In Cuyahoga County, Ohio, nearly 200 people have died from opioid-related overdoses in the first five months of this year. That means that this one U.S. county is on pace to lose more than 700 people to fatal overdoses by the end of 2017.
Terry Allan, health commissioner at the Cuyahoga County Board of Health, and colleagues across the county have spent years building and scaling up a multifaceted response to the opioid addiction and overdose epidemic that includes getting people into treatment, changing clinical prescribing habits, preventing deadly overdoses, and dealing with the often-heartbreaking social and economic fallout for families and children. There’s no “one magic pathway” for dealing with this problem, Allan told me, “it’s a continuum that has to be well-supported given the trend we’re on.” Ohio now leads the nation in opioid overdose deaths.
Allan said work is paying off — for example, nearly 1,000 lives in Cuyahoga County have been saved from a fatal opioid overdose in the last few years thanks to expanded access to naloxone — but the opioid problem in no where even close to subsiding. The reality, Allan said, is “we’re not seeing this trend abate.”
He was just as honest about the kind of impact the GOP health care bills would have on the county’s opioid epidemic: “You’d end up with a lot of people being turned away from lack of services. …We’d essentially be putting up the white flag — and now is not the time to pull back.”
The most obvious impact from the GOP health care proposals, both of which severely cut Medicaid funding and are expected to result in more than 20 million additional Americans without insurance, is that people would lose access to addiction and behavioral health services. The loss of access would be the result of losing insurance, whether Medicaid or private coverage, or from scaling back the Affordable Care Act’s essential health benefits, which required insurers cover substance use disorder services along with a number of other basic health services. Both the House and Senate repeal-and-replace bills would allow states to redefine or opt out of the essential health benefits requirement.
But another, less talked about setback for those suffering from opioid addiction would be elimination of the ACA’s Prevention and Public Health Fund (PPHF), which the House bill eliminates in fiscal year 2019 and the Senate bill eliminates in fiscal year 2018. The PPHF — the nation’s first mandatory stream of funding for improving the public’s health — is now the sole source of funding for the Centers for Disease Control and Prevention’s Preventive Health and Health Services Block Grant. That block grant is a critical source of flexible funding for health departments in every state, where officials use the flexible monies to address localized problems, from improving food-borne illness outbreak response to ensuring access to emergency medical services in rural communities. If the GOP succeeds at eliminating the PPHF, the block grant goes away with it.
In Cuyahoga County, that flexible block grant money has gone to support its injury prevention work — and the biggest injury threat now facing the county is opioid addiction. Allan said his agency uses the grant money to procure and distribute naloxone (which is now being carried by police in nearly every jurisdiction in the county), educate local clinicians on better prescribing practices (this is essential, as prescribing is a main driver of the opioid epidemic) and for convening the Cuyahoga County Opiate Task Force, which coordinates a multisector response to the epidemic. Allan said the health board organizes its opioid response according to five buckets: prevention, education, treatment, enforcement and recovery. If the response effort doesn’t account for and coordinate across those five buckets, “we’re just playing whack-a-mole,” he said.
Cuyahoga’s opioid addiction and overdose problem is a complex one that requires the kind of equally complex response that public health is uniquely adept at leading. The loss of the Preventive Health and Health Services Block Grant would put all that work at risk.
“All those dollars are tied to the ACA and without those dollars, this work would really be in dire straits,” Allan told me. “I’m not sure the state would be in a position to fill in the budget gap if the block grant went away. …Our concern is that we’d likely see, on a statewide basis, the support system we’ve built begin to atrophy. We’d be at a loss to deal with the volume that we’re dealing with right now.”
Beyond the public health response, about 700,000 Ohioans have gained insurance coverage through the ACA Medicaid expansion that the GOP bills would eventually eliminate. The expansion has meant many more Ohioans are able to access addiction treatment services, Allan said. If that Medicaid coverage went away, he said, the fear is that many of those saved from a fatal overdose via naloxone would have no where to go for help after being released from the hospital. It’s a wasted opportunity to get people into treatment and keep them from ending up back on the streets and using, he said.
“The impact of this isn’t just to the individual,” Allan told me. “It has communitywide implications for families and to our economy.” To put it even more bluntly, Allan said a loss of coverage for and access to addiction services will simply mean “more people will die.”
Research has shown that the ACA Medicaid expansion has improved access to opioid addiction treatment. In a June report from the Urban Institute, researchers found that many low-income adults in the 32 expansion states have gained access to buprenorphine, which reduces the symptoms of opioid withdrawal and cravings. But while researchers found a more than 70 percent increase in buprenorphine prescriptions per enrollee in Medicaid expansion states, programs are still struggling to meet the needs of such a large addiction epidemic. Another recent report from the Urban Institute found that the ACA Medicaid expansion did indeed fill a significant access gap in substance use disorder treatment, and that efforts to repeal the ACA — such as the House GOP bill — would likely result in millions losing addiction treatment coverage.
“We feel like we’ve been able to make some significant progress with this problem because of the resources the ACA has provided,” said Jeff Duchin, health officer at Public Health — Seattle & King County. “All that would be lost if we lose the funding that’s given people access to (opioid addiction) treatment. It’s very worrisome.”
Like communities across the country, the Seattle and King County area has experienced an increasing number of people addicted to opioid drugs and heroin, with about one person dying every one-and-a-half days from an opioid overdose, Duchin told me. Because of the increasing number of deaths and rising prevalence of addiction, the opioid epidemic has become a high priority for the public health agency in the past two years. In 2016, city and county officials convened a Heroin and Prescription Opiate Addiction Task Force.
Duchin said Public Health — Seattle & King County works particularly close with its sister agency in the county, the Department of Community and Human Services, which coordinates inpatient and outpatient addiction treatment for residents. In addition, ACA-funded Community Transformation Grants are slowly enhancing the effectiveness of that care by supporting efforts to integrate physical and behavioral health services in a single location, Duchin said. Work is now underway to develop these more integrated models of care, where patients can access all the services they need at one place, including housing and social services, but such work takes time.
“It makes the most sense if you want to help people — it’s a big way to lower barriers and allow people to get all the care they need at one stop,” he said of such efforts. “We can’t achieve it overnight, but we’re moving in that direction. …But until we get there, we need to provide low-barrier access to treatment in more traditional contexts. That means increasing the treatment capacity in the community for people with addiction and at the same time, trying to make much of that treatment available where people can also get care for their physical health needs.”
Public Health — Seattle & King County now operates a number of safety net services that reach at-risk, marginalized and underinsured populations. For example, its needle exchange offers access to buprenorphine and its mobile medical units provide access to naloxone, as does its health care program for the homeless, to which Duchin said they hope to add buprenorphine access as well.
Right now, Duchin said the city and county are doing a good job of meeting demands for inpatient addiction care, “but we’re not anywhere close” to meeting demands for outpatient care. To fill that gap, Duchin and colleagues hope to recruit many more primary care physicians willing to integrate buprenorphine treatment into their practices.
“Without a doubt, the Medicaid expansion has greatly strengthened our safety net,” Duchin told me. “We can serve many more lower-income adults not only with physical medical care and preventive care, but we’re able to get them access to behavioral services too. Without that expansion, many would just lose access to those services and we don’t have the local revenues to continue to provide them. …Letting people progress untreated to more complicated stages of disease is not only inhumane and leads to unnecessary human suffering, but it’s more costly to the community.”
Allan in Ohio put it in even simpler terms: “This level of addiction is unprecedented. It needs to be a national priority, and we need to demonstrate that by putting resources toward it. We need to put our money where our mouth is.”
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for 15 years. Follow me on Twitter — @kkrisberg.