In an attempt to sell wavering Republicans last week on the steep Medicaid cuts in the GOP’s health care overhaul, Senate Majority Leader Mitch McConnell put $45 billion on the table to help combat the nation’s ongoing opioid epidemic.
On Monday night, McConnell abandoned that iteration of his party’s plan to repeal and replace Obamacare simultaneously after learning he did not have enough votes to proceed. In doing so, he left behind that proposed funding measure—and in doing so, left the entire provision in limbo.
And now, it’s unclear whether the funding will be preserved in the newest iteration of the Republican health care strategy: to vote on a 2015 repeal bill immediately, and come up with a replacement plan within two years. That effort faced new roadblocks on Tuesday afternoon when three moderate Republican senators pledged to vote against a procedural measure on the legislation.
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Still, Republican leaders plan to hold a procedural vote on the legislation next week, McConnell said Tuesday. When asked for details on possible funding to combat the opioid crisis, a spokesman for McConnell’s office pointed The Daily Beast to the 2015 legislation—which allocates $750 million per year for two years in the form of state grants “to address the substance abuse public health crisis or to respond to urgent mental health needs within the State.”
Those funding levels are almost certainly not enough to satisfy centrist Republicans concerned about the effects on Medicaid in their states. The $45 billion allocated under the previous plan, the Better Care Reconciliation Act, was intended to provide additional resources to states where individuals could lose access to drug treatment programs as a result of losing Medicaid expansion coverage.
McConnell plans on having an open amendment process, but only if the bill can get to the floor in the first place. As of Tuesday evening Republicans did not have the support of 50 senators needed to continue the legislative process.
“Clearly, we’re going to have to take another approach. But we’re going to have to address the problem. It’s an enormous problem,” Sen. Roger Wicker (R-MS) told The Daily Beast after taking a long pause to think through his response.
Wicker wasn’t alone. No senator who spoke with The Daily Beast could say where Tuesday’s developments left funding for the opioid epidemic, and seemed blindsided when pressed further on the issue. If the Affordable Care Act remains intact, experts say, and the Medicaid expansion population would not be affected—meaning the $45 billion proposed in the BCRA would not be necessary.
The opioid crisis has reached the level of an epidemic, according to experts. The number of Americans who have died from prescription opioid drug overdoses has quadrupled since the turn of the century, according to the Centers for Disease Control. In 2015 alone, more than 15,000 Americans died from opioid overdoses. Republicans and Democrats generally agree that the crisis deserves federal attention.
With that in mind, the latest iteration of the Better Care Reconciliation Act, unveiled last week, included $45 billion for opioid treatment, recovery and research. The funding was viewed as necessary to woo some of the more moderate GOP senators—particularly those who hail from states that have been hit the hardest by the crisis.
But McConnell’s overture on funding for the opioid crisis wasn’t enough to get centrists such as Sen. Susan Collins (R-ME) on board, in part due to the steep spending caps on Medicaid that were left intact in the new legislation. For those same reasons, Collins said Tuesday she would vote against a procedural vote to consider the 2015 repeal legislation.
“I do not think that it’s constructive to repeal a law that is so interwoven within our healthcare system without having a replacement plan in place. We can’t just hope that we will pass a replacement within the next two years,” Collins said in a statement. “Repealing without a replacement would create great uncertainty for individuals who rely on the ACA and cause further turmoil in the insurance markets.”
Sen. Shelley Moore Capito (R-W.V.) also came out against a clean repeal of the Affordable Care Act, citing uncertainty that would would result amid the opioid crisis and her state’s decision to expand Medicaid under the Affordable Care Act. Capito previously voted in favor of a clean repeal in 2015.
“I cannot vote to repeal Obamacare without a replacement plan that addresses my concerns and the needs of West Virginians,” Capito said in a statement. She was followed by Sen. Lisa Murkowski (R-AK), who put the nail in the coffin when she told reporters she, too, would not support a clean repeal—dropping Republican support below the 50-vote threshold required.
Senators from states that expanded Medicaid have expressed the most serious reservations about each version of the Republican health care plan, saying the proposed caps would handicap their states’ ability to provide for those who rely on the program.
On a call with reporters, Sen. Rob Portman (R-OH)—who along with Capito pushed for the $45 billion to be added to the BCRA—said the House- and Senate-passed repeal-and-replace measures were not “responsive to what we have going on in Ohio, which is not just expansion of Medicaid, but an opioid epidemic, and Medicaid is a significant payer for that.”
Portman is undecided on the procedural vote scheduled for next week, but said it’s not “appropriate just to repeal. We’ve also got to put a replacement in place to help deal with the very issues I just talked about.”
Sen. Tom Carper (D-DE), a former governor, said he was especially concerned about the lack of appropriate funding to combat the opioid crisis. Close to $200 billion of Medicaid funds will be spent over the next 10 years for the opioid epidemic if the current law is not changed, Carper said, adding that the $45 billion allocated in the BCRA is not nearly enough to offset the Medicaid cuts.
“If given a choice to spend $200 billion or $45 billion over the next, you know, 10 years to provide addiction treatment, as opposed to $45 billion?” Carper told The Daily Beast. “I think we’re going to need something closer to $200 billion.”
As the Affordable Care Act remains the law of the land, funding for substance abuse treatment will still come through the federal government. But if there are changes—like those proposed by Republicans in the BCRA—that equation could become more complicated.
“The ACA Medicaid expansions are still in place so that gives the states some stability on how to fund treatment,” Eric Seiber, associate professor of health services management and policy at Ohio State University, told The Daily Beast. “A key question is whether Congress will include extra funding for services in states that did not expand Medicaid under the ACA.”
In the meantime, some senators seemed open to the prospect of working in a bipartisan manner to address the opioid crisis apart from the effort to reform the health care system.
“We should find another way to do it. The whole key now is let’s do things that both parties can agree on. Opioid funding? That’s something both parties can agree on,” Sen. Tim Kaine (D-VA) told The Daily Beast. “Instead of doing the one-party jam-through, let’s do something both parties agree on—and that would be at the top of the list.”
Another Democratic senator, Ben Cardin of Maryland, said it would be a “long shot” for Republicans to include substantial opioid funding in a repeal or replace bill.
“I think it depends what [McConnell] needs for votes. I don’t think he can get the votes on the repeal, so I think this is going to be academic,” Cardin told The Daily Beast. “If he’s going to try to buy votes, I don’t know where he gets the money from. Because there’s no money in this.”
Activists are pushing Republicans to abandon their efforts to scrap the Affordable Care Act, and instead work with Democrats to fix it. If not, they warn, millions would lose access to the care they need—through the insurance exchanges, Medicaid expansion, and essential health benefits—to fight addiction.
“You’ll have tens of thousands of people who will die next year because there are 2 million people in this country right now getting treatment for addiction based on the Medicaid expansion. And if that’s repealed and not replaced... most of them will not be able to afford treatment without the insurance,” Gary Mendell, who heads up the anti-addiction group Shatterproof, told The Daily Beast.
