Dr. Constance Scharff is a senior addiction research fellow and director of addiction research for Cliffside Malibu, an evidence-based addiction treatment center. She is a regular columnist for Psychology Today and has written extensively on the repeal of the Affordable Care Act. We talked to her about how the ACA has impacted treatment for the opioid epidemic, and how the changes proposed by the GOP will impact families struggling with this problem.
Q: According to government statistics from 2012, an estimated 2.1 million people in the United States are suffering from substance use disorders related to prescription opioid pain relievers and an estimated 467,000 addicted to heroin. In your experience, how has the Affordable Care Act impacted care for those people?
A: The ACA has helped untold numbers of people access quality addiction treatment and provides emergency services to others. What exactly has the ACA done? It has forced insurance companies to pay for addicts’ treatment instead of considering many addicts as people with “pre-existing conditions.” It, with the Mental Health Parity and Addiction Equity Act, has made addiction a disorder that must be treated no differently than a physical issue like cancer or diabetes. It has expanded Medicaid coverage so that the poorest Americans have access to evidence-based addiction treatment, including life-saving emergency care in the case of overdose. It has shined a spot-light on the positive results treatment can have and caused communities to demand further access to life-saving care.
Q: The Republicans have finally revealed their plan to replace the ACA, including replacing Medicaid coverage with block grants. How will that impact states in the grips of the opioid epidemic?
A: Moving Medicaid to a block-grant system will be devastating to the nation’s most vulnerable individuals. Currently, Medicaid is funded in a flexible way. States show need based on the number of poor (an agreed upon income based on a percentage of the poverty rate) and the federal government funds states based on that need. When the economy is lagging or there are larger pools of poor individuals in a state, the federal government kicks in more money for healthcare. Under a block grant system, each state receives a set amount of money, with that amount reviewed every three years. If the economy hits hard times, it is likely that the amount given to states in the form of block grants will decrease, rather than increase. Almost all block-grant funded programs atrophy over time. It is accurate to say that this change in funding will cost lives.
“If Medicaid expansion is halted and if there are cutbacks, these states will be the hardest hit and the impact will be measured by body count.”
Q: One of the other proposed changes to the ACA is the elimination of tax credits for people with few financial resources. How will that impact care for people and families dealing with addiction?
A: Eliminating tax credits based on income will mean hundreds of thousands, even millions, will find themselves priced out of the health insurance market.
Families that have one or more members struggling with substance abuse often find themselves with limited income, particularly when one of the adults in the household is unable to work or work regularly. Those without extended-family support or work-provided health insurance will likely find themselves with no coverage at all.
For families with teen or young adult addicts in the home, they may still find resources available by keeping the kids on the parents’ health insurance policies. For those over the age of 26 with a substance abuse problem, unless the family can afford quality health insurance, the addict will fall to Medicaid coverage. As Medicaid is overburdened, this means limited or no access to care.
Q: Many of the states that voted for President Trump–and by extension these changes to the ACA–are among the states hardest hit by the opioid epidemic. If the changes proposed by the Republican congress are passed, what will that mean for these states and the addicted population there?
A: It will be devastating for these states and some of the governors are voicing their opposition to the proposed revisions to the ACA. Gov. Kasich, of Ohio, is an outspoken critic of measures that would pull back from the Medicaid expansion his state has needed to address the opioid epidemic.
Already, states like Ohio, West Virginia, and Kentucky do not have enough addiction treatment to meet the need. If Medicaid expansion is halted and if there are cutbacks, these states will be the hardest hit and the impact will be measured by body count. I say that very seriously. The proposed changes to the ACA will result in deaths due to addicts who previously might have been able to seek treatment being unable to access care.
Q: Here in New England we often hear that there just aren’t enough beds to keep up with treatment needs. What, if anything, could the government do to help solve this problem?
A: Some of this is a problem of perception. No, there are not enough treatment beds in many areas of the country to meet the demands of addicts. So send your addicted loved ones to the areas where there are empty beds! If you have medical insurance, there are facilities in California, Florida, and Texas (as examples) that would be glad to take your loved one and provide quality, evidence-based treatment. Don’t let the cost of an air or bus ticket keep your loved one from treatment. In many cases, being away from home is actually a benefit to those in treatment, because the pressures of home and the friends and family that support substance abuse are far away.
Here’s the hard truth. The government isn’t going to solve the addiction treatment crisis in this nation. Medicaid is going to be cut. The best-case scenario is that state governments will prioritize funding for addiction prevention and life-saving activities like making naloxone (the opioid overdose reversal drug) available widely. Publicly funded treatment programs should triage and give priority to the lowest income individuals. Families with the means to get their loved ones to treatment in other parts of the nation should do so.
If you have a loved one who needs help, they need help now. You can’t wait until the government takes action. You very likely can’t wait months for a bed to free up in your local area. Send your loved one where the treatment is, instead of hoping they don’t die before a bed becomes available where you are.