Fate of Medicaid expansion rests with senators from drug-torn states

Republican Sens. Rob Portman of Ohio and Pat Toomey of Pennsylvania are in the epicenter of the nation’s opioid addiction crisis.

Both their states experienced record spikes in drug overdose deaths in 2015—a 20.5% increase in Ohio, to 3,050, and a 30% jump in Pennsylvania, to 3,500.

The two states have something else in common. Both expanded Medicaid under the Affordable Care Act, extending coverage to more than 1.4 million low-income adults. As a result, an estimated 150,000 Ohioans and 63,000 Pennsylvanians received addiction treatment.

But now Portman and Toomey are tasked by Senate Majority Leader Mitch McConnell (R-Ky.) to come up with a compromise between GOP conservatives and moderates on capping Medicaid spending and rolling back the ACA’s Medicaid expansion. That’s a key disagreement holding up Senate Republicans’ version of ACA repeal-and-replace legislation.

McConnell’s assignment puts Portman and Toomey in a very tough and highly visible spot. Phasing out enhanced federal funding for Medicaid expansion would end coverage for hundreds of thousands of people—including many with substance abuse disorders—because the states couldn’t afford to continue the expansion on their own. The commercial health plans that Republicans propose as a substitute generally don’t offer benefits for substance abuse treatment that are nearly as good as what Medicaid offers, providers say.

Before the expansion, “we’d be in the unfortunate situation seven months into the fiscal year of telling people, ‘You need detox. We’ll detox you, but we don’t have the next level of care you need,’” said Jack Carroll, executive director of the Cumberland-Perry Drug & Alcohol Commission, which manages public funding for substance abuse treatment in the two Pennsylvania counties. “That’s like telling someone with a broken leg that we can’t afford a cast so we’ll give you an Ace bandage.”

But that’s what many people with addictions in America hear. Nearly 3 million U.S. residents were addicted to prescription opioids or heroin in 2015. Medicaid provided coverage to more than 650,000 of them, according to the Kaiser Family Foundation. It’s the biggest single payer for substance abuse treatment, covering about about 21% of the nation’s $33.9 billion bill in 2014, according to a 2016 Health Affairs article.

That coverage makes a difference: Medicaid beneficiaries are twice as likely as the uninsured to receive residential or outpatient treatment.

Ending the Medicaid expansion “would be nothing short of disastrous for my state,” said GOP Pennsylvania state Rep. Gene DiGirolamo, who chairs the state’s House Human Ser-

Receiving treatment and getting sober is “a lifechanging experience. I never could have thought this was possible. I’ve done a lot of wrongs in my life. Now I’m able to get back to a lot of people back home and help out people in the community.”

Johnny Wade, left, a recovering client, and Andrew Albrecht, executive director of the Counseling Center

Ending the Medicaid expansion “would be nothing short of disastrous for my state.”

Gene DiGirolamo Pennsylvania state representative and chair of the House Human Services Committee

vices Committee. “If the expansion goes away, people with drug and alcohol addiction will show up at hospital ERs, go back on the street, and end up in jail or tragically dead.”

Portman says he wants to repeal enhanced Medicaid expansion funding slowly—to protect those with addictions. “We have an opioid crisis in this country, and I’m going to continue to work with my colleagues on solutions that ensure those who are impacted by this epidemic can continue to receive treatment,” he said in response to the House’s passage of the American Health Care Act last month.

In contrast, Toomey wants rapid repeal of the extra federal funding, telling reporters last month that “no one will lose their federal Medicaid eligibility and no one currently covered by Obamacare will have the rug pulled out from under them.” Toomey, a noted hawk on budget deficit issues, also is pushing to cap the growth of Medicaid spending more tightly than in the House bill, which experts say would further reduce funding for substance abuse and mental health treatment.

The two senators reportedly haven’t yet reached a compromise solution. “We are trying to find some common ground,” Toomey told reporters.

Their offices did not make the senators available for interviews for this article.

Changes to the ACA’s required coverage for essential health benefits and pre-existing conditions could also reduce access to addiction treatment, experts say.

Despite a federal law requiring parity in benefits for physical and behavioral care, private plans often don’t cover needed services at the same level as Medicaid does. Plus, the high deductibles in private plans mean that individuals and families often have to pay several thousand dollars toward the cost of a detox or rehab stay before insurance kicks in.

Carroll of the Cumberland-Perry Drug & Alcohol Commission says it’s difficult even for someone with a good insurance plan to access addiction treatment comparable to that provided by Medicaid.

Lauryn Wicks of Mechanicsburg, Pa., can corroborate that. She went through a harrowing experience in 2009 seeking addiction treatment for her son, even though she had a rich private health plan. Her family ended up having to refinance their home and borrow money from relatives to pay tens of thousands of dollars for out-of-pocket expenses for her son’s treatment. She now works with several advocacy groups seeking better access to addiction treatment services.

In February, while Wicks was on Capitol Hill to testify before an opioid addiction task force, she and her colleagues visited Toomey’s office and spoke with one of his staffers to urge full funding for federal reform initia- tives on mental health and substance abuse treatment. One of her advocacy colleagues attending that meeting had lost a child to addiction and had two other children who were incarcerated due to opioid disorders.

Johnny Wade, 31, of New Boston, Ohio, who was uninsured before Medicaid expanded in his state, has been sober for 20 months after receiving intensive treatment. Now, he works as a janitor at the agency where he got sober and lives in supportive housing there. “I never could have thought this was possible,” Wade said, adding that he’s trying to help others in the community.

Wicks wonders how personal stories like that—which Toomey and other members of Congress regularly hear from their constituents—could fail to change her senator’s viewpoint.

“It’s baffling to understand Sen. Toomey’s position,” she said. “In the midst of the worst public health crisis of our time, it would put so many lives at risk. I cannot understand what would be gained.”