Not so long ago, the scourge of opioids seemed unstoppable. More than 400,000 Americans died from drug overdoses between 2020 and 2023. The toll was more than twice as large as that from either guns or vehicle accidents. But 2023 now appears to have been a turning point. Since then, annual overdose deaths have declined more than 25 percent, thanks partly to a creative public health campaign to expand access to treatments like Narcan and Suboxone. The crisis is finally easing.
President Trump’s big domestic policy law threatens that progress. The law’s Medicaid cuts, which finance lower taxes for the wealthy, will deprive millions of Americans of health insurance. These changes will harm people with all sorts of medical conditions. Yet addicts are particularly vulnerable because of how many of them are on Medicaid. The program covers nearly half of non-elderly adults with an opioid addiction, according to KFF, a health research group. Without insurance, many will drop out of treatment and relapse. Researchers at Boston University and the University of Pennsylvania estimate that the law will end access to opioid treatment for more than 150,000 Americans.
The recent fall in overdose deaths should be a cause for celebration, and one that the country’s leaders should look to build on. Opioids have been an important factor in the shocking stagnation of American life expectancy in recent decades. In the 1980s, life expectancy here was similar to the levels in many other rich countries; today, the United States comes in last. No other wealthy nation experienced a similar spike in overdoses in the 2000s.
Mr. Trump, Vice President JD Vance and other Republican leaders have rightly described opioids as a national tragedy that demands action. Instead of taking steps to continue the recent progress, however, they are undermining it. This is one more way in which they are failing to live up to their promise to govern as champions of the working class that voted for them in large numbers last year.
This is not the first time that America’s political leaders have failed to take the opioid crisis seriously. After Purdue Pharma, a company owned by the Sackler family, introduced OxyContin in 1996, the painkiller quickly became the drug at the center of the epidemic. Overdose deaths doubled between 1999 and 2006. Still, Congress did not pass major legislation to address the crisis until 2016. Not until 2017 did a president, Mr. Trump, declare a national emergency. Even these actions produced underwhelming results — what Dr. Leana Wen, a former health commissioner of Baltimore, once described as “tinkering around the edges.”
While Washington dithered in the 2010s, local and state health officials began to make progress. They cracked down on easy opioid prescribing and persuaded firefighters, police officers, schools and libraries to carry the overdose antidote Narcan. Some of these efforts had nothing to do with the federal government. But many quietly relied on Medicaid, the federal health insurance program that covers low-income and disabled people. The Affordable Care Act, which President Barack Obama signed in 2010, included a major expansion of the program, and states used Medicaid funds to expand addiction treatments. Vermont, for example, built an elaborate “hub and spoke” system that links people to addiction care. The types of treatment provided by these programs can have large effects, reducing deaths by 50 percent or more, studies show.
As addiction doctors can explain, their patients are already among the most difficult to link to treatment. They lead chaotic lives, sometimes lacking a reliable place to sleep, and are cut off from their friends and families. Many rely on Medicaid for health care because they have nowhere else to turn.
Mr. Trump’s budget law effectively undoes much of the good that the Affordable Care Act did. It is also likely to damage addiction treatment for people who are not on Medicaid, by weakening clinics and hospitals that treat addiction. As people lose coverage and drop out of treatments, facilities will lose Medicaid revenue from those patients. Many of these facilities rely on the program to stay open: Nearly two-thirds of patients getting outpatient treatment for opioid addiction are on Medicaid, according to KFF. Already, some rural hospitals have warned that the Medicaid cuts will force them to close or reduce services.
Members of Congress were aware of the threat to opioid treatment when debating the budget bill, and they included a provision meant to shield people with substance use disorders from losing Medicaid coverage. The law includes an exemption that spares them from the work requirements that now apply to Medicaid recipients. But they will likely need to complete a complex process to receive the exemption, the sort of process that causes people to fall through cracks of a bureaucracy. One example: Some people will struggle to obtain a doctor’s diagnosis for a substance use disorder, which the exemption requires. The law creates something of a Catch-22: To obtain health insurance, many addicts first must see a doctor.
Mr. Trump’s law does include other elements that can mitigate the opioid crisis, particularly efforts to crack down on drug trafficking at the border and through the mail. Those policies are helpful, and they are a reminder that Mr. Trump and his aides recognize the damage that opioids have done. But in the service of showering tax cuts on people who do not need the money, the rest of the budget law undermines the benefits of the crackdown.
Even after the recent declines, the death toll from overdoses remains far too high — quadruple what it was at the start of the century. Policymakers could do so much more. They could make treatment more affordable and accessible by pushing more hospitals, doctors and clinics to offer lifesaving medications and requiring insurers to cover treatment. Federal, state and local governments could also dispense sticks along with carrots — by, for example, using the threat of legal penalties to push people into treatment. Portugal has followed this approach, with success.
As a start, though, Congress should undo the damage from the budget law. It still has time to do so. The worst of the health care cuts will not take effect until late 2026. Lawmakers can repeal the cuts before then and look for ways to reduce the deficit that do not take lifesaving benefits from the neediest Americans. Short of repeal, Congress could increase funding for addiction treatment to make up for the Medicaid cuts, as it did with a fund for rural hospitals in the domestic policy law. “We will not rest until we have ended the drug addiction crisis,” Mr. Trump said during last year’s presidential campaign. It was the right promise, and he should live up to it.
Source photograph by Jose A. Bernat Bacete, via Getty Images.
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