Rob Portman's dilemma: How to repeal Obamacare without undermining opioid fight

WASHINGTON — Sen. Rob Portman has been pushing for aggressive congressional action to curb the opioid epidemic. The Ohio Republican is also working hard to repeal and replace the Affordable Care Act.

Critics say those two goals are in direct conflict, and that nothing would do more to worsen the opioid crisis than GOP efforts to unravel the 2010 health care law, also known as Obamacare.

Portman’s dilemma was on stark display May 25, when he convened a hearing on how to stop the flow of deadly synthetic opioids into the U.S. He hoped the session would galvanize support for his legislation to block those drugs from entering the U.S. through the postal system. And it did, to a point.

But the witnesses also pleaded with Portman and other senators not to undermine the ACA — specifically warning against cutting Medicaid and ending the 2010 health law’s provision allowing states to expand Medicaid to cover low-income childless adults with incomes at or below 138% of poverty.

“Don’t take away my ability to treat my patients and keep them safe,” begged Dr. Terry Horton, the chief of addiction medicine at an early intervention program in Delaware. Horton said he currently has “no problem” getting addicts into treatment within 24 hours, and sometimes even faster.

That access to care “is entirely dependent on Medicaid,” he said. “Without Medicaid, that care would collapse.”

Thomas P. Gilson, the chief medical examiner for Cuyahoga County, Ohio, noted that treatment slots in his state are far more scarce. As a result, he sees overdose victims in his morgue within days of being hospitalized for a previous overdose, after which they were sent back on to the street instead of to treatment.

“Anything like Medicaid expansion being eliminated, (anything) that limits people’s access to health care, I can’t see any good coming from that in this crisis, especially with its mortality,” Gilson told the Senate Homeland Security and Governmental Affairs subcommittee.

Portman said he is acutely aware of the possible consequences of rolling back Medicaid, a joint federal-state insurance program for the poor, elderly and disabled. Under Obamacare, Ohio and 31 other states (plus the District of Columbia) expanded Medicaid, with Washington paying more than 90% of the cost for the new enrollees.

In Ohio, that move has helped about 700,000 people gain health coverage, with many accessing desperately needed services for addiction treatment as the state grapples with the opioid epidemic. Nationally in 2016, Medicaid paid for 24 percent of buprenorphine prescriptions, a medication has proved highly effective in treating opioid addiction, according to Richard Frank, a health economist at Harvard University.

Frank said Medicaid coverage for opioid treatment was even higher, an average of 41 percent, in the five states with the highest opioid overdose mortality rates: West Virginia, New Hampshire, Kentucky, Ohio, and Rhode Island.

Portman concedes that Obamacare has helped expand treatment, but he said the law has also ushered in “skyrocketing premiums and deductibles” that are “unsustainable for Ohio families and small businesses.” He and other critics note that some insurance companies are dropping out of the health care exchanges, leaving those in the individual market with meager or non-existent coverage options.

Read more:

Major insurer Anthem to withdraw from Ohio health care exchange

Rob Portman in crosshairs of Obamacare repeal debate

Anti-addiction advocates: Health bill could kill treatment

“We can and must do better than Obamacare, but we should do it in a way that protects the most vulnerable in our society,” he said in a statement to The Cincinnati Enquirer.

The House-passed Obamacare alternative would freeze the Medicaid expansion program in 2020, with states losing the extra federal money to cover new enrollees. And it would also transform the program by ending the current “federal match,” under which Washington provides states with a set percentage to cover the cost of the program. Instead, states would get a capped amount of money for each beneficiary — a move that critics say would force states to either cut services or shoulder the new costs.

Portman said the House bill is a no-go for that very reason, arguing it would drop states off a funding “cliff” and could jeopardize Ohioans’ access to opioid-addiction treatment. He is part of a small group of Senate Republicans trying to craft an alternative.

In those closed-door strategy sessions, Portman has pushed his GOP colleagues to adopt a more gradual end to the Medicaid expansion — with Washington decreasing its federal contribution for new enrollees over several years, instead of the abrupt Jan. 1, 2020, date. He is also seeking a new pot of money devoted specifically to make sure addicts who gained insurance under Medicaid can keep receiving treatment after the program is rolled back.

On Medicaid specifically, Portman and a few other Senate Republicans have floated a 7-year phase-out of Medicaid expansion, starting in 2020, that would gradually reduce the federal match to states. The idea is to give states an extended “glide path,” as Portman has called it, to help states adjust their Medicaid programs.

“Our goal is to ensure that those who have expanded Medicaid have the help they need to get back on their feet, receive the care they need, and gain meaningful employment with health coverage in the private market,” Portman said.

Some advocates say Portman’s proposal would be better than the House bill's quick cutoff, but the end result would still be the same.

“This is simply a question of how fast to boil a frog. The end is the same for the frog,” said Joe Parks, medical director for the National Council for Behavioral Health and the former director of Missouri’s Medicaid program.

Parks said it’s “wishful thinking” for lawmakers to believe they can repeal the Affordable Care Act and cut Medicaid without exacerbating the opioid crisis.

Horton, the addiction physician, said the current Medicaid program is the best tool he has to fight this epidemic.

"I am really fearful that some of the cuts that are proposed will completely gut the system that I rely on to treat my patients and help them get to a better place," he said. “Without it, the war is lost.”