They are adults when they show up, but Lois Vance watches them grow.
When they first arrive at the Kanawha City Health Center, they are hunched over, and the men wear their baseball hats tipped low.
Vance, addiction care coordinator, tells them to get that hat out of their face and look her in the eye. There is no shame here.
She recently sat in a meeting room at the center, surrounded by four of the 24 people in the addiction treatment program, and they talked about what the GOP plan to repeal the Affordable Care Act would mean for them.
The version of the Senate plan released last week, like the previous versions of the bill before it, would disproportionately hurt the opioid-addicted population.
“If they lose their insurance, the whole world is going to be looking down on them again,” she said.
Three of the four, who all live in Kanawha County and asked that only first names be used, are on Medicaid.
The Congressional Budget Office hasn’t released an estimate for the newest version of the bill. But it estimated the similar previous version would cut Medicaid by $772 billion over 10 years, based mainly on ending the extra funding for states that expanded Medicaid under the Affordable Care Act and setting per-capita-based caps on traditional Medicaid payments to states. It estimated 15 million fewer people would have Medicaid in 10 years.
When states spend money on Medicaid, the federal government pays a matching rate that varies by state. West Virginia has the highest matching rate in the country at 73 percent. Health policy experts say a per-capita-based cap would cut that payment because the cost of health care expenditures would grow faster than the maximum payments.
The current version makes similarly deep cuts to Medicaid. Like previous versions, it would end Medicaid expansion in West Virginia, which covers nearly 10 percent of the population and sets per-capita based caps, although they could be removed during a public health emergency.
Medicaid is the single largest payer of substance abuse and mental health treatment in the country. Nationwide, Medicaid covered three in 10 people with opioid addiction in 2015, according to the Kaiser Family Foundation. West Virginia has the highest overdose death rate in the nation, mainly due to opioids.
Phil, who is older than the others in the program, gets excited talking about the young people he’s watched get better.
“They get employed,” he said. “They start taking care of their children. They start paying taxes and being a contributing member of society.
“If an addict is lucky, they might have one opportunity in their life to find a program of this caliber,” he said.
Chad got to be there for his daughter’s 7th birthday party.
“We all got one more high in us,” he said. “But I don’t think we got one more recovery left.”
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The last version of the GOP bill had about $2 billion in grant funding for opioid treatment. The current version provides $45 billion over 10 years for grants to states to combat the opioid crisis.
Health policy and health economics experts have said that still wouldn’t be enough to protect the opioid-addicted population.
Sen. Shelley Moore Capito, R-W.Va., and several other senators have been advocating for $45 billion, a figure based on an estimate released by Richard Frank, a health economist at Harvard Medical School, and Sherry Glied, dean of New York University’s School of Public Service.
Frank noted they had estimated $4.5 billion was spent on mental health and addiction treatment among the Medicaid expansion population in 2016. Senators multiplied that number by 10 and asked for $45 billion over 10 years.
Frank, who also served as assistant secretary for Planning and Evaluation at the U.S. Department of Health and Human Services, noted people who are addicted to opioids tend to have higher rates of Hepatitis C, HIV and other health problems — conditions associated with both poverty and drug addiction.
He also noted the epidemic is rapidly growing.
“To think that what was good in 2016 is going to be good in 2026 is both incomplete and a stretch,” he said.
Frank estimated the federal government would need to spend $183 billion instead. Medicaid spends, on average, $11,000 to $12,000 a year on each person addicted to opioids and $3,000 to $4,000 on the average person.
And according to the Agency for Healthcare Research and Quality, opioid-related hospitalizations are growing at a rate of 5.7 percent per year, and opioid-related emergency room visits grew at a rate of 8 percent per year since 2005.
Frank estimated that if the epidemic continues to grow at 5.7 percent per year, covering the health care needs of the opioid-addicted population currently covered by Medicaid expansion would cost $14 billion in the first year and in excess of $183 billion over 10 years.
“We’re looking at triple the cost, and so to say that you’re just going to carve out the addictions piece and not take into account all the other things that go wrong when someone’s addicted seems like it’s not going to be solving the problem,” he said.
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Medicaid expansion, a provision of the Affordable Care Act, brought Medicaid in most states to people who made up to 138 percent of the poverty line ($16,643 per year for an individual in 2017). For those people, the federal government pays a matching rate of about 90 percent.
State officials have said the cuts would end Medicaid expansion in West Virginia, taking coverage away from 170,000 people. GOP leaders in Congress have said Medicaid expansion would be “phased out,” but state officials have said expansion was contingent on the extra dollars.
Before the Affordable Care Act, Medicaid mainly covered people with children, the elderly and the physically disabled. Substance abusers — often able to work but making little money, or unable to work but not about to tell the government why — often were not covered.
“People liken the withdrawal to the flu times 10, which is the only apt way to describe it, but it really doesn’t fit,” said Greg, one of the men at Kanawha City Health Center. “Unless you’ve felt it, there’s no way to accurately describe it. That’s why you’re not able-bodied.”
In 2016, about 50,000 of those covered by Medicaid expansion in West Virginia had substance-use disorders, according to the Department of Health and Human Resources.
“That was the whole idea of the expansion,” said Craig Robinson, executive director of Cabin Creek Health Systems. “This was about the working poor that don’t have health coverage. That’s the West Virginia population — low-income working people. That’s what we are.”
Cabin Creek Health Systems is made up of several rural health providers, including Kanawha City Health Center.
“In some cases, it’s hard to know which came first, the addiction or the poverty,” Vance said.
Phil, one of the program participants at Kanawha City Health Center, was injured working in a coal mine in 1986. A doctor at a pain clinic prescribed opioids, he built up a tolerance and he eventually became addicted.
“Ninety percent of people I know, it wasn’t some trauma,” he said. “It was a matter of growing up here in West Virginia. It’s everywhere you go.”
He later started working as a teacher.
“For 20-some years I looked like I was a dead man — like a typical junkie you’d see every day, except I had to get up every day and put on a tie and go to work,” he said.
Before he found the Kanawha City Health Center, he looked for treatment, but most places accepted only cash.
“If I lose my insurance, you’re looking at a dead man,” he said.
Greg said his boss fired him when he asked if he could take a different day off for treatment.
He had known the man his entire life. He worked there five and a half years.
“I think it was just the stigma of addiction,” he said.
As he walked out the door of the center, he repeated how grateful he was someone listened to him.
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As a federally qualified health center, Kanawha City Health Center is required to serve the low-income. So if the bill passed, it would serve people who lost Medicaid using a sliding-scale payment system.
“Many of them would find they couldn’t pay that,” Vance said.
“The bus fare is a barrier,” added Emily Selby-Nelson, director of behavioral health services.
The loss in funding would also mean, according to Robinson, the center would likely lose more than 20 employees. The bulk of its patients are covered by Medicaid.
“It would go back to the days we were scratching around, trying to get people in specialty care, trying to help them avoid bankruptcy,” Robinson said. “It’s a miserable way to live.”
The National Institute on Drug Abuse considers poverty a “risk factor” for drug addiction.
“It’s a principal determinant for addiction,” Robinson said. “It’s not the only one, but it’s important because of the stress it means to children and families.”
A 10-year grant, Robinson said, “doesn’t fit the nature of the problem.”
“There’s broader health implications for this,” he said. “There’s the mental health piece. There’s all the chronic problems that accompany addiction. It requires from childhood to adulthood care to be able to address it.”
State officials have also said West Virginia’s entire health care infrastructure would collapse if federal funding declines. Under a previous version of the bill, they estimated West Virginia would lose more than 10,000 jobs.
“I think the economic distress that would cause would mean the problem of addiction would be aggravated,” Robinson said. “It both means that there’d be more addiction, and that we’d have a much more difficult time treating it.”
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Keith Humphreys, professor of psychiatry and behavioral health sciences at Stanford School of Medicine, also pointed out grants wouldn’t cover other problems.
“They have all the problems that everyone else has,” he said. “As people get older they have multiple conditions — not because they’re addicted, because they’re human.”
Humphreys, who is from West Virginia, also noted states and treatment providers would have to apply for the grants, and smaller, rural health care providers “would have to know how.”
“You would never go into a hospital and say, ‘I have cancer,’ and expect someone to say, ‘Well, we didn’t apply for a cancer grant this year,’” he said. “It’d be a separate program. It’d be separate paperwork and all that, and some places wouldn’t do it.”
The newest version of the bill could also make obtaining coverage harder for people who have been addicted to opioids to find coverage on the private market because it would allow insurers to sell plans that discriminate against people with pre-existing conditions by charging higher rates.
“Who’s going to want to cover people who have in their record that they were opioid addicted?” Humphreys said.
People with Hepatitis C could also be denied coverage or charged more.
“I think there’s probably no state in the union that would lose more than West Virginia if this passed,” he said.
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“I think that, logically, to me, if you’re taking away people’s ability to pay for treatment, then you can continue to throw money at different target areas, but it’s ultimately not going to really make enough changes for the whole person that’s going to be necessary,” said Dr. James Berry, addiction psychiatrist and medical director at West Virginia University’s Chestnut Ridge Center.
“The problem with the new bill is that it would provide grants rather than actual Medicaid insurance,” he continued. “With Medicaid insurance, it allows doctors, such as myself, to treat a whole range of diseases that people have who are affected by addictions.
“For instance, we would not be able to treat all the psychiatric problems that are associated with addiction — depression, anxiety, in very severe cases, schizophrenia, medical complications, infectious disease, Hepatitis C, Hepatitis B, HIV, endocarditis, which is an infection of the heart valves.
“None of this would be able to be managed if people do not have the actual insurance to treat this full range of conditions,” he said.
Berry estimated one-third to one-half of his patients have Hepatitis C.
He predicted if the bill passed, the center would go back to treating patients “acutely” like it did before the Affordable Care Act. In other words, treating overdoses or offering detox — making sure the patient doesn’t die, at least right now.
It was more discouraging back then, he said. Doctors would start patients on medications, but they’d relapse quickly because they couldn’t continue to pay for them.
“We’re able to provide the full range of services,” he said. “We just see people get better.”
WVU’s program will continue to exist, he said. But the bill will be “devastating to the people who don’t have the financial resources in order to take advantage of programs such as ours.
“This is not a hopeless condition, as long as people have the opportunity,” he said.
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At Kanawha City Health Center, about 80 percent of patients in the medication-assisted treatment program have Hepatitis C, according to Vance.
Depression, anxiety and post-traumatic stress disorder are common as well, according to Selby-Nelson.
An estimated 39 percent of people with substance-use disorders have a co-occurring mental health diagnosis, according to the 2014 National Survey on Drug Use and Health.
The medication-assisted treatment program involves both mental health treatment and suboxone, which is used to treat opioid dependence.
Cabin Creek Health Systems didn’t begin offering medication-assisted treatment until after the Affordable Care Act was enacted. It modeled West Virginia University’s program.
“Given the high rate of co-morbid psychiatric diagnoses observed in this study population, it is important to identify treatments that can address both the mental health and substance abuse symptoms,” said Keith Zullig, chair of the department of social and behavioral sciences at WVU’s School of Public Health.
Cabin Creek Health Systems hoped to begin offering medication-assisted treatment at its other rural sites. Sissonville was scheduled to be next.
Billy, one of the program participants, takes medication for diabetes, high blood pressure and anxiety.
“Why bother to treat your addiction if you can’t treat your diabetes?” Vance said.
There are a limited number of spaces in the program — 30 at current funding levels.
Vance noticed some of the men seemed to be taking up more room.
“This is what recovery looks like,” she said.
To Vance, Billy looks about 4 inches taller than the day he walked in about a year and a half ago.
“I thought he was dead, and someone forgot to tell him to lie down,” she said.
About three weeks in, he started walking straighter.
“It’s like a different man, and I’ve seen that in all of these men,” she said.
“If it wasn’t for them, I would have blown my head off,” Billy said. “If they take it away, that’s where I’ll go back to.”
Reach Erin Beck at 304-348-5163,
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