PORTSMOUTH, Ohio (Reuters) - Dusti Hill scooped her two-year-old daughter, Porter, into her arms one day this June in a room filled with toys and cartoon murals, relishing their reunion after 10 months apart.
Porter and her sisters, twin toddlers, had been placed in foster care last August after their mother used suboxone, an addiction medication that itself can become addictive. Now Hill was weeks into recovery at Stepping Stone, an addiction treatment center in Ohio where mothers strive to regain custody of their children.
“Coming to treatment, it made me find myself again – the me I was before I did drugs,” Hill said. “If it weren’t for this place I wouldn’t get my kids back. I wouldn’t be happy.”
This July, Hill completed treatment and returned home with her oldest daughter to Gallipolis, Ohio, a small town in the state’s southeast section. She hopes to regain custody of her twin girls in the coming weeks and eventually return to school, earn a degree in alcohol and drug dependency, and become a counselor.
Hill benefited from the Affordable Care Act, dubbed Obamacare, the healthcare law enabling states to expand Medicaid to adults earning up to 138 percent of the federal poverty level. The law requires insurers to cover 10 essential health benefits, including addiction treatment and mental health services.
That program deeply expanded treatment targeting opioids and heroin, Reuters found in a study of state programs nationwide. But now Medicaid faces a political U-turn, bringing worry to beneficiaries like Hill, and states like Ohio.
Thirty-one states, including Ohio, expanded Medicaid, making Obamacare the most comprehensive financial government response to America’s growing opioid and heroin epidemic.
Reuters examined data for 13 of the 31 states from 2013 to 2016, and found that at least eight more than doubled spending on substance use disorder services. Reuters also examined spending from 12 states that did not expand Medicaid. While eight states increased spending, none doubled spending; four experienced decreases.
States that expanded Medicaid have had far greater capability to tackle the crisis than those that didn’t, Reuters found. Of 10 expansion states that provided data, at least four more than doubled the number of people treated. None of the 10 non-expansion states providing data saw such an increase.
The expansion allowed thousands of people struggling with addiction to get help, many in economically depressed pockets of the country hit hard by the crisis.
In January 2014, Chuck Oliver ate 50 sleeping pills, saying he hoped to die. He ended up at an Ohio crisis center, where he learned he was eligible for Medicaid, enrolled in a 90-day treatment program, went to a doctor and got medication to treat his hepatitis C. Now, he teaches classes to other men in recovery.
“I got blood drawn, got a physical, found out I needed glasses, got me eyeglasses, and I’ve been on the journey since then,” said Oliver, 43.
Even with the rise in spending, the battle against opioids and heroin – among the country’s most pressing public health crises – is far from solved. Opioids played a role in more than 33,000 deaths in 2015, according to the Centers for Disease Control and Prevention, and estimates show the death rate has continued rising.
New, more potent opioids have made their way into communities like Portsmouth, a once-vibrant manufacturing city that produced shoes and steel but was devastated by the disappearance of those jobs. Today, quaint coffee shops and restaurants alternate with pawn shops in the city center, while a mix of freshly painted and dilapidated homes line its outskirts.
Under a pending Republican healthcare bill backed by President Donald Trump, federal spending on Medicaid would be cut by more than $700 billion over the next decade, according to the Congressional Budget Office, a nonpartisan government agency. An earlier version of the legislation passed the U.S. House of Representatives in May but failed to pass the Senate in July, leaving Republicans divided on the path forward.
Trump and many Republicans have called on the Senate to keep working to pass a repeal or replacement of Obamacare that would likely include Medicaid cuts, and senators have come under pressure from high-powered conservative groups to continue pushing the legislation.
If some form of the legislation becomes law, states would be left to make up the lost federal money at a time when many are grappling with strained budgets. Ultimately, some health care officials say, individuals like Hill and Oliver would be affected most.
“Medicaid expansion is the single biggest thing that’s ever happened to us,” said Andy Albrecht, executive director of The Counseling Center, a treatment provider with 23 locations across Ohio, including Portsmouth’s Stepping Stone. “It’s an all-hands on deck approach to meet the need and it’s still not there.”
On Capitol Hill, Republican lawmakers have spent months trying to make good on a seven-year campaign promise to repeal and replace Obamacare, former Democratic President Barack Obama’s signature domestic policy effort.
Republicans say the law is too costly, imposes too many regulations that drive up the price of insurance and is an example of government overreaching into people’s healthcare. The law extended insurance to 20 million Americans.
Their efforts have been plagued by party infighting and vigorous opposition from the medical and hospital industries, which say the bill would harm groups including the poor, elderly, sick, disabled and those struggling with addiction.
Last month, an effort to replace the law collapsed in the Senate after three Republican senators – Maine’s Susan Collins, Alaska’s Lisa Murkowski and Arizona’s John McCain – voted against a bill that aimed to continue negotiations with the House.
Treatment providers and advocacy groups had called on key Republican lawmakers, including Shelley Moore Capito of West Virginia and Rob Portman of Ohio – senators from two states among the hardest hit by opioids – to oppose the legislation. Both supported the Senate proposal, but after the effort failed, urged bipartisan legislation.
In West Virginia, Medicaid more than doubled the amount spent on those struggling with addiction, from $90.8 million in 2013 to about $243 million in 2016, with about half spent on people who gained insurance through the expansion. In Ohio, spending on treatment drugs and support services for opioid addiction more than tripled, going from $107 million in 2013 to $373 million in 2016.
A version of the Senate bill that failed to garner enough support set aside $45 billion through 2026 for opioid addiction and substance use disorders. On the ground in drug-plagued states, experts say that’s not nearly enough. Ohio alone, for instance, spends nearly $1 billion per year on the opioid crisis, a state report said.
Ohio Republican Governor John Kasich, an outspoken critic of the GOP bill, said it would cripple the fight against opioid addiction.
The money set aside, Kasich said, is “like spitting into the ocean.”
Senate Majority Leader Mitch McConnell, whose home state of Kentucky suffers one of the highest rates of overdose deaths in the country and is among the states that has benefited most from the Medicaid expansion, released a revised draft of his healthcare bill in July that included more money to combat the epidemic. He said it would strengthen Medicaid “while ensuring that those who rely on this program don’t have the rug pulled out from under them.”
As a presidential candidate, Trump vowed to ensure that people struggling with addiction could access treatment, and on Thursday, the president declared the opioid epidemic a national emergency. After the Senate legislation failed to pass, Trump said the three senators who voted against the measure let the country down. He vowed to let Obamacare “implode.”
The political fight flares as overdose deaths continue across working class pockets of the country. West Virginia, Ohio, Kentucky, Louisiana, Pennsylvania and Tennessee – all of which have Republican senators who supported the healthcare repeal effort – witnessed a dramatic rise in deaths in 2015, the CDC reported.
Meantime, some in recovery cling to a lifeline.
Day after day this June, Cassie sat on the floor of a pale green nursery with painted pink butterflies, rocking her two-month-old daughter, Jorja, and dreaming of the day she could bring her child home.
Jorja was in her makeshift nursery at Lily’s Place, a facility in Huntington, West Virginia, treating babies born dependent on opioids in this city on the mouth of the Guyandotte River. Jorja was battling neonatal abstinence syndrome because Cassie had been using painkillers when she learned she was pregnant, continuing an addiction that began a decade earlier. For years, she says, she could not get into treatment because she lacked health insurance or was put on a months-long waiting list.
“It’s the most helpless feeling,” said Cassie, who requested her last name be withheld. “It absolutely ruins your life. Look what it’s done to my baby.”
Cassie stopped using drugs when she learned she was pregnant, she said, and a doctor prescribed medication to help treat opioid addiction. The medication is intended to wean Cassie off opioids, but does not deprive the body or the fetus of the drug altogether to help prevent severe withdrawal.
Cassie finally got help, she said, thanks to her insurance through Medicaid. Jorja eventually recovered, and Cassie got to take her home this summer.
Dusti Hill was 17 when, she said, a boyfriend introduced her to Oxycontin. For years, she fought a losing battle with painkillers.
She said she didn’t know the drugs were addictive until it was too late. Oxycontin launched an 11-year addiction that led to two jail stints, including one 60-day stay where she finished the remainder of her first pregnancy.
In December 2015, Hill was pregnant for the second time and gave birth to identical twin girls born dependent on opioids. The babies spent 17 days in the hospital suffering from withdrawal.
“I know how it feels to withdraw, so to look at these two babies sneezing and just not feeling good – they had feeding tubes and incubators,” Hill said. “I got my tubes tied after I had them because I figured I’d be a drug addict my whole life and I was not going to put kids through that again.”
That’s when she came to the attention of Child Protective Services, which began visiting her and her daughters.
In August, Hill told her caseworker the truth: She’d been taking suboxone without a prescription. CPS put her three girls in foster care. Hill, sinking into a deep depression, began using suboxone more heavily, usually intravenously. She stopped paying her bills and seldom left the house.
Six months later, Hill decided she was ready for rehab, knowing she would never get her daughters back otherwise.
Medicaid card in hand, she turned to The Counseling Center.
Hill’s daughters came to live with her at the center in June. She spent her days in treatment classes while the facility’s employees cared for her daughters and other children with mothers in recovery. The four returned each night to their shared bedroom at Stepping Stone, which has nearly doubled its number of beds under the Medicaid expansion.
The Counseling Center has added three more locations in some of the state’s most rural counties, and nearly doubled the number of patients annually to 1,200.
Still, its waiting list is 150 names long.
The Counseling Center created 67 full-time jobs under Obamacare’s Medicaid expansion in three counties, and some 98 percent of its patients rely on the government program.
Under the Republican bill, providers say hundreds of patients would lose their insurance. The center would have to eliminate most of the newly created jobs, directors said.
“We’ve been able to hire staff and create programs and do things we never dreamed of being able to do,” said Albrecht, the center’s executive director. “It’s a daunting task to keep up with the demand and phone calls and number of treatment beds we need.”
Other times, families ponder what could have happened had government support arrived sooner.
With an academic scholarship in hand, Ryan Brown left Charleston, West Virginia, in 2004 to attend West Virginia University three hours away.
The fall of his sophomore year, his parents, Cecilia and Bobby Brown, found him thin, disheveled and skipping class. He soon left school. Heroin had taken hold.
His parents sent him to Narcotics Anonymous meetings and counseling. Yet they couldn’t get him into deep treatment programs. Ryan lacked health insurance and languished on long waiting lists.
Heroin always won. Bobby Brown walked to the family’s living room one day to find the TV missing. Another day, the computer was gone. Ryan sold them at a pawn shop. “It’s just hell when you see your kid with an addiction problem and you can’t stop it,” Bobby Brown said.
In 2011, Ryan overdosed in the family’s upstairs bathroom. When the police arrived, his father begged them to take Ryan to jail, desperate to keep him away from heroin. The pleas didn’t work.
In April 2014, almost a decade after his fight with addiction began, Ryan’s Medicaid card arrived in the mail. It would have allowed him to afford treatment and the medication intended to wean him off heroin.
Two days later, detectives showed up at Bobby and Cecilia Brown’s doorstep. Inside a department store bathroom, their son had fatally overdosed.
Editing by Ronnie Greene