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The Senate health care bill would make one of America’s deadliest public health crises worse

The bill is a disaster in the making for America’s opioid epidemic.

Kellyanne Conway sounded like she couldn't believe what she was hearing.

Asked on CNN last month about why the Senate health care bill to replace Obamacare (the Better Care Reconciliation Act) would do “nothing” to address the opioid epidemic, the White House senior counselor shot back: “That’s not true, and that is not fair. That is so not fair. … It actually helps no one to peddle the false rumor that this health care bill does ‘nothing’ to help.”

If this “rumor” is false, it’s because the Senate health care bill is worse than nothing. A new version of the bill released on Thursday does create a $45 billion fund for addiction and mental health treatment. But the rest of the bill slashes access to insurance — cutting off tens of millions of people from health plans, particularly Medicaid — and imposes other regulatory changes that, experts and advocates argue, add up to much steeper cuts than the $45 billion the bill includes for the opioid crisis.

If a revised Senate bill maintains similar cuts to Medicaid and reduced support for enrollees on Obamacare’s marketplaces, “then $45 billion over 10 [years] will not be nearly enough,” Richard Frank, a health economist at Harvard, told me. (We will have to see a new Congressional Budget Office report, now that the Senate has revised its bill, to see if the cuts to Medicaid and Obamacare’s marketplaces are as deep as they were in the previous version of the bill.)

This repeats many of the same mistakes of the House health care bill, although that bill didn’t include a fund for addiction and mental health care.

America’s opioid epidemic has already led to the deadliest drug overdose crisis in US history. In 2015, drug overdose deaths climbed to 52,000 — an all-time record, based on federal data. Roughly two-thirds of those deaths were linked to opioids. The death toll climbed to 59,000 to 65,000 in 2016, according to a New York Times analysis.

If it passes, the Senate health care bill stands to make this worse — by limiting access to care that can prevent addiction and overdose. To understand how, here’s a breakdown of the three major ways the Senate bill will affect the epidemic.

1) The bill makes massive cuts to health insurance, especially Medicaid

The Congressional Budget Office has not gotten a chance to score the revised Senate health care bill. But when it looked at a previous — and fairly similar — version, it found a lot of people will lose access to insurance through the bill: 22 million. Not all or even most of these people are struggling with addiction, but a significant number likely are.

By slashing access to health insurance, the bill cuts off the one thing that makes addiction treatment affordable to potentially millions of patients. Obviously, losing insurance can be bad for anyone, whether they’re struggling with addiction or not. But it’s particularly troubling for patients suffering from addiction who rely on insurance to pay for treatment and medications.

Consider the most devastating insurance cuts in the Senate bill — to Medicaid. Based on the CBO’s previous estimates, the Senate bill would slash Medicaid by about $772 billion over 10 years. That happens not just by ending the Obamacare-funded Medicaid expansion (which lets anyone in participating states who earns up to 138 percent of the federal poverty level sign up for Medicaid), but also by creating additional caps on how much federal money states can get for the public health insurance program.

Medicaid currently plays a big role in addiction care. According to a 2014 study by Truven Health Analytics researchers, Medicaid paid for about 25 percent — $7.9 billion of $31.3 billion — of projected public and private spending for drug treatment in 2014. That made it the second-biggest payer for drug treatment spending after all local and state government programs.

By slashing Medicaid, the Senate bill will make it a lot harder for patients to use the program for this kind of addiction care. And Medicaid will have a more difficult time paying for addiction care for patients who remain on the rolls — potentially leading Medicaid to, for example, resist paying for certain kinds of treatment.

There’s a secondary effect: If treatment programs suspect they’re going to have fewer people using their services (since fewer people will have insurance), they’ll probably be more reluctant to open up more facilities. And that could leave even more areas without any options for care.

“A key issue here is that [addiction] care is not like oncology or cardiology,” Keith Humphreys, a drug policy expert at Stanford University, previously told me. “Most providers are small, mono-business entities that can’t absorb costs elsewhere in their care systems. What this means is that while hospitals will not go broke if poor people get less oncology care coverage, many [addiction] treatment agencies will.”

And the bill makes cuts from an already insufficient starting point. According to a 2016 report by the surgeon general, just 10 percent of the people with a drug use disorder got specialty treatment, due in large part to a severe shortage in addiction treatment options. That was with Obamacare largely in place. So what the US is doing is already inadequate, and the Republican bill is set to make the situation even worse.

2) The bill threatens Obamacare protections for addiction treatment coverage

Beyond the insurance cuts, the Senate bill would make regulatory changes that could severely limit the accessibility of addiction care.

Under Obamacare, the law mandated a few “essential health benefits,” which require insurers to provide specific kinds of care. Among those essential health benefits was a big one for the opioid epidemic: addiction and mental health care.

The Senate bill, however, lets states obtain waivers to overhaul their health insurance markets, which they can use to pull back essential health benefit requirements. And the bill also sunsets, after 2019, essential health benefit requirements for Medicaid altogether.

Before the essential health benefits mandate, it was common for insurers on the individual market to leave out addiction treatment in their plans. If someone with a drug use disorder wanted to get coverage, she would typically need to find a more expensive plan that did include addiction treatment — and perhaps she wouldn’t be able to find a plan, particularly an affordable one, at all.

“Over the last 60 years, 70 years, or so, insurers have scrupulously avoided enrolling people with mental health and addictions as much as possible,” Frank previously told me. “That’s because they are more complicated and expensive to treat. And they did so by offering either no coverage or limited coverage.”

According to a previous analysis by Frank and Sherry Glied of New York University, this part of Obamacare helped 2.8 million Americans with drug use disorders and nearly 1.3 million with serious mental disorders. These people would stand to lose potentially lifesaving addiction and mental health coverage if essential health benefits were repealed, whether through their states or in a more sweeping Obamacare repeal than the Senate is currently proposing.

Republicans have long decried Obamacare’s essential health benefits, arguing that mandating so much coverage for insurers makes health plans far too expensive. It’s true these requirements do make insurance overall more expensive, since they force insurers to cover more stuff. But the idea is that by requiring everyone to cover these benefits, the cost is shared by the whole insured population, not just the people who need, say, drug treatment — and would otherwise have to find a way to pay for it on their own.

Republicans simply say the trade-off isn’t worth it, since it makes insurance a bit more expensive for everyone.

But without these protections, people with drug use disorders will suffer as insurance becomes less accessible and skimpier. As Jessica Goense, who obtained care at a New Jersey addiction program with the help of Obamacare-expanded Medicaid coverage, recently told me, “If it wasn’t for insurance, I wouldn’t be here.”

3) The bill's $45 billion fund for drug treatment and mental health care is nowhere near enough to outweigh the cuts

To try to make up for the cuts, the Senate bill includes $45 billion over 10 years that targets the opioid epidemic but will go to drug treatment and mental health care in general. That number is based on the study by Frank and Glied, which found that the Obamacare-funded Medicaid expansion helped the public health program spend $4.5 billion a year on substance use and mental health conditions.

While the extra money will certainly help to some extent, experts, including Frank, say it doesn’t go far enough.

For one, the extra funding only addresses the immediate concerns of patients with substance use disorders, but not the other problems they face. For example, people suffering from drug addictions are often at heightened risk for HIV and hepatitis C infection, which can spread through shared needles. Those are extra costs to the health care system caused by addiction that drug or mental health treatment alone can’t address.

When you account for those other problems, Frank estimates that it would take more than $183 billion over 10 years to make up for all the cuts.

These calculations are also only for the bill’s effects on people at or below 200 percent of the federal poverty level. Even more funding than the $183 billion would be needed to address cuts to support people at 200 to 400 percent of the federal poverty level, who also stand to lose access to adequate insurance under the Senate bill's changes to the individual market.

Advocacy groups have also decried the funding as unfair and even stigmatizing to patients struggling with addiction and mental health issues. In a statement, the National Council for Behavioral Health argued, “Grants are not a substitute for health coverage. We don’t rely on grants for the treatment of heart disease or cancer, and addiction and mental health should be no different.”

Humphreys echoed the concern: “This would presumably be a grant program separate from mainstream health care, meaning we’d continue the problem [Obamacare] was solving, i.e., integrating [addiction] care with the rest of health care. When the money is separate, the care is uncoordinated and of lower quality.”

He added, “It also puts you in a bad spot as a patient: What if you turn up to a clinic that didn’t apply for the grant funds that year? We don't say, ‘We will have a health care system, and some hospitals have the option of applying to our cancer fund if they want to care for that disease’; we treat cancer care as part of the essential work of hospitals, and that’s what we should do with addiction too.”

The bill is also very vague in how the money will be doled out, only stating that the secretary of health and human services will decide what to do with the money each year as they deem appropriate. So whether the money is actually used effectively is a lingering concern.

The bottom line, then, is that the Senate bill’s cuts are so far-reaching that even $45 billion in funding is nowhere near enough to make up for the massive losses elsewhere.