Alex Shelton was that friend who shows up at your house in the middle of the night, barefoot, in the snow, and says “my car got ambushed.”
He didn’t look sick. He was in his early 20s. Able-bodied. But while work is sparse in McDowell County, where he grew up, others his age were working in the mines and starting families.
Shelton’s life, meanwhile, was a series of disasters.
When Shelton showed up at his friend’s house that night, the friend took him home to Shelton’s mom’s house. The friend waited until the next evening to show Shelton where he had wrecked his vehicle.
“I thought I was doing OK,” Shelton said, “even though everything around me was falling apart.”
Shelton was that family member who showed up intoxicated at family gatherings. That friend always trying to pick a fight.
“I’m from a small town,” he said. “There’s not really much going on there in the way of work. It’s kind of bad down there.
“If you can’t work like 60 to 70 hours a week in a coal mine, then you don’t have a job. I couldn’t physically or mentally handle that, especially then, because I was on drugs.”
Before the Affordable Care Act was implemented and West Virginia expanded its Medicaid program so all adults who make up to 138 percent of the federal poverty level could qualify, Shelton would not have been eligible for the insurance. Prior to expansion, most enrollees were children, the elderly and the disabled.
And while Shelton’s illness certainly was disabling, he didn’t meet the requirements.
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Shelton, now a recovery coach at Prestera Center, is covered by Prestera’s private health insurance.
Kim Miller, a spokeswoman for Prestera, said many patients with substance-use disorders covered by Medicaid expansion move to private insurance in recovery.
“Their lives improve,” she said. “They get off of Medicaid. They get weaned off the system.”
Shelton wouldn’t have been eligible for assistance based on disability, either, according to Ann McDaniel, executive director of the West Virginia Statewide Independent Living Council.
You have to be someone who’s “been through treatment and is no longer using to qualify,” she said.
After Republican leaders in Congress announced a plan to repeal and replace the Affordable Care Act, several health care providers that offer addiction treatment in West Virginia said the proposed replacement, the American Health Care Act, would be devastating to people seeking treatment for a substance-use disorder in the state, mainly because it would significantly decrease Medicaid funding. The Congressional Budget Office estimated the American Health Care Act would reduce direct Medicaid spending by $880 billion from 2017 to 2026.
The repeal of Medicaid expansion was the most pressing concern for several providers. The federal government paid 100 percent of Medicaid funding for the expansion population from 2014 to 2016. The number is to decline gradually to 90 percent by 2020.
Under the American Health Care Act, this extra funding would end. West Virginia’s federal matching rate for other Medicaid patients is about 70 percent.
Expansion brought $732 million in federal funding to West Virginia in 2015, according to the Robert Wood Johnson Foundation. From 2013 to 2015, the state’s uninsured rate dropped by nearly 60 percent, from 13.4 percent to 5.4 percent, largely due to Medicaid expansion.
The low-income patients who visit Prestera, a community mental health and substance abuse treatment center that serves several counties in Southern West Virginia including Kanawha, would be disproportionately affected by the elimination of Medicaid expansion.
About 75 percent of Prestera’s clients are on Medicaid, according to Miller. She recalled in prior years about 50 percent of patients were covered by it.
“That gives us a funding source,” she said. “That’s less care that we’re just giving away.”
Before Medicaid expansion, Prestera wasn’t able to offer medication-assisted treatment.
“We’re a nonprofit,” she said. “We’re a very fragile organization. We definitely will suffer in different ways.”
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Medicaid expansion began in West Virginia in 2014. About 170,000 West Virginians were enrolled in expansion as of last week.
According to the Department of Health and Human Resources, 9,614 patients with any substance abuse diagnosis and 5,635 patients who saw a provider primarily for that reason were covered by Medicaid expansion in 2014.
By 2016, 50,507 patients with any substance abuse diagnosis and 19,817 patients who saw a provider primarily for that reason were covered by Medicaid expansion.
Medicaid expansion money spent on substance abuse treatment, including services and prescriptions, increased from about $25 million in 2014 to $111,767,057 in 2016.
In 2013, 5,827 people with opioid abuse diagnoses were covered by Medicaid, according to the DHHR. Medicaid paid for $6.8 million in opioid abuse-related claims that year. By 2016, the number had increased to 14,808 patients. Medicaid paid for more than $17 million in opioid abuse-related claims that year.
Donna J. Cooke, CEO of Logan-Mingo Mental Health and a licensed psychologist, saw an increase in clients when Medicaid was expanded.
“I think we all got a big surprise there,” she said. “And what I think the reason for that is, you just had folks that never sought mental health or addiction treatment. They just thought that services were not available to them. It was much greater than what I think anybody could have expected.”
She saw an even bigger increase in clients at the community mental health center when the mines closed in 2015 and 2016. People who once had private insurance turned to Medicaid expansion.
“We have more people waiting to get into treatment than what any of us can serve,” she said. “Not just community mental health centers, but private practitioners and everything, because we’re in the midst of an epidemic.”
Coal miners started coming in for anxiety. People were more susceptible to opiate addiction.
“If they were to cut out the expansion or carve out substance abuse treatment from Medicaid, it would be devastating to the residents in the southern part of the state,” she said. “You know, people need jobs, but we can’t offer a clean workforce if we don’t have the treatment.”
Craig Robinson, executive director of Cabin Creek Health Systems, said the rural health care provider was able to begin offering medication-assisted treatment at the Kanawha City Health Center because of the Affordable Care Act. Experts at West Virginia University’s addiction program have taught care managers, therapists and physicians to treat substance abuse as a team, he said. They also have hired addiction specialists.
“The Affordable Care Act made available additional funding for community health centers that wanted to expand their mental health services and provide addiction treatment services for opiate addiction specifically, which is the big problem in Kanawha County and in the state,” he said. “They made the decision that the epidemic was so severe that there needed to be additional addiction care services, and there had been success in integrating addiction care with primary care. That’s what we’re doing now and it has worked.”
Almost 90 percent of its patients are covered by Medicaid.
Robinson said the program had been “very gratifying for the professionals that are involved in doing that care because of the impact it’s had on people’s lives.”
Cynthia Persily, president and CEO of Highland Hospital, said she thinks “our current addiction problem would worsen without the care these patients are receiving through Medicaid expansion.” Last fiscal year, 842 patients who went through detox at the psychiatric hospital were covered by Medicaid.
“I think that Medicaid expansion is the biggest source of assistance for patients who have mental health and substance abuse disorders that we’re seeing, and I think the loss of it would really leave lots of West Virginians without access to their needed addiction treatment and mental health care,” she said.
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Two health policy analysts in West Virginia said they also worried about Republicans’ proposed changes to the Medicaid funding structure and the potential effect on addiction treatment.
Simon Haeder, a health care policy researcher and professor of political science at WVU, said he is concerned about the effect of funding Medicaid per capita, or based on historical spending rates instead of based on care needed, because it would limit the federal government’s financial role.
“Even if the funding grows over time (e.g. by adjusting it for inflation), this growth will not keep pace with the costs for the Medicaid program, particularly in poor states like West Virginia, with many residents disabled, aged, and severely sick,” he said in an email.
According to a report by the State Health Reform Assistance Network, supported by the Robert Wood Johnson Foundation, “If West Virginia’s historical spending rates are indicative of its future spending rates, over time, federal Medicaid funding under a capped funding proposal would fall short of West Virginia’s needs.”
“The states would have to decide what benefits to cut (or limit) — substance abuse treatment could be subject to those cuts,” Haeder said.
He added that defunding Medicaid expansion “would make it virtually impossible for West Virginia and most states to realistically continue the Medicaid expansion.”
Since House leaders canceled a planned vote on the American Health Care Act in March, conservative members of the House Freedom Caucus negotiated an amendment last week that would allows states to opt out of certain requirements, including the requirement to offer “essential health benefits,” such as maternity care or mental health treatment.
Haeder said eliminating the essential health benefits “would allow insurers to sell skimpier plans, most likely without substance abuse treatment because it is expensive.”
Kat Stoll, a health policy analyst for West Virginians for Affordable Health Care, said changing Medicaid’s funding structure, reducing the federal government’s contribution, would “reverse our communities’ progress fighting the opioid epidemic.”
“The Republican House bill under debate in D.C. will shift a huge financial burden from the federal government to the state — and West Virginia cannot shoulder that additional burden of health care costs,” said Stoll, who also is a health analyst for the West Virginia Center on Budget and Policy.
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Shelton, the Prestera recovery coach, remembers sitting in a detox waiting room when a man came over and handed him a pamphlet about 12-step programs.
“I just remember thinking, ‘This guy thinks I’m a drug addict,’” he said.
Shelton, who is a recovery coach in the Jefferson/St. Albans area, was eventually treated at Prestera.
“It’s all on the inside,” he explained. “You look like everybody else, but you’re just incapable of functioning like a normal person — all of your moods and all of your motives are to get high. It doesn’t translate real well into real life stuff ... At first you think you’re crazy, then you think you’re just a bad person. It took a long time for me to realize it’s a disease, and I had to treat it to get better.
“People don’t realize how debilitating it is to be an addict. It’s a full-time job getting high.”
He said he remembers those early sober days and the feeling of being overwhelmed by bustling traffic and passing people.
At Prestera, he was treated not only for the addiction, but the underlying anxiety.
Free programs, he noted, don’t have the health care providers on staff certified to treat those mental health conditions.
“I’ve got a lot of good stuff going on right now,” he said. “It’s all possible because I was able to get in treatment when I was. I got the right kind of help, when I needed it.”
He had an uncle who was sick, too. He had reminded Shelton of himself — that drunk uncle who showed up to family gatherings.
“He couldn’t quit drinking and getting high,” he said. “He ended up killing himself. That’s something I thought about after I got clean. He probably could have gotten clean, too, if he got help.”