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More opioid funding won’t save the Senate health care bill

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

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Defector of the Day: Sen. Shelley Moore Capito (R-WV)

Each day leading up to the Senate vote, we'll take a closer look at a Republican senator who seems to be on the fence on the Better Care Reconciliation Act, what they want, and what role they're likely to play in the debate. Today we focus on an essential swing vote who has been fixated on the opioid crisis, Sen. Shelley Moore Capito of West Virginia.

Tom Williams / Getty Images

No health care bill is passing the Senate without Sen. Shelley Moore Capito (R-WV).

But she’s making herself tough to get these days. Capito has been asking for $45 billion in federal funding to address the opioid crisis and less severe spending caps for Medicaid. Her state has been devastated by the opioid crisis, now killing 30,000 American annually, and a third of its families are on Medicaid.

She finally got the first condition Wednesday night, when Politico reported that Senate Majority Leader Mitch McConnell would increase the bill’s funding for the opioid crisis from $2 billion to $45 billion.

But a couple of days ago, Capito told me that wouldn’t be enough. She also wants a more generous spending cap for Medicaid — which, to be clear, still fundamentally changes the program from an open-ended entitlement.

Right now the Senate spending caps are even harsher than the House’s were. The CBO estimated the Senate bill would reduce Medicaid spending by $772 billion over 10 years, versus current law, and lead to 15 million fewer Americans being enrolled in the program. It also eventually ends the generous federal funding for Obamacare’s Medicaid expansion; Capito has okayed that provision, though she has pushed for the phaseout to be more gradual.

“More opioid funding would be very good, very beneficial, but the core for me is the Medicaid provisions,” Capito said then. “You can grant the state more money for treatment, but if you can’t access the treatment, it’s not going to do you any good.”

What about now that a big chunk of change — $45 billion — has officially been added to the bill?

“I’m optimistic on the opioid funding, but I haven’t had anything finalized yet,” she told me.

Does she still need Medicaid changes to support the bill?

“I’m still looking at it,” she said. “I’m not convinced I’m there. I’m not there yet, I know that.”

I observed she seemed a little more optimistic than she had earlier in the week.

“I wouldn’t characterize it like that,” she said, with a bit of a smile.

People who advocate for more opioid addiction treatment and funding in Washington are watching Capito and her compatriot, Sen. Rob Portman of Ohio, closely. They want more funding for state programs, sure — though they wonder if any money added to the Senate health care bill would be mandatory spending — but they are primarily concerned with Medicaid.

Medicaid is the largest payer of addiction treatment in the country, and Capito and Portman's request for $45 billion was based on the expected Medicaid cuts. But even members of President Trump's own commission on opioids said that wasn't enough money. Outside estimates think a number closer to $200 billion over 10 years would be needed, Politico reported.

So addiction recovery advocates in Washington are urging Capito and Portman to hold their ground and press for less steep Medicaid cuts. The medical treatment that people in recovery need goes beyond addiction services.

"With the proposed cuts to Medicaid in this bill, even if there were $50 billion included for [recovery] services, consumers would still be at risk because of problems that accompany addiction such as hepatitis, HIV, and endocarditis," Andrew Kessler, who focuses on these issues at Slingshot Solutions, told me recently. "To say nothing of the mental health disorders that can often accompany addiction."

"So whether McConnell is trying to buy a couple of votes for either $2 billion or $50 billion," he continued, "in the end, we hope that senators who have long supported the [recovery] community won't sell their votes for 30 pieces of silver."

Chart of the Day


California's big success stopping mothers from dying during childbirth. Nationwide, 22 mothers out of every 100,000 live births died during childbirth in 2013. California has found a way to buck that trend. Vox's Julia Belluz went there to find out how.

Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

Today's top news

  • "Medicaid becomes big threat to GOP’s healthcare revival": “The biggest problem for Senate Republicans struggling to revive their healthcare legislation is the one that has bedeviled them from the beginning: Medicaid. Deep cuts to the social safety net have led to a revolt from centrist GOP senators backed up by their home-state governors, who accepted federal funding under the Affordable Care Act to expand their Medicaid rolls.” —Rachel Roubein and Jessie Hellmann, the Hill
  • "Senate adds opioid money, HSA changes to health bill to woo holdouts": “Senate Majority Leader Mitch McConnell, R-Ky., in an attempt to woo holdouts, is changing the healthcare bill to add $45 billion in spending to fight opioid abuse and to allow health savings accounts to be used to toward premiums, according to a source familiar with the matter. The changes come less than a day after McConnell met with key centrist holdouts on the bill, including Sen. Shelley Moore Capito, R-W.Va.” —Robert King, Washington Examiner
  • "GOP Signals It Will Keep Obamacare’s Investment Tax on the Rich": “Republican Senator Bob Corker said Thursday that he expects GOP leaders to scrap a provision in their health bill that would repeal a tax on investment income that affects high-income earners. The Tennessee Republican said the decision to retain Obamacare’s 3.8 percent tax on net investment income would help Republicans boost subsidies for low-income people in the individual exchanges.” —Sahil Kapur, Steven T. Dennis, and Laura Litvan, Bloomberg

Analysis and longer reads

  • "What the Republican Health-Care Holdouts Want": “Short of simple persuasion, [Sen. Mitch] McConnell’s narrow path to passage likely involves a combination of more money sought by moderates and a loosening of existing regulations that conservatives want—if the various factions will agree to a trade. Here’s a rundown of the holdouts’ demands.” —Russell Berman, the Atlantic
  • "In McConnell’s Own State, Fear and Confusion Over Health Care Bill": “In few places are the political complexities of health care more glaring than in this poor state with crushing medical needs, substantially alleviated by the Affordable Care Act, but where Republican opposition to the law remains almost an article of faith. While some Senate moderates say the Republican bill is too harsh, Rand Paul, Kentucky’s other Republican senator, is among Senate Republicans who say they are opposed to the current bill for a different reason: They believe it does not go far enough to reduce costs.” —Sheryl Gay Stolberg, New York Times
  • "Hospitals struggle with the high-deductible dilemma": “In 2016, for the first time, more than half of all workers (51%) with single coverage faced a deductible of at least $1,000, according to a study released last September by the Kaiser Family Foundation/Health Research & Educational Trust. The study showed that 29% of workers were in high-deductible plans compared with 20% two years earlier. Hospitals are struggling to collect that increased patient share of the cost.” —Dave Barkholz, Modern Healthcare
  • "Health Care Uncertainty Leaves Many Missouri Counties Without ACA Marketplace Coverage": “July 17th is the deadline for health insurers to files rates for 2018, and it appears that dozens of Missouri counties may be left with no one selling plans on the Affordable Care Act’s health exchange. That could make it much harder for thousands of Missourians to get the health insurance they need – although there’s still room for insurers to enter the market and some health experts still hold out hope for what they call 'bare counties.'” —Alex Smith, KCUR

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