Medicaid could be deal-breaker

As opioid crisis rages, drug treatment advocates pressure senators from hard-hit states

The Senate GOP health care proposal would dramatically revamp Medicaid, capping future spending on that safety-net program in a way that could cause heartburn for moderate Republicans.

The issue of Medicaid — a joint federal-state program that provides health insurance for the poor, disabled and elderly — is particularly contentious because it’s become a lifeline for those suffering from opioid addiction.

Any cuts to Medicaid could exacerbate an epidemic that is already claiming the lives of 91 Americans every day. As that crisis ravages low-income, rural communities across the country, GOP senators from the hardesthit states — including Ohio and West Virginia — have said they can’t support a bill that restricts access to already scarce addiction treatment.

The law the Republicans are trying to unravel, the Affordable Care Act, has dramatically expanded treatment over the last seven years, mainly through an expansion of Medicaid to cover more low-income, childless adults.

“The expansion population — mostly young and middle-aged adults without a college education — is the group most impacted by the opioid crisis,” said Joe Parks, medical director for the National Council for Behavioral Health and the former director of Missouri’s Medicaid program.

The GOP bill would “take away their coverage for addiction,” Parks said. “It’s kind of like cutting down the water supply before the forest fire is under control.”

The Republican senators most focused on the opioid issue were careful not to condemn the proposal on Thursday, even as they expressed serious concerns about the Medicaid provisions.

The Republican plan includes two big changes to Medicaid. First, it would end the ACA’s Medicaid expansion by slowly reducing the enhanced federal funding that covers the new enrollees over three years, starting in 2021 and ending in 2024.

The second change would cap the federal contribution to states for the entire Medicaid program — giving states a fixed, per-person allotment. That cap would increase over time, but at a lower rate than medical inflation, meaning the federal dollars would not keep up with health care costs.

The House’s health care bill, passed in May, would cut off the extra federal Medicaid expansion money more quickly, in 2020, but set a higher inflation rate for the federal per-capita match.

Conservatives have argued the current Medicaid program is unsustainable, and they pushed the Senate plan to be more aggressive in slowing the growth of that program. Sen. Pat Toomey, R-Pa., was among those championing the lower Medicaid inflation rate.

“This measure does not pull the rug out from anyone currently covered by Obamacare, and keeps the Medicaid expansion covering able-bodied, workingage, childless adults, while asking the states to eventually contribute their fair share for this care,” he said in a statement Thursday. “This bill works to ensure Medicaid is sustainable for future generations by modestly reducing, seven and a half years from now, the rate at which federal spending on the program will grow.”

But while conservatives were happy with that provision, moderates seemed queasy.

The Medicaid change “would translate into literally billions of dollars of cuts, and that would mean states would be faced with very unpalatable cases of restricting eligibility or allowing rural hospitals to go under,” said Sen. Susan Collins of Maine, a pivotal GOP player in the debate.

Governors had urged lawmakers to include more flexibility in the Medicaid program. But Massey Whorley, senior policy adviser to Democratic Gov. Terry McAuliffe of Virginia, said this isn’t what they had in mind.

“The only flexibility we’re being given is the flexibility to make cuts,” Whorley said. “It’s like saying, ‘Hey states, you’re on the hook for all the extra costs.’ ”

Two other key lawmakers — Sens. Rob Portman, R-Ohio, and Shelley Moore Capito, R-W.Va. — had urged GOP leaders to include a seven-year phase-out of the Obamacare Medicaid expansion — ending the higher federal funding for that program in 2027. They also wanted an extra $45 billion in the GOP bill dedicated solely to opioid treatment over the next 10 years.

The plan unveiled on Thursday includes the four-year phase-out and just $2 billion in extra opioid money for 2018.

“It’s not nearly the amount we had asked for,” Capito said after leaving a closed-door GOP briefing on the plan. Capito said she needed to analyze the proposal more thoroughly before she could determine whether to support it.

Portman also is undecided. “I continue to have real concerns about the Medicaid policies in this bill,” he said in a statement.

Collins, Portman and Capito are coming under intense pressure from treatment advocates who fear the GOP bill will be a “death sentence,” as one critic put it, for those suffering from addiction. Earlier this week, a group of substance abuse and mental health groups launched a radio ad campaign urging the trio to oppose the Senate proposal.