Even as the heroin and prescription opioid crisis deepens nationally, thousands of poor patients with addiction cannot get treatment in states where political leaders have opposed the Affordable Care Act.
Those patients are languishing on waiting lists for recovery programs or unable to get medicine to combat addiction because they can't afford prescriptions, according to health officials nationwide.
Poor adults in states that expanded Medicaid through the health law have access to medical insurance and a way to pay for addiction treatment. But 19 states, all with Republican governors or legislatures, have rejected federal aid to expand Medicaid eligibility, essentially making coverage available only to poor children, pregnant women and seniors.
"The best way to get treatment if you're addicted to drugs in Missouri is to get pregnant," said Dr. Joe Parks, director of that state's Medicaid program, which has not been expanded.
Medicaid expansion would bring billions of federal dollars into Missouri and other states, but opposition is fierce in GOP-controlled legislatures, where lawmakers argue Medicaid is unaffordable.
That has left Missouri trying to cobble together money for addiction recovery programs from other federal grants and state tax revenues. Those funds are limited, however, and waiting lists remain long for many programs, state officials say.
Missouri had the 16th-highest rate of opioid overdose deaths in 2014, according to a recent analysis by the nonprofit Kaiser Family Foundation.
"Not expanding Medicaid has been a tragedy," said Mark Stringer, the state's mental health director.
The opioid crisis, fed by widespread abuse of prescription painkillers and inexpensive heroin, has been linked with rising mortality rates and was responsible for nearly 29,000 overdose deaths in 2014, according to federal data.
In Nebraska, another state that has rejected the Medicaid expansion, First Step Recovery, an addiction clinic in Lincoln, routinely sees uninsured patients drop out and relapse because they can't afford a sustained treatment program, said Jared Ray, the clinic's substance abuse director.
A 30-day supply of Suboxone, a leading addiction medication, costs $353, Ray said. And a year of treatment, including medications, medical appointments and drug counseling, can run as high as $10,000, even with hefty discounts the clinic offers to uninsured patients.
"It's damn near impossible for many people to get the services they need," he said.
Many of these patients would be eligible for Medicaid coverage if the state expanded eligibility through the federal health law. It is difficult to estimate how many poor, uninsured Americans with substance abuse disorders could qualify for Medicaid coverage in the 19 non-expansion states, but federal data suggest there are likely several hundred thousand.
Historically, most states funded addiction programs through a kind of charity system, as many patients lacked health coverage and couldn't afford methadone, buprenorphine and other so-called medication-assisted treatments that are recommended for patients seeking to end their dependence on heroin or prescription painkillers.
But without the steady funding that health insurance like Medicaid provides, addiction programs across the country were frequently overwhelmed, especially as the current epidemic intensified.
"We were always having to turn people away," said Dr. Yngvild Olsen, medical director at the Institutes for Behavioral Resources, a large treatment center in Baltimore.
Expanding Medicaid — as Maryland has done — hasn't removed all the obstacles to getting patients needed care.
In many states, addiction services are still poorly coordinated, and few specialists are available to oversee treatment. And some Medicaid programs still don't cover the full range of medication treatments.
But Olsen said that as Medicaid coverage has expanded, more patients have come in who wouldn't have tried to quit previously because it was so difficult to get into a program. Now, patients have more options as new addiction clinics are opening.
In Massachusetts, another state that guarantees coverage, addiction specialists at Massachusetts General Hospital in Boston have seen a similar improvement in access, said Dr. Sarah Wakeman, who runs the hospital's substance abuse disorders initiative.
"Before, medications were just prohibitively expensive," said Wakeman, noting that buprenorphine and naltrexone, another common medication for addiction, weren't even an option for most uninsured patients seeking treatment for addiction.
Today, nearly half the patients who come through the program are on Medicaid, which often offers better coverage for addiction medications than do some private health plans, she said.
On Capitol Hill, Republicans are promising new aid to states to battle what many lawmakers are calling an addiction epidemic.
And seniors lawmakers from the House and Senate are working on legislation that would strengthen federal support for addiction treatment efforts around the country.
Among other things, the legislation would expand prescription drug monitoring programs and support programs to identify inmates in the criminal justice system with substance abuse disorders.
And it would expand the availability of naloxone, a drug often used by police and other first responders to reverse overdoses.
But Republican lawmakers championing the substance abuse bills have said nothing about Medicaid coverage, which most GOP lawmakers have pledged to roll back as part of their campaign to repeal the Affordable Care Act.
That leaves one of the most important tools off the table, said Dr. R. Corey Waller, a Michigan addiction specialist and senior official at the American Society of Addiction Medicine.
"In states that have expanded Medicaid, this legislation is going to be very helpful," Waller said. "Everywhere else, it's just window dressing."
June 18, 3:29 p.m.: This article has been revised for additional details and for clarity.