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

Modern Healthcare - - NEWS - By Har­ris Meyer

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.”

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