Ohio’s Medicaid rollback plan spurs addiction debate

July 03--Ohio public officials and health policy experts are concerned the deep Medicaid cuts proposed under Senate Republicans' plan to repeal and replace the Affordable Care Act could weaken efforts to address the state's opioid epidemic.

Over several years, Senate Republicans' proposed plan would phase out the Affordable Care Act's Medicaid expansion. The expansion made Medicaid available to people with annual incomes below 138 percent of the poverty line. The senate bill would also change Medicaid from an open-ended entitlement to a federal grant program with a fixed budget.

The program also faces challenges at the state level, where a House-Senate budget conference committee last week voted 4-2 along party lines to keep a Senate-passed provision requiring the state to ask for federal approval to freeze enrollment in the program beginning on July 1, 2018. Although Gov. John Kasich blocked the freeze with his line-item veto authority late Friday night, the House has already postponed its summer recess and scheduled a Thursday session for possible veto overrides.

Medicaid covers nearly half of all prescriptions for the addiction treatment drug buprenorphine in Ohio, according to a 2016 report by New Jersey-based IMS Institute for Healthcare Informatics. In 2016, the ACA's expansion made up 43 percent of Medicaid spending on mental health and substance abuse in the state.

Given Ohio's current fiscal situation, the state would not have the funds to fill the hole left by the rollback of the Medicaid expansion, said Tracy Plouck, director of the Ohio Department of Mental Health and Addiction Services.

"Having a payer source for clinical services is absolutely important," Ms. Plouck said. "So the elimination of Medicaid expansion during this challenge that we're experiencing with opiates in our state would have terrible consequences not only for people who are currently enrolled in treatment ... but also for individuals who would never have the opportunity in the future to enroll."

But for Tom Zawinowski, president of the Ohio Tea Party group We the People Convention, Medicaid cuts are not the issue. Mr. Zawinoski thinks the Senate bill does not go far enough, a shortcoming he attributes to the influence of Washington lobbyists.

Funds used to finance the Medicaid expansion would be better spent on research to cure opioid addiction, he said.

"Medicaid was for the elderly, for children, and for disabled people," Mr. Zawinowski added. "Medicaid expansion gave free health care to able-bodied, single people who made under a certain amount of money. That's just a gift. That's just welfare."

Mr. Kasich and U.S. Sens. Rob Portman (R., Ohio) and Sherrod Brown (D., Ohio) have all expressed serious concerns about how the Senate bill would affect the state's ability to address the opioid epidemic.

In addition to slashing Medicaid spending, the Republican plan would remove addiction treatment from the list of 10 essential benefits included in all expansion plans. As a result, even those who keep their Medicaid coverage could lose access to treatment services, said Julia Zur, a senior policy analyst with the Kaiser Family Foundation's Program on Medicaid and the Uninsured.

On Thursday top GOP senators added a $45 billion appropriation aimed at helping states address the opioid crisis to the bill in an effort to help win over moderates such as Mr. Portman and Sen. Shelley Moore Capito (R., West Virginia).

The two senators, who announced their opposition to the bill in a joint statement last week, had requested $45 billion nationally over the next 10 years -- an average of $4.5 billion annually.

Prior to Thursday's agreement, the bill would have apportioned just $2 billion in 2018, with no mention of future spending on the issue.

Ohio alone spends just shy of $1 billion annually on fighting the epidemic. Health policy experts said it was unlikely the original $2 billion allocation would make much of a dent in the opioid addiction battle.

"It's highly unlikely that that amount would fill the unmet need," said Amy Bush Stevens, vice president for prevention and public health policy at the Health Policy Institute of Ohio.

But even the new allocation is likely too austere, Ms. Zur said. In 2014, national spending on substance use disorder treatment amounted to nearly $34 billion, $7.1 billion of which came from Medicaid.

"$4.5 billion a year would probably be substantially lower than what's necessary," she said.

Ms. Capito has said she will not support the bill even if it includes the $45 billion she and Mr. Portman requested.

"More opioid funding would be very good and very beneficial, but the core for me is the Medicaid provision," she said.

Beyond the sheer quantity of money allocated to fight the epidemic, shifting Medicaid from an open-ended entitlement to a fixed federal grant could restrict coverage of treatment for one or more additional disease or health conditions at the same time.

Ms. Plouck and Ms. Zur said people with addiction problems often suffer from other medical conditions too. The Senate Republicans' bill might not provide coverage for all the full range of services needed by many, they said.

"Regardless of whether it's enough money, it doesn't fulfill paid access to the whole range of services that somebody would need," Ms. Zur said.

For providers, the lack of year-to-year consistency in the grant structure would make it "hard ... to really have a business model, to do planning," Ms. Zur said.

The Republican bill will not come to the Senate floor until after the July 4 recess.

Contact Jacob Stern at: [email protected] or 419-724-6050.

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