Graham-Cassidy bill violates the 'first, do no harm' oath

Graham-Cassidy bill violates the 'first, do no harm' oath
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In 1983, Senator Bill CassidyWilliam (Bill) Morgan CassidyCoushatta tribe begins long road to recovery after Hurricane Laura Senators offer disaster tax relief bill Bottom line MORE became a physician, reciting the oath that physicians have repeated for a millennium — first do not harm. Today, in proposing his repeal and replace bill with Senator Graham, Senator Cassidy violates that oath.

The Graham-Cassidy bill repeals the Medicaid expansion, allows states to waive essential health benefit requirements, and eliminates subsidies that allow low income people to purchase health insurance and health care. This will profoundly harm many of America’s most vulnerable citizens, among them, those affected by the opioid epidemic.

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The bill would weaken the fight against the effects of opioids. The bill’s proposed changes to essential health benefit provisions would make it much harder for people to buy insurance that covered opioid treatment. Before insurers were required to include these benefits in health plans, 34 percent of plans didn’t cover substance use treatment at all.

 

The bill’s elimination of the Medicaid expansions and of subsidies for the purchase of private insurance would make it much harder for low-and middle-income people to afford any insurance coverage at all. Those harmful direct effects of the bill will be amplified by its indirect consequences of the bill.

In the midst of this terrible epidemic, these reductions in coverage would increase the financial burden on health care providers who are treating both those with addictions and their households and communities. And the ruinous consequences of the bill for state budgets would reduce the State’s capacity to address the devastating effects of the epidemic on children, families, and communities.

Consider the potential direct and indirect impacts of just one component of the bill — repeal of the Medicaid expansion — on two states that have been hard hit by the epidemic: Ohio and West Virginia. In Ohio, 702,000 people were covered under the Medicaid expansion in 2016, among them, about 25,270 who had an opioid use disorder.

Ohio’s own analyses show that Medicaid expansion led to improvements in access to care for 75 percent of this group. Medicaid helped save lives by increasing access to the opioid-reversal drug, naloxone.

It paid for longer-term treatment, to address and conquer addictions. It also enabled a nine-fold increase in treatment of the infectious disease hepatitis C and of other illnesses that accompany opioid use disorders. Those direct benefits of Medicaid helped Ohio community hospitals cope with the 75 percent increase in opioid-related hospital stays that occurred between the beginning of 2012 and the middle of 2016.

Back in 2012, before the Medicaid expansion, 19 percent of those hospital stays were for people who were uninsured — today, just 3.5 percent of those stays are for uninsured people. Hospitals, freed from a burden of uncompensated costs that’s estimated at $42 million annually, have more resources available to care for everyone in the community.

But treatment costs money. The cost of care for a person with an opioid use disorder is approximately $11,000 per year, so the cost of treating those with an addiction within the expansion population in Ohio amounts to $278 million per year. Without the Medicaid expansion funding, Ohio will be hard-pressed to pay for medical care, and for the increased burden of foster care, community support, and law enforcement that also accompanied the epidemic.

The picture in West Virginia looks distressingly similar. About 50,000 people in the Medicaid expansion population in the state suffer from a substance use disorder. The Medicaid expansion paid for $112.9 million of treatment in 2016.

West Virginia hospitals saw 1,350 opioid-related hospital admissions in early 2012, before the Medicaid expansion, and 22 percent were uninsured. As the epidemic exploded, hospitals treated 1850 opioid related cases in late 2015 — but because of the Medicaid expansion, just 2.7 percent were uninsured. The Medicaid expansion reduced opioid-related uncompensated care in West Virginia hospitals by over $10 million in 2015.

Sadly, the toll of the epidemic extends beyond those with a disorder themselves. The consequences of the epidemic for families and communities would make the effects of the Graham-Cassidy bill’s cuts even more destructive. West Virginia would lose funding to care for substance use problems in its Medicaid expansion population even as the state budget had to cope with increased demands on its existing programs for children and families.

Between 2012 and 2016, the state saw an increase from 500 to about 850 in cases of neonatal abstinence syndrome — a consequence of babies born with opioid addiction. It costs between $41,000 and $93,000 to treat each case. That’s a cost to the state of some $35 million in 2016. Those babies often don’t have a stable home to return to — so the state’s existing programs must also cope with a 54 percent increase in foster care cases.

In the context of the opioid epidemic, Medicaid expansion has acted as disaster relief for states like Ohio and West Virginia. It has helped them to face the immediate and horrendous consequences of the epidemic, by providing access to emergency reversal therapy and long-term treatment.

It has helped them to maintain the infrastructure to serve their communities, by reducing the burden of uncompensated care on hospitals. It has allowed states to allocate their limited funds to the children and families damaged by the epidemic. The Graham-Cassidy bill would cut those lifelines and in place of a helping hand, inflict tremendous harm.

Richard G. Frank, Ph.D., is the Margaret T. Morris Professor of Health Economics in the Department of Health Care Policy at Harvard Medical School, and Sherry Glied, Ph.D. is Dean of the Wagner School of Public Service at NYU.