This week’s Public Health News Watch focuses on the repeal of the Affordable Care Act and how the opioid epidemic in the United States needs plays a pivotal role in any suggested replacements.
Folk/rock singer Neil Young decried the personal harm and collateral damage caused by injection drug use in his song “The Needle and the Damage Done.”
In a sense, nearly 25 years after the song’s release, he could add a new verse regarding healthcare reform.
Indeed, it seems, based on recent media reports, that the latest epidemic of injection drug abuse in the United States played a role in derailing President Trump’s attempts to “repeal and replace” the Affordable Care Act (ACA), otherwise known as “Obamacare.” At issue, specifically, was the provision of the proposed legislation that, over the next 10 years, would have, according to Congressional Budget Office figures, cut Medicaid funding by $839 billion and, ultimately, lead to 14 million Americans being dropped from the rolls of the government-administered program.
An article published in The New York Times on March 28, 2017 noted that several “moderate” Republicans went against their colleagues in Congress and the GOP-controlled White House due, in large part, to the effect the changes in Medicaid would have had with regard to the opioid epidemic in their districts. In recent years, multiple states—including Virginia, Massachusetts, Kentucky, and West Virginia—have cited significant problems with opioid use.
A study published March 29, 2017 in JAMA Psychiatry found that the number of heroin users and those with heroin use disorder in the United States increased significantly (by nearly 5 times) during the period of 2001 through 2013. In their survey of 79,402 adults, the researchers from the Columbia University Mailman School of Public Health found that the prevalence of heroin use increased from 0.33% in the time period 2001-2002, to 1.61% in 2012-2013. The prevalence of heroin use disorder increased from 0.21% to 0.69% over the same period.
Although, Young didn’t mention infectious diseases in “The Needle…,” he very well could have. Opioid abuse in general, and injection drug use, specifically, have been linked with a number of public health challenges, including the spread of HIV and hepatitis C. Recently, as we reported in Contagion®, increased non-prescription opioid use has been linked with case clusters of HIV in Kentucky, Tennessee, and West Virginia, among others, based on an analysis performed by the Centers for Disease Control and Prevention. In addition, a report published by the Brookings Institute this month, suggests that this particularly high-risk and harmful drug use may, in fact, be the result of “poorer health and mental health, social isolation, obesity, marriage (or lack of marriage), poorer labor market opportunities, and weaker attachment to the labor market,” the authors told the Guardian.
All of which brings us back to Medicaid and its effect on healthcare delivery (and possible reform of the delivery system). What started as a relatively small component of social reforms initiated by then-president Lyndon B. Johnson in the 1960s—when, initially, only 2% of Americans qualified for Medicaid—has become, effectively, the largest insurer in the United States, with more than 74 million people enrolled, according to Centers for Medicare and Medicaid Services data. Part of this increase in Medicaid recipients can be attributed to the ACA, which, for states that opted in, expanded eligibility to include persons with incomes at 138% of the poverty level.
Notably, for the 31 states (and Washington, DC) that signed on for this component of the ACA, the federal government covers the costs for the bulk care provided these “new” Medicaid recipients—including addiction and mental health treatment. In fact, in announcing his “no” vote last week, Pennsylvania Republican Congressman Brian Fitzpatrick said he was basing his decision on “the impact on the single most important issue plaguing [his district], and the issue that I have made my priority in Congress: opioid abuse prevention, treatment and recovery,” according to The Times.
And Fitzpatrick was, of course, hardly alone. Which means, any future attempts to tear up the ACA will have to address the opioid epidemic and related issues or, as Young would put it, they will be “gone, gone, the damage done.”
Brian P. Duleavy is a medical writer and editor based in New York. His work has appeared in numerous healthcare-related publications. He is the former editor of Infectious Disease Special Edition.