The opioid crisis is decimating communities across the country. Yet, the Senate Republicans’ Better Care Reconciliation Act (BCRA) would gut treatment and other services for substance use disorder (SUD) by cutting Medicaid funding by 36 percent and eliminating the Affordable Care Act’s (ACA) requirement that health plans provide affordable coverage of SUD services. To help win votes of wavering senators, the latest version of BCRA now includes a separate $45 billion fund for treatment of people with opioid use disorders (OUD). Yet this fund would barely provide a drop in the bucket for addressing the opioid crisis and would not come close to making up for the damage of the drastic cuts to Medicaid funding and ACA protections.
First, BCRA’s opioid fund, which runs from 2018 to 2026, is not even remotely close to the amount needed to cover actual treatment costs. In 2026 alone, states would need $41.5 billion to provide OUD treatment, but would only get $5 billion from BCRA’s opioid fund. This gap is particularly worrisome in the states with the highest rates of overdose deaths. In 2026, West Virginia would need $351 million, but will receive a mere $61 million from the BCRA fund. Ohio, where almost 500,000 individuals have received SUD treatment since the state expanded Medicaid, would need $2.2 billion, but would only receive $272 million. As Governor John Kasich has said, the BCRA funding would be so low compared to the amount needed that its effect would be “like spitting in the ocean.”
Funding is not the only problem with BCRA’s approach. While the most effective way of preventing opioid-related deaths is to identify and treat mental health and substance abuse problems before OUD develops, the BCRA fund would only be available for the cost of “treatment and other recovery services.” Without access to comprehensive and affordable preventive services, like SUD screening, individuals with OUD will only be able to access treatment once OUDs have already developed. At this point, treatment will be more costly and may be less effective. Beginning treatment after OUDs have developed will also have negative consequences on the economy. While BCRA reduces federal spending now, failure to prevent OUDs from developing will lead to higher state and federal expenditure on treatment in the future and will increase the burden on safety-net hospitals with higher uncompensated mental health and SUD costs.
Moreover, as opposed to the current ACA coverage structure, the BCRA fund would separate OUD treatment from other mental and physical services. This will have disastrous consequences for people with OUD, who are more likely to have disabilities and other co-occurring diseases, such as depression, HIV, and chronic diseases. The Substance Abuse and Mental Health Services Administration (SAMHSA) has stated that “people with co-occurring disorders are best served through integrated treatment.” For example, for individuals with OUD who also have chronic diseases, these chronic conditions must be properly and concurringly treated to decrease opioid dependence. Even if these individuals obtained OUD treatment through the BCRA fund, they will likely be unable to afford treatment for their chronic conditions without the current ACA protections, which will result in continuous overuse of opioids to control pain.
Finally, BCRA grants can be ended by the federal government at any time and, while the epidemic is expected to grow in the next decade, the BCRA fund ends in 2026. This is a significant change from the current Medicaid funding structure and ACA protections which ensure that individuals at risk of overdose can access preventive and treatment services when they need it without the uncertainty surrounding federal funding that BCRA would create.
With the opioid epidemic showing no signs of receding, Senate Republicans must maintain appropriate funding and coverage protections that ensure that people at risk of overdose can access OUD preventive and treatment services. BCRA’s opioid fund falls well short of this imperative. Senators from states hardest hit by the opioid crisis must not be fooled by this shell game that takes billions of dollars away from life-saving prevention and treatment.