Senate repeal bill's fate may hinge on funding for addiction treatment

Two moderate Republican senators from states hit hard by the opioid addiction epidemic are pushing to add a reported $45 billion in 10-year funding for substance abuse services to the Senate bill to repeal and replace the Affordable Care Act.

That's likely to complicate the efforts of Senate Republican leaders to pass the bill under budget reconciliation rules that require it to meet deficit reduction targets, as they race to hold a vote on the Senate floor next week. Finding those drug treatment dollars would mean cutting other spending in the bill or keeping some ACA taxes that conservatives want to quickly repeal. But Senate GOP leaders may have to seriously consider their request because both senators, Shelley Moore Capito of West Virginia and Rob Portman of Ohio, doubt whether they can support the bill. They worry the legislation would roll back the Medicaid expansion that has enabled tens of thousands of their constituents to receive substance abuse treatment. And their votes are pivotal in passing the bill in the Senate. "I need assurances that those folks who are using Medicaid expansion for that coverage are going to be covered for that problem," Capito told reporters last week. "It's absolutely critical to my state, and we've got huge problems." "We're just trying to make sure that at a time we are facing this crisis, we are not making things worse," Portman said. Given the national political prominence of the addiction epidemic, some observers believe the issue could make or break the Republican effort to repeal and replace Obamacare, depending on how it's handled. Capito and Portman, whose states have among the nation's highest overdose death rates, are in a particularly tough spot. "Substance abuse could end up being key to whether this bill can get a majority in the Senate or not," said Larry Levitt, a senior vice president at the Kaiser Family Foundation. There are no details available on the Capito-Portman proposal, because the Senate GOP bill is being written behind closed doors with no hearings scheduled. The $45 billion pot may come on top of several extra pots of money totaling $138 billion in the House GOP repeal bill that would be offered to the states to fund reinsurance, high-risk pools, people with pre-existing conditions, and maternity and mental health services. But policy experts and providers question whether the temporary addiction treatment dollars would make up for the permanent loss of hundreds of billions in federal funding for Medicaid expansion to low-income adults. They note that a large percentage of people with drug problems also have mental health and chronic physical conditions and now are able to receive comprehensive care for all their needs through Medicaid in the 31 states that expanded eligibility. "Having funding for drug and alcohol treatment is better than no funding at all, but that pales in comparison to having full health insurance through" Medicaid, said Jack Carroll, executive director of the Cumberland-Perry Drug & Alcohol Commission, which manages public funding for substance abuse treatment in two Pennsylvania counties. Experts testifying at last week's first meeting of the President's Commission on Combating Drug Addiction and the Opioid Crisis also stressed the importance of the Medicaid expansion for boosting access to substance abuse treatment. In addition, they pointed to the ACA's requirement that commercial health plans and Medicaid managed-care plans cover mental health and substance abuse services, which the House GOP repeal bill would let states waive. Some observers see the proposal for extra substance abuse treatment funding as a move to give Senate GOP moderates political cover to vote for a bill that would strip insurance from an estimated 13 million to 23 million Americans in the midst of an unprecedented opioid epidemic. "That's aimed at buying their votes," said Joe Antos, a conservative health policy expert at the American Enterprise Institute who favors keeping a more limited Medicaid expansion. "It's just moving the money around in hopes of getting 50 votes, as opposed to spending money to help low-income people in a way that's most efficient and effective." Levitt said it's unclear how the proposed substance abuse funding, as well as the extra pots of money in the House bill, would be parceled out. "There is a big difference between an entitlement program like Medicaid that guarantees coverage to eligible people, and a discretionary pot of money that may or may not be sufficient or continue over time," he said. "I suspect, if this bill became law, there would be a lobbying frenzy in state capitals to stake claims on this money, pitting advocates for low-income people against hospitals and insurers," he added. The offices of Capito, Portman, and Sen. Pat Toomey of Pennsylvania, who also has emphasized the importance of expanding substance abuse treatment, did not respond to requests for comment for this article. Toomey, whose state suffers a high rate of opioid addiction, wants a faster phaseout of the Medicaid expansion and tighter caps on total Medicaid spending growth than Capito and Portman support. An estimated 30% of adults who have received coverage under the ACA's Medicaid expansion have a serious mental illness and/or substance abuse problems, and about 1.3 million people receive treatment for those disorders through that coverage. In Capito's West Virginia, about 50,000 of the 175,000 Medicaid expansion enrollees had a diagnosis of substance abuse in 2016, and their total treatment cost $112.9 million, according to state data. Without the enhanced federal payments for expansion, the state would not be able to afford it to keep it, said state spokeswoman Allison Adler. "They are planning to destroy the progress we made in substance abuse and mental health in one poorly planned, ill-defined move," said Mary Crouch, president of the West Virginia Association of Alcoholism & Drug Abuse Counselors. In Ohio, Medicaid expansion has enabled an estimated 150,000 adults to receive addiction treatment, while the total in Pennsylvania is 63,000. Political observers in both those states doubt they could afford to keep their expansions without the extra federal dollars, given their difficult budget situations. Just in the two small, rural Pennsylvania counties served by Carroll's agency, 787 Medicaid expansion beneficiaries with a primary diagnosis of opioid dependence accessed substance abuse treatment services through Medicaid in 2015 and 2016, out of a total of 15,105 expansion enrollees, at a cost of nearly $4 million. "If they weren't eligible for (Medicaid), I'm not sure where those folks would have gotten that treatment otherwise," Carroll said. Hospitals also are worried about the impact of rolling back the Medicaid expansion on substance abuse treatment. In a letter sent to the U.S. Senate Monday, the American Hospital Association said there's clear evidence that the ACA's expanded coverage has helped address behavioral health and addiction treatment needs. "The opioid epidemic plaguing our country is a compelling reason why Medicaid expansion should not be curtailed, and Medicaid funding should not be slashed," the AHA wrote. There's widespread agreement that Medicaid is a key payer for the nation's substance abuse treatment, given persistent problems in accessing such treatment through private health plans. Opioid-addicted adults who have Medicaid coverage are nearly three times more likely than privately insured adults with addiction problems to receive inpatient or resident treatment, and almost twice as likely as privately insured adults to receive outpatient care from a mental health center, according to the June 2017 report of the Medicaid and CHIP Payment and Access Commission. But the Republican repeal-and-replace legislation threatens that access to treatment, the report noted. States that have expanded Medicaid under the ACA must cover 10 essential benefits including mental health and substance abuse treatment. The GOP bill, however, would allow states to drop those benefit requirements in their Medicaid managed-care plans and for commercial health plans as well. On top of that, the House GOP repeal bill's proposal to cap the annual growth of federal Medicaid payments to the states likely would force states to pare back or eliminate addiction screening, early intervention and treatment services if they become optional benefits. "This should be routine coverage in all health plans," said Deb Beck, president of the Drug and Alcohol Service Providers organization of Pennsylvania. "If we lose this, people who would have gotten help won't get it, and they'll show up in emergency rooms and jails. It doesn't make any sense to do damage to the Medicaid expansion in the middle of an epidemic."