The trouble with fighting opioids while cutting Medicaid

Asked about the latest GOP plans to reduce health-care spending, Rick Petaccio rolls up his work shirt to show a scar on his left bicep, one of many he bears from abscesses due to injection-related infections.

"I was on Medicaid when treated for all of my abscesses, and my hepatitis A, B, and C were detected with the aid of Medicaid," the Philadelphia man said. His hepatitis D was found later, during Petaccio's 21 years of sobriety that followed his 21 years addicted to various drugs, mainly opioids. Since his substance-abuse treatment was successful and he now has a job, treatment for the hep D was covered by the commercial insurance policy he got through his employer.

Petaccio, 58, now manages a Northeast Philadelphia methadone clinic where 90 percent of patients are covered through public funding, mainly Medicaid. If Republican health-care proposals in Congress cut back those dollars, the cash-strapped state would most likely have to take steps such as limiting the duration of methadone maintenance.

"It would put them in jeopardy of relapse," Petaccio said, and the fentanyl that is sometimes mixed in with heroin could be fatal. "You don't know what you are sticking in your arm anymore."

The bill offered by Senate Majority Leader Mitch McConnell (R., Ky.) on Thursday offers a bone to moderates from addiction-devastated states who have worried about cutting Medicaid: an extra $45 billion over 10 years targeted to opioid addiction. Petaccio and others like that idea — but only if people can still get the other health-care services Medicaid pays for.

Without that care, Petaccio's hepatitis infections — common among drug injectors, and also contagious — could have grown far worse. They were diagnosed through routine health care generally available only to people with insurance.

The bills in Congress would roll back the Affordable Care Act's expansion of Medicaid and place caps on the growth of the entire program, which was set up a half-century ago to increase according to need. Conservative Republicans say spending has grown out of control.

Sen. Pat Toomey (R. Pa.) calls the opioid epidemic "a full-blown crisis," but he has downplayed the potential impact that changes to Medicaid would have on treatment, and pointed to the billions of dollars added in the latest version of the GOP bill to help address substance abuse.

"I've never bought the argument that the changes in Medicaid are going to be harmful for the treatment of opioids," Toomey said this week. He has argued that as federal Medicaid spending scales back, states can  pick up more of the cost.

Democrats and some Republicans, especially governors, say that's unrealistic. An analysis of McConnell's original Senate bill by the consulting firm Manatt Health found that New Jersey would have to come up with $12.3 billion in state funds between 2020 and 2026  just to maintain current levels of Medicaid coverage. Pennsylvania would need $13.7 billion. Anything less could mean balancing opioid treatment against health coverage for the elderly and disabled children.

Sen. Bob Casey (D., Pa.) dismissed the enlarged GOP fund for substance abuse.

"The bill still pulls the rug out from under those who need treatment for an opioid addiction. Those suffering from addiction and their families need coverage and long-term quality treatment, not some grant," Casey said in a statement Thursday.

Benjamin Cocchiaro, a family medicine physician at a clinic run by the Hospital of the University of Pennsylvania, grew animated during an interview about the issue outside a Wednesday night community meeting on the opioid crisis in the Kensington section of Philadelphia.

"The cost of taking away Medicaid is incalculable," he said, referring to dollars as well as lives.

"If a patient comes to me and says, 'Hey, Doc, I have this sports injury and I need more Percocet,' I can help my patient," he said, by weaning him off opioids and treating the pain with alternative therapies. In the absence of health coverage, however, a dependency on prescription medications that could have been handled through primary care visits may instead "ramp up" to more potent street drugs, deteriorating health, and an overdose. That patient, if he lives, may have "turned into a million-dollar ICU admission," Cocchiaro said.

Elvis Rosado, outreach coordinator for Prevention Point Philadelphia, the syringe-exchange and health-care provider that organized the community meeting, seemed briefly befuddled when asked about the congressional notion of targeting $45 billion to tackle opioids while at the same time capping federal spending on Medicaid.

"Would you put money into diabetes but take away insurance coverage?" he said.

Staff writer Jonathan Tamari contributed to this article.