President Donald Trump, motivated by a congenital inability to admit defeat, is trying to revive Republican efforts to repeal the Affordable Care Act. The move is getting resistance from a surprising corner, as attorneys general from 19 states and the District of Columbia sent a letter to the president expressing concerns about what this means for their ability to fight crime.
What does health care have to do with crime? According to the attorneys general, quite a bit, due to the epidemic of opioid addiction.
"As the chief law enforcement officials in many of our states, we are on the front lines of battling this epidemic," reads the letter, which was sent on April 21. "But we know that law enforcement alone cannot end this crisis. Our residents also need access to drug treatment."
Most of the focus on Republican health care efforts has understandably been on what it means for individuals who could lose their health insurance if the GOP successfully pares down Medicaid and reduces the subsidy system that makes private health insurance more affordable under the Obamacare laws. But this letter highlights another problem, which is that undermining the health care system will have broader consequences for state and local governments. Nowhere is this more evident than when it comes to fighting the drug addiction epidemic.
“If you repeal the Affordable Care Act or you dramatically transform the Medicaid program in such a fashion that it doesn’t have the resources to pay for these services, that funding is going to dry up and you’re going to shift back onto states this big financial burden," explained Brendan Saloner, an assistant professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, in a phone interview. "That’s going to cause a lot of pain on states.”
Saloner, with Temple University economics professor Catherine Maclean, recently published a paper for the National Bureau of Economic Research that examines the effect of the Medicaid expansion on substance abuse treatment. Saloner and Maclean looked at states that accepted the Affordable Care Act's provision offering Medicaid coverage to people with an income lower than 138 percent of the poverty line, to see the impact on the provision of substance abuse treatment in those states.
While the researchers didn't find any evidence, at least to this point, that the Medicaid expansion is resulting in more people accessing treatment facilities, they did find that a huge proportion of the financial burden for such treatment had been shifted onto the Medicaid system. This, Saloner argued, helps both the states and the individuals.
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“Out-of-pocket costs for a substance-use disorder can really be catastrophic for some people," Saloner explained. “It can be one more thing weighing them down as they try to establish themselves on the road to recovery.”
But it was the states themselves that really had the most to gain. Substance abuse treatment is expensive and patients often can't afford it themselves. Without generous Medicaid coverage, states are often the ones left to foot the bill. That's a daunting prospect under any circumstance, and one that has grown only more dire in recent years, as the opioid addiction epidemic has spiraled out of control. Most state governments can't legally run at a deficit, which means that funds spent on substance abuse treatment is money not being spent elsewhere.
And as the letter from the group of attorneys general makes clear, the costs to states in cutting funding for substance abuse treatment can have a ripple effect, causing expenses in other departments, particularly those involving law enforcement, to rise.
“We often think of this as a medical issue, and I think that’s the appropriate way to think of it in the context of Medicaid," Saloner said when I asked him about this matter. "But it’s also an issue that has ramifications for the criminal justice system and for social services for a variety of other non-health related government activity and government spending."
Instead of diminishing funding for programs such as Medicaid, Saloner said his research suggests that governments need to invest more in helping addicts receive treatment.
“You can’t just wish for Medicaid, on its own, to get more people into treatment," he said. "This underscores the point that health insurance alone will not do the trick.”
The fact that increased Medicaid spending didn't result in more treatment facility admissions, he argued, points to a supply-side problem: There simply aren't enough slots in treatment programs, and many people who need help — including some individuals who have the means to pay for it — are stymied because they can't find an available spot.
Saloner also argued that there needs to be more coordination between government officials and health care providers like doctors and emergency rooms, in order to identify who needs help most urgently. All these things require increased investment in the short term, although they should pay off by reducing long-term health care costs and law enforcement costs. Unfortunately, the federal government is run by Republicans who seem hell-bent on slashing government services, especially with regard to health care, so that they can finance tax cuts for corporations and the rich.
This is particularly gruesome in light of Trump's repeated promises to do something about the opioid crisis, both on the campaign trail and in office.
"We want to help those who have become so badly addicted," Trump said during a White House meeting on the issue in March. "This is a total epidemic and I think it is probably un-talked about compared to the severity we are witnessing."
But the very thing that is relieving some of the stress on states trying to fight this issue — Medicaid financing — is now under attack by Republicans who oppose any form of government financing for health care on ideological grounds. Once again we are learning that Trump's bigly campaign rhetoric has little or nothing to do with his actions as president.