In late May, several senators went to the floor of the Senate to talk about people in their states who are affected by the opioid crisis. Sen. Shelley Moore Capito, R-W.Va., talked about Chelsea Carter.
"She told me her drug habit began when she was 12 years old," said Capito.
West Virginia has the unfortunate distinction of having the highest per-capita death rate from opioids — 36 out of every 100,000 people died from overdoses on heroin, fentanyl and other opioids in 2015. But Chelsea Carter is one of the lucky ones.
"Her story — Chelsea's story — is an example of the progress that can be made by fully committing to fighting the drug epidemic and that there are victories," Capito said, "that there are programs that work."
Carter has been in long-term recovery since September 2008.
"I've come a long way from where I was nine years ago sitting in a jail cell," Carter said in a phone interview with NPR.
She went from facing jail time to drug court, treatment, college and graduate school and is now the program director at Appalachian Health Services. All the while, the crisis in the state where she grew up only got worse.
Carter estimates that about 90 percent of the people who come to her clinic for treatment for addiction are on Medicaid, the federal program for the poor that West Virginia chose to expand under the Affordable Care Act, also known as Obamacare.
The Senate health care bill would phase out that expansion and, over time, make cuts to traditional Medicaid (as compared with the anticipated spending under current law). And so, Carter is watching the debate closely.
"We are losing people daily to this," said Carter. "I am treating generations of drug abuse, and with the people dying of opiate drug overdoses every day, I just don't see how we could cut funding from something that's saving lives."
On Tuesday, Capito announced that she opposes the health care bill in its current form. She cited cuts to Medicaid and concern about what the bill would mean for people dealing with opioid addiction.
"West Virginia has the largest Medicaid population in the country. I recognize that many West Virginians rely on health coverage and access to substance abuse treatment because of my state's decision to expand coverage through Medicaid," Capito said in a written statement released shortly after it was announced the health care vote wouldn't happen this week.
"I have studied the draft legislation and CBO analysis to understand its impact on West Virginians. As drafted, this bill will not ensure access to affordable health care in West Virginia, does not do enough to combat the opioid epidemic that is devastating my state, cuts traditional Medicaid too deeply, and harms rural health care providers," the statement continued.
There is a pretty direct correlation between states with high overdose death rates and Republican senators expressing reservations with the bill.
"It doesn't protect Nevadans on Medicaid and the most vulnerable Nevadans," Sen. Dean Heller, R-Nev., said at a press conference announcing his opposition to the bill. "On Medicaid expansion, probably half — half — the dollars that were spent on that were on mental health and opioid abuse."
Republican governors have also come out against it, including Charlie Baker from Massachusetts, Chris Sununu from New Hampshire, Brian Sandoval from Nevada and John Kasich from Ohio. All four states have expanded Medicaid and have high overdose death rates.
Heller and others could still change their minds or be persuaded by changes to the bill. And one lever that Senate Majority Leader Mitch McConnell, R-Ky., could employ is increased funding in the bill for grants to help states respond to the opioid crisis.
Currently, the bill would give states $2 billion to deal with opioids in 2018. Sen. Rob Portman from Ohio, another Republican who opposes the bill in its current form, is pushing for that fund to go up to $45 billion over the next decade.
But even $45 billion wouldn't be enough, says Richard Frank, a professor of health economics at Harvard Medical School who had served in the Obama administration.
"It is one part of trying to compensate from taking people's insurance away, but it doesn't cover nearly what the needs are from these populations," said Frank.
Additional needs often include treatment for hepatitis C or HIV as well as car accidents, coverage for emergency room visits and the provision of life-saving rescue drugs, he said.
"My estimate is that we're talking $180 billion over 10 years not $45 billion," said Frank.
A study by the Urban Institute released Wednesday found that "between 2011 and 2016, spending on Medicaid-covered prescriptions to treat opioid use disorder and overdoses increased 136 percent from $394 million to $930 million."
"States with the highest overdose mortality rates in 2015 — including Kentucky, Massachusetts, Ohio, Rhode Island, and West Virginia — have seen particularly fast growth in spending for OUD treatment over this period," the study's abstract also says.
The Congressional Budget Office estimates that in 2026, there would be 15 million fewer people covered by Medicaid than under current law. The White House and some congressional Republicans cast doubt on the estimates of the CBO. And supporters of the bill argue that states would have more flexibility to tailor Medicaid coverage to the needs of their populations.
Michael Botticelli, the last drug czar under President Barack Obama, says love it or hate it, Obamacare did allow a lot more people to get treatment.
"It's really hard to understate the dramatic increases we're going to see in overdose deaths," said Botticelli, who now heads the Grayken Center for Addiction Medicine at Boston Medical Center.
In 2015, the last year for which data has been released, 34 percent of people receiving treatment for opioid addiction were covered by Medicaid, according to an analysis by Frank.
"You know, we're in the greatest health crisis that we've had since the height of the AIDS epidemic and we've seen the dramatic gains that we've been able to make and that people are able to make with Medicaid coverage," said Botticelli.
Botticelli finds it hard to believe senators whom he worked with to combat the opioid epidemic would consider voting for the current version of the health care bill. And, at the moment, it's still an open question as to whether they will.
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