A drug epidemic is ravaging the United States, and it's getting worse, not better. More than 52,000 Americans died from drug overdoses in 2015, more than died from automobile accidents or firearms. That's far more than died from overdoses in any year during the crack epidemic of the 1980s.
Most of those deaths were from opioids – prescription painkillers, heroin and fentanyl, a dangerous synthetic drug. In Maryland, where I live, opioid deaths jumped 62% in the first three quarters of 2016; Gov. Larry Hogan, a moderate Republican, declared a state of emergency and asked the federal government for help.
But you wouldn't know that from the American Health Care Act of 2017, the House Republican proposal to repeal Obamacare and replace it with a smaller, cheaper health insurance program.
Not only does the bill offer no solutions for the drug crisis; it would make the problem worse by making dramatic cuts in Medicaid, the healthcare program that covers low-income people.
Under Obamacare, Medicaid was enlarged to allow people with incomes up to $16,400 (for a single person) to enroll – at least in the 31 states that agreed to the expansion.
The House bill would roll back that expansion, mainly by capping federal payments to state Medicaid programs. In total, it would cut Medicaid funding by an estimated 25%, or $880 billion over 10 years – the largest cost saving in the bill.
The bill also includes a provision allowing states to drop mental health and addition services from their Medicaid plans. (Obamacare required those services to be included.)
Health economists worry that once federal subsidies are capped, states may find themselves choosing whose Medicaid to fund: mothers and children, elderly nursing home residents, or drug users.
"They can continue to take on those responsibilities and pay for it out of their own budgets, or, if they are under pressure, they have to scale back," said Richard G. Frank of Harvard Medical School. "Historically, states have been loath to cover substance abuse treatment."
A Medicaid cut that large, Baltimore health commissioner Leana Wen told me, "could cost the lives of thousands of people. It's medically irresponsible. And it's fiscally irresponsible; it will create costs down the road."
Already, Dr. Wen noted, only about 1 in 10 drug abusers get addiction treatment.
"That's a statistic we would not find acceptable for any other disease," she said. "We wouldn't accept it if we were providing insulin to 1 in 10 diabetics, or making chemotherapy available to only 1 in 10 cancer patients."
Wen works for a Democratic mayor in a Democratic city. But there are Republicans who agree – especially governors in the states that expanded Medicaid and now rely on the program for addiction treatment.
"Don't kill Medicaid expansion," Ohio Gov. John Kasich pleaded this week on NBC's "Meet the Press." His state had more opioid deaths than any other in 2015; an estimated 151,000 Ohioans are getting drug or mental health treatment under Medicaid.
"If you're drug addicted, if you're mentally ill, you have to consistently see the doctor. From what I see in this House bill, the resources are not there," Kasich said. "It's not that we love Obamacare. It means don't throw the baby out with the bathwater."
Sen. Rob Portman, an Ohio Republican, won reelection last year partly because of his dogged work to increase federal spending on the drug epidemic. Last week, Portman signed a letter demanding that states be given time for an orderly transition to a new system – at least until 2020, hopefully longer.
But House conservatives want to cut Medicaid funds even faster than the bill proposes.
It's a classic conflict between Republican pragmatists and hard-liners – and the man in the middle is President Trump.
During the campaign, Trump criticized the Obama administration for failing to stop the drug epidemic, and promised that he would fix it. At a rally in New Hampshire, Trump promised "a plan to end the opioid epidemic," and released a statement saying he would incentivize state and local governments to mandate drug treatment. And in his formal speech to Congress last month, Trump renewed the pledge. "We will expand treatment for those who have become so badly addicted," he said, without offering any details.
But the House bill goes in the opposite direction; it would cut drug treatment, not expand it. Of all Trump's promises, this might be the cruelest to break. Has he noticed?