It is now clear that a repeal of the Affordable Care Act’s Medicaid expansion will remove a key source of treatment for people suffering from addictions. Proposed cuts would severely impact a number of states that have been hit hardest by the opioid epidemic such as Kentucky, Ohio, Nevada and West Virginia.
Those states have effectively used the Medicaid expansion to fight the epidemic. Thousands of lives have been saved through the purchase of the opioid reversal drug naloxone and by increasing the use of Medication Assisted Treatment paid for by Medicaid. Prior to the Medicaid expansion, states that subsequently expanded and those that did not expand Medicaid treated similar numbers of people with Medication Assisted Treatment. Today the expansion states treat four times as many people as in 2009 — while the non-expansion states treat roughly the same number as they did then.
Republican Senators and members of the Trump administration have argued that ending the expansion would not harm people in the expansion states because, under the Better Care Reconciliation Act, they would instead be able to purchase private health insurance. As the Congressional Budget Office has shown, the high deductibles ($13,000), modest premium subsidies, and likely waivers of the Essential Health Benefit in the BCRA mean that the claim is surely false. Under the BCRA, people with low incomes and at elevated risk for substance use disorder who gained coverage under the Medicaid expansion would lose Medicaid and access to care through private insurance would be financially out of reach.
People with private insurance who have a substance use disorder are likely to lose coverage as well. Private plans, including those participating in the Health Insurance Marketplaces, have seen large increases in people seeking care for an opioid use disorder, a doubling according to a recent Blue Cross-Blue Shield Association Report. Under the BCRA, CBO projects private plans would be less likely to cover opioid addiction prevention and treatment. Millions of current enrollees would lose health insurance coverage altogether due to reduced subsidies, higher premiums, and higher deductibles.
What does that mean for states? In Nevada, an estimated 34,017 people with a substance use disorder are covered under the state’s Medicaid expansion, while 12,864 people with an SUD are enrolled in Marketplace plans and receiving a subsidy. In Ohio, an estimated 68,000 Ohioans with an SUD would lose Medicaid coverage — including about 444 whose lives have been saved in 2016 through Medicaid-paid naloxone. In West Virginia, 50,000 people were treated for a SUD related problem in 2016 that was paid for by the Medicaid expansion at a cost of $112 million. The BCRA promises only inadequate block grants to replace this support for SUD care.
How will these people get treated and how will the states be able to absorb the costs? The sad fact is that people with addictions, their families, their providers, and their Senators cannot fund necessary care for pennies on the dollar. Quite simply, this bill will increase the suffering and risk of death for some of the most vulnerable Americans. Bipartisan health policy proposals have historically sought to protect our sickest and weakest neighbors. Our commitment to doing so is inscribed on government buildings. It is time for politicians to follow the Hippocratic oath that is demanded of our nation’s healers: First, do no harm.
Richard G. Frank is the Margaret T. Morris Professor of Health Economics in the Department of Health Care Policy at Harvard Medical School. He previously served as the assistant secretary for Planning and Evaluation at the Department of Health and Human Services.
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