmed substance abuse and mental health coverage would no longer be mandated under the Medicaid expansion. Instead, individual states could decide whether or not to include mental health coverage in their Medicaid plans. (Energy & Commerce Democrats)

The Republican proposal to replace the Affordable Care Act would strip away what advocates say is essential coverage for drug addiction treatment as the number of people dying from opiate overdoses is skyrocketing nationwide.

Beginning in 2020, the plan would eliminate an Affordable Care Act requirement that Medicaid cover basic mental-health and addiction services in states that expanded it, allowing them to decide whether to include those benefits in Medicaid plans.

The proposal would also roll back the Medicaid expansion under the act — commonly known as Obamacare — which would affect many states bearing the brunt of the opiate crisis, including Ohio, Kentucky and West Virginia. Thirty-one states and the District of Columbia expanded Medicaid under the ACA.

"Taken as a whole, it is a major retreat from the effort to save lives in the opiate epidemic," said Joshua Sharfstein, associate dean at Johns Hopkins Bloomberg School of Public Health.
Advocates and others stress that mental-health disorders sometimes fuel drug addiction, making both benefits essential to combating the opioid crisis.

Related: [Where opiates killed the most people in 2015]

Nearly 1.3 million people receive treatment for mental-health and substance abuse disorders under the Medicaid expansion, according to an estimate by health care economists Richard G. Frank of the Harvard Medical School and Sherry Glied of New York University.

House Republicans confirmed the benefit cuts during a meeting of the House Energy and Commerce Committee on Wednesday. Republicans on the committee argue that the change would give states additional flexibility in coverage decisions, and believe they would continue to provide addiction and mental-health coverage to Medicaid recipients if needed.

During the committee meeting, Rep. Joe Kennedy (D-Mass.) asked a GOP staffer whether those benefits are "no longer essentially covered, or required to be covered, by this version of this text. Is that not correct?"

"The text before us does remove the application of the essential health benefits for the alternative benefit plans in Medicaid," a lawyer for Republicans on the committee responded.

"Including mental health?"

"Yes."

Rep. Joe Kennedy (D-Mass.) said he and Rep. Peter Welch (D-Vt.) introduced an amendment during the committee meeting to include mandates for substance abuse and mental-health coverage, but it was voted down along party lines.

Several Republican senators expressed concern about removing the benefits. Sens. Rob Portman (Ohio), Shelley Moore Capito (W.Va.), Cory Gardner (Colo.) and Lisa Murkowski (Alaska) sent a letter to Senate Majority Leader Mitch McConnell (R-Ky.) stating that the plan does not "provide stability and certainty" for individuals and families enrolled in Medicaid expansion programs, or flexibility for states.

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President Trump decried violence he claims plagues American cities in a speech to law enforcement officials in Washington, D.C., Feb. 8. He vowed to have their backs in fighting crime, illegal immigration and drug trafficking. (The Washington Post)

President Trump has made combating the nation's drug-overdose problem a focal point of his campaign and his presidency.
"We will stop the drugs from pouring into our country and poisoning our youth," he said in a speech before Congress last week, "and we will expand treatment for those who have become so badly addicted."

Related: [Opioid distributors sued by West Virginia counties hit by drug crisis]

Trump has endorsed the Republican plan to replace the ACA.

A record number of people — 33,000 — died of opiate overdoses in 2015, according to the Centers for Disease Control and Prevention. Opioids now kill more people than car accidents, and in 2015 the number of heroin deaths nationwide surpassed the number of deaths from gun-related homicides. Authorities are also grappling with an influx of powerful synthetic narcotics responsible for a sharp increase in overdoses and deaths over the past year.

The 15 counties with the highest death rates from opiate overdoses were in Kentucky and West Virginia, according to a group of public health researchers, writing in the New England Journal of Medicine. Both of those states expanded Medicaid. Taking away those benefits, they wrote, would affect tens of thousands of rural Americans "in the midst of an escalating epidemic."

Medicaid pays for 49.5 percent of medication-assisted treatment in Ohio, 44.7 percent in West Virginia and 44 percent in Kentucky when the drug buprenorphine, which is used to manage chronic opiate use disorder, is administered, according to Rebecca Farley, vice president of policy at the National Council for Behavioral Health.

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Chillicothe, Ohio is grappling with an addiction epidemic driven by opioids like heroin. But some here aren’t letting overdoses rule. (Lee Powell/The Washington Post)

Public health officials and advocates say there is a nationwide shortage of treatment programs to serve the growing problem of addiction and its effects, including diseases associated with long-term IV drug use such as hepatitis C and HIV.

Related: [Heroin deaths surpass gun homicides for the first time, CDC data shows]

Shawn Ryan, a doctor with Brightview Health in Cincinnati, which provides addiction treatment mainly to patients on Medicaid, said states are starting to increase drug addiction services to respond to rising needs, but the process could take years.

"The outpatient addiction treatment services that are starting to ramp up . . . they could be crushed by this if not done in a way that specifically protects the most vulnerable populations," he said.

Stripping away addiction treatment services from low-income people is especially harmful, Frank, of Harvard, said in an interview, because the prevalence of drug abuse is much higher for people living well below the poverty line. He said Medicaid recipients who are covered for addiction treatment and maintain their coverage through 2020 would not lose the benefit under the GOP proposal. But, he added, because addiction is a chronic-relapse disease, people may get clean, relapse, stop working and need to go back on Medicaid.

"It's a disease that hits suddenly at various points in the life cycle," Frank said.

Some GOP lawmakers advocate a full repeal of the ACA, a move that would result in loss of coverage for 2.8 million people, 222,000 of whom have an opioid disorder, Frank and Glied, of NYU, estimate.

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Respondents who took part in The Washington Post-Kaiser Family Foundation survey on long-term, opioid painkiller use share their experiences of living with pain. (Monica Akhtar, Erin Patrick O'Connor/The Washington Post)

Gary Mendell, founder of the anti-addiction organization Shatterproof, said the group plans to run campaigns against the rollback in eight states where Medicaid was expanded, urging people to contact their elected officials. Mendell, whose son battled addiction and died in 2011, said the drug-abuse battle has transcended party lines. Last year, Congress passed a landmark bill to fight opiate addiction.

"It's been a bipartisan effort to attack the opiate epidemic," he said, "and now Republicans are putting fighting the opiate epidemic in the back seat to politics."

Correction: A previous version of this story incorrectly named the organization for which Rebecca Farley works. It is the National Council for Behavioral Health. It also misidentified the school for which Joshua Sharfstein works. It is the Johns Hopkins Bloomberg School of Public Health.


Katie Zezima is a national correspondent covering drugs, guns, gambling and vice in America. She covered the 2016 election and the Obama White House for The Post.

Christopher Ingraham writes about politics, drug policy and all things data. He previously worked at the Brookings Institution and the Pew Research Center.

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