Doctors, governors and health-care advocates are pressing Congress to lift a decades-old rule that greatly restricts Medicaid from being used to fund care for opioid addiction.
Lifting the limits could help thousands of people — but could cost as much as tens of billions of dollars over a decade, a daunting sum to try to pay for.
Lawmakers are nonetheless talking about including at least a partial lifting of the limits in broader opioid legislation that could come to the House floor by Memorial Day.
While conservatives are not dismissing the idea, saying they recognize the need to fight the opioid epidemic, any discussion of ways to pay for the expensive change would be challenging.
“We’re always concerned with additional spending,” said Rep. Mark Walker (R-N.C.), chairman of the conservative Republican Study Committee. But he did not slam the door on the idea either.
“If you can draw me a straight line that this stems the tide of what we’re seeing … I’m not going to sit there and say ‘Hey, count me out,’ ” Walker said.
The idea of bolstering Medicaid to help people with an opioid addiction comes as the GOP has been discussing reforms to the program aimed at lowering its cost. At the state level, Republican governors and legislatures have pushed to impose work requirements on Medicaid recipients.
Additional Medicaid spending would be a departure from Republican proposals last year to reduce spending on the program.
Daniel Raymond, policy director of the advocacy group Harm Reduction Coalition, said he was worried that the new Medicaid funding for opioid addiction, if approved, might be offset with cuts to other Medicaid spending.
“I would hate for those offsets to be pulled out of the Medicaid program itself,” he said.
Combating the opioid epidemic has been a bright spot of bipartisanship in recent years, as lawmakers in both parties have faced pressure to come up with solutions. Overdose deaths increased nearly 28 percent from 2015 to 2016.
The change being pursued would provide access to treatment facility beds to people.
It would lift limits that prevent Medicaid from paying for care at treatment facilities with than 16 beds, known as the Institutions for Mental Diseases exclusion. This restriction was put in place decades ago to prevent the warehousing of people with mental health disorders in large institutions, but is now widely seen as an outdated barrier.
President Trump ’s opioid commission last year called waiving the restrictions “the single fastest way to increase treatment availability across the nation.”
The National Governors Association pressed for the change in January, saying the current limits are an “arcane federal policy” limiting treatment.
The American Medical Association, the leading doctors’ group, wrote to lawmakers last month calling for lifting the limits, saying it is “essential that treatment capacity be increased as expeditiously as possible.”
A top Republican on the committee overseeing the issue said lawmakers should try to find a way to get past the obstacle of cost.
“As I understand it, that exclusion is years old, and the world’s a different place today, and it does interfere with being able to treat the number of people who need to be treated,” said Rep. Michael Burgess (R-Texas), the Energy and Commerce Health Subcommittee chairman.
“There’s obviously a cost associated with it, and that’s kind of been the stumbling block,” Burgess added. “We’re smart people; we’ll work on that.”
The Trump administration is already taking some actions on its own, speeding up the process for states to apply to waive the limits.
One possibility for Congress to lower the cost is to lift the limits some, but not all, of the way and to focus the spending on opioid treatment rather than on mental health.
Sen. Dick Durbin (Ill.), the No. 2 Senate Democrat, has proposed allowing federal Medicaid dollars to pay for addiction services at treatment facilities with less than 40 beds. He says he’ll push to include that language in the opioid package that lawmakers are crafting. The bill has both Republican and Democratic co-sponsors and a companion in the House.
Durbin’s office hasn’t received an official score from the Congressional Budget Office on how much the bill would cost. But his office believes it would be “a fraction of the figures that have been tossed out” for a full repeal — a conclusion based off of recent state and federal actions and existing information and models, wrote Emily Hampsten, a spokeswoman for Durbin.
Some, such as Sen. Sheldon Whitehouse (D-R.I.), argue that a change could actually save money elsewhere, by decreasing emergency room visit costs.
Others note that while the change would be helpful, it won’t by itself curb the epidemic.
Chuck Ingoglia, the senior vice president of public policy and practice improvement for the National Council for Behavioral Health, said making sure other types of care are available to the community is also necessary.