In one part of the room, lawmakers and public health experts debated whether an increase in opioid abuse among Medicaid expansion states could be a direct result of Obamacare policy. In the other part by himself—a shock, I tell you—was Rand Paul.
“We’re fools to sit up here and say, ‘causation versus correlation.’ People are dying in Medicaid, and we’re giving it away for three bucks,” he said Wednesday. The “it” are prescription opioids: oxy, hydrocodone, codeine, and the like, which can be dangerous on their own and gateways to the black market when addicts are cut off. Paul’s Republican colleague, Senator Ron Johnson, had just released a report tying drug abuse and crime associated with those drugs to Medicaid expansion: For example, the report notes an unusual increase in drug-overdose deaths and opioid-related hospital stays covered by Medicaid in expansion states. It leaves aside the role heroin and illicit fentanyl have played in exploding the national crisis, since they aren’t obtainable through insurance.
Johnson, who convened a government affairs committee hearing about his findings, wanted to ask the experts if Medicaid expansion was partly liable for the apparent phenomenon, even though the program also helps pay for addiction treatment. Paul indicated that the question missed the point.
“If we can’t get over the fact that if you give people free medication and then we overprescribe it that there’s going to be a problem, we have to have significant rules in place,” he said—government rules, which better control and monitor opioid prescriptions written for Medicaid patients. There was amusement in Paul’s voice when he reflected on him, of all people, favoring health regulations. But such is the severity of the opioid epidemic—and Washington’s responsibility to manage taxpayer money.
Republicans, including both Johnson and Paul, see an obvious relationship between no-cost, addictive, prescription medication and drug abuse and crime. Johnson points to a particular excerpt from the book Dreamland: The True Tale of America’s Opiate Epidemic, which highlighted the town of Portsmouth, Ohio: “If you could get a prescription from a willing doctor—and Portsmouth had plenty of them—Medicaid health-insurance cards paid for that prescription every month,” wrote author Sam Quinones. “For a three-dollar Medicaid co-pay, therefore, addicts got pills priced at thousands of dollars, with the difference paid for by U.S. and state taxpayers. A user could turn around and sell those pills, obtained for that three-dollar co-pay, for as much as ten thousand dollars on the street.”
Johnson’s report cites numerous such instances among 110 cases nationwide (a sampling, hardly exhaustive). The reasoning goes that if a state expands Medicaid, there will be more enrollees to engage in similar behavior. But Medicaid is a means to an end for addicts and the criminals who exploit them, making it a secondary issue, if one worthy of special consideration. The primary issue is the availability of the drugs in the first place: A recipient can’t get them for free if they can’t get them at all. Or, as Georgetown University health care expert David A. Hyman put it Wednesday, “It’s important to recognize … it takes a physician to write the prescription.”
Paul wants there to be fewer of them for opioids—and more oversight when they’re written.
“I think it has to be very, very dramatic, and I think it’s going to have to actually be in law. As much as I’m for freedom of the physician to prescribe stuff, if it’s federal money, we’re going to have to oversee the federal money, and we’re going to have to figure out a way to say, maybe other than terminal patients and a few other people, it needs to be something else [than opioids],” he said.
State Medicaid programs already have authority to monitor the prescription habits of providers. The Center for Medicare and Medicaid Services reported in October that every state but Florida has a “lock-in” program, which restricts high-volume beneficiaries to specific doctors and pharmacies to monitor their behavior and deter misuse of medical services. Forty-nine states told CMS they maintain databases on controlled substances given to consumers, which providers can use to identify potential fraudsters and drug abusers. Three-quarters of the states have changes “in place” to limit quantities of prescribed opioids.
The key is to implement these programs effectively. A CDC survey from 2012 of Medicaid agencies and health professionals cited funding and staffing shortages as roadblocks, more so than “technical problems.” And states merely have to report to the federal government on their activity; it’s not as if they’ll be held accountable for the poor performance of initiatives not every state undertakes.
But given Washington’s added financial stake in Medicaid, via the expansion, Paul wants even more and stricter policies—rules, not mere suggestions. He even hints at limiting what drugs can be prescribed to Medicaid patients for certain conditions.
“I’m not so sure Oxycontin should be used for chronic pain—at all,” he said. Rather, he called Ibuprofen “a very potent painkiller,” especially in higher doses. He seemed to speak from memory.
“I’ve had a lot of experience with pain, myself.”
