Senators consider killing Medicaid expansion that helps residents from their drug-torn states

Republican Sens. Rob Portman of Ohio and Pat Toomey of Pennsylvania represent states at 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 700,000 low-income adults in each state. That expansion has enabled an estimated 150,000 Ohioans and 63,000 Pennsylvanians to get addiction treatment.

"Thank God we expanded Medicaid because that Medicaid money is helping to rehab people," Ohio GOP Gov. John Kasich said in January.

But now the two senators find themselves at the turbulent center of the Republican drive to repeal and replace Obamacare. They've been asked by Senate Majority Leader Mitch McConnell to come up with a compromise between GOP conservatives and moderates on capping Medicaid spending and rolling back the ACA's Medicaid expansion to low-income adults. 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. Substance abuse rehab providers, lawmakers and policy experts in Ohio and Pennsylvania warn that phasing out enhanced federal funding for Medicaid expansion would effectively 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.

On top of that, the commercial health plans that Republicans want to offer as a substitute generally don't offer benefits for substance abuse treatment that are nearly as good as what Medicaid offers, providers say.

All this would mean lots of people in Ohio, Pennsylvania and other states who are in desperate need of addiction treatment likely wouldn't get it, because state and county funding would fall short of meeting the soaring demand, as it did before the Medicaid expansion, experts 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 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."

With nearly 3 million Americans addicted to prescription opioids or heroin in 2015, Medicaid provides coverage to more than 650,000 non-elderly adults with addiction, according to the Kaiser Family Foundation. It's the biggest single payer for substance abuse treatment, covering about $7.1 billion of the nation's $33.9 billion bill in 2014, according to a 2016 Health Affairs article.

That Medicaid coverage makes a difference: People on Medicaid are about twice as likely as the uninsured to receive residential or outpatient treatment. Nearly 441,000 non-elderly adults with opioid addiction were uninsured in 2015.

Ending the Medicaid expansion "would be nothing short of disastrous for my state," said Pennsylvania state Rep. Gene DiGirolamo, a Republican who chairs the Pennsylvania House Human Services 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 tragically dead or in jail."

"The Medicaid expansion is the single biggest thing that's happened to our agency," said Andrew Albrecht, CEO of the Counseling Center, a drug and alcohol treatment center in Portsmouth, Ohio, that serves a lower-income, white community facing a severe opioid and heroin epidemic. "Prior to expansion, we had to ration care. If the expansion ended, we'd have to make some really tough decisions about how many men we could treat."

Portman has called for moderating or at least delaying the repeal of enhanced Medicaid expansion funding, saying the expansion needs to be protected to allow people to continue to receive addiction treatment. He has said he wants a "soft landing" for expansion enrollees and states.

"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 is pushing for 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." He added that the House bill's Medicaid changes "probably" are "a little too sudden" and that he would be open to a "conversation about easing the transition."

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.

Besides phasing out expanded Medicaid coverage, the House Republicans' repeal-and-replace bill being considered by the Senate would allow states to opt out of the ACA's required coverage for essential health benefits such as mental health and substance abuse treatment. In addition, it would allow states to let insurers price plans based on applicants' pre-existing conditions, such as drug addiction. These provisions likely would reduce access to addiction treatment, experts say.

Healthcare providers say it's hard to square the stated concerns of GOP lawmakers such as Portman about ensuring access to substance abuse treatment with their plans to roll back Medicaid and consumer protections in commercial health plans.

Andy Carter, CEO of the Hospital and Healthsystem Association of Pennsylvania, said merely delaying the phase-out of enhanced federal funding for expansion by a few years, as Portman has suggested, wouldn't solve the massive problems the rollback would cause. Eliminating the requirement for plans to cover mental health and substance abuse treatment also would be harmful.

"The reductions in coverage could undermine our efforts to get people into treatment and address the opioid crisis," said Carter, who predicted his state would discontinue the Medicaid expansion if it lost those extra billions in federal dollars.

One beneficiary of Medicaid expansion is Johnny Wade of New Boston, Ohio, who received intensive substance abuse treatment in 2015 and 2016 at the Counseling Center through his state's Medicaid expansion after long being uninsured. The 31-year-old, who said he previously used any drug he could get his hands on, has been sober for 20 months and is working as a janitor at the agency and living in supportive housing there.

Before the Medicaid expansion, Wade probably would not have received treatment at the agency, Albrecht said. That's because he had moved from Springfield, Ohio, to the Portsmouth area to get away from bad influences, but he wouldn't have been eligible for local public funding because he wasn't a permanent local resident.

Receiving treatment and getting sober is "a life-changing experience, I never could have thought this was possible," Wade said. "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."

The Medicaid expansion has allowed the Counseling Center to substantially expand its addiction treatment capacity. Since 2014, it has nearly doubled the number of adult men it has served, from 600 to 1,100. Nearly 400 of those clients were diverted from the county jail. The agency has enlarged its men's program from 16 beds before Medicaid expansion to 72 beds now. Over the last year, half of its male clients have completed the agency's highest level of care.

"It's really opened the doors for the coverage of males to receive drug and alcohol treatment in a way that was never available before," Albrecht said.

The agency also provides physical healthcare services to its clients through its sister agency, Compass Community Health, a federally qualified health center. Medicaid expansion has increased the capacity for delivery of those healthcare services as well, Albrecht added.

As part of the expansion, the agency has added 67 staff jobs, with $2.3 million in additional payroll. Many of the new hires are alumni of the substance abuse treatment program. "Medicaid expansion has provided a jolt to the southern Ohio economy," he said.

Similarly, Gaudenzia, Pennsylvania's largest drug and alcohol treatment provider, has seen a surge in clients since Democratic Gov. Tom Wolf implemented that state's Medicaid expansion in 2015.

The not-for-profit agency, which treats about 20,000 clients a year, traditionally has provided uncompensated services for uninsured clients as part of its mission, said Mark Sarneso, the agency's regional director. Nevertheless, expanding Medicaid has helped a lot because clients and their families are more willing to seek out treatment when they know they have a payment source, he said.

In addition, the flow of Medicaid dollars has eased the strain on state and local funding for substance abuse treatment, which typically would run out halfway through the fiscal year, forcing providers to turn clients away. "Now you don't see counties saying to providers, 'We're out of money.' It's been significant and positive."

Sarneso and other providers caution that shifting Medicaid expansion enrollees into private plans, as Toomey and his GOP colleagues seek to do, will not ensure adequate coverage for substance abuse treatment.

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 the insurance kicks.

"Private coverage is not as good as Medicaid for substance abuse treatment," Carroll said. "It's difficult even for someone with a good insurance plan to access comparable care."

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 borrowing 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 testifying 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 initiatives 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.

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 view that Medicaid expansion must end. She has written to Toomey about the issue but has received no response.

"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."