This article was originally published by the Charleston Gazette-Mail.

Low-income West Virginians received $90 million worth of mental health and substance abuse treatment last year, and nearly $300 million over the last four years, under a law the Trump administration is trying to repeal, according to West Virginia health officials.

Under the Affordable Care Act, commonly known as Obamacare, West Virginia expanded its Medicaid program to those who make up to 138 percent of the federal poverty line.

According to the West Virginia Department of Health and Human Resources, the state’s expanded Medicaid program spentabout $58 million on mental health and substance abuse in fiscal year 2015, $61 million in 2016, $79 million in 2017 and $90 million in 2018.

President Donald Trump’s administration said Tuesday it supports striking down the entire Affordable Care Act. Trump’s Department of Justice wrote that it agrees with a Texas judge’s December ruling that the law is unconstitutional.

The Trump administration had previously argued that only parts of the law — protections for those with pre-existing conditions and limits on premiums for older, sicker people — should be struck down. Trump urged congressional Republicans last week to come up with a law to replace the ACA if it is repealed, although Congress could not do that in 2017-18, when both the Senate and House were controlled by Republicans.

West Virginia is among the states that would be hardest hit by the loss of the health care law, said Simon Haeder, an assistant professor of political science in the John D. Rockefeller IV School of Policy & Politics at West Virginia University.

Loss of access to drug treatment is one of a “slew” of reasons why, Haeder said.

The law requires that health insurance companies pay for substance abuse treatment. Between expanded Medicaid and those who bought plans this year on the state’s health insurance marketplace — which also was created under the ACA — the law provides health care coverage for about 180,000 West Virginians.

“When you gain coverage, you gain access to treatment services,” Haeder said.

West Virginians die from drug overdoses more frequently than residents of any other state.

Haeder said the number of West Virginians who have gotten drug treatment after gaining health care coverage through the ACA “has to be in the tens of thousands of individuals.”

At PROACT, an outpatient drug treatment facility that opened in October in Huntington, between 71 and 75 percent of patients are Medicaid recipients, said Mike Haney, the facility’s director. He doesn’t know how many of PROACT’s Medicaid patients have coverage because of the Medicaid expansion.

But Haney said it would be difficult for PROACT to keep its doors open if expanded Medicaid patients were to lose coverage and stop treatment.

“We would probably have to step back and look at the kind of services we offer,” Haney said. “Because there’s some services, such as the spiritual care, that’s not billable but it’s needed and we can offset it with the money from the traditional-type services.

“But if it came down to our funding, we would have to look at realistically some of the programs that we offer and how can we make them sustainable on their own,” Haney said.

Haney said the ACA has also made it easier for people to get drug treatment by requiring that health insurance companies cover it.

If the ACA goes away, so does that requirement, Haney said. But he wonders if insurance companies might choose to continue coverage anyway, because it’s cheaper for an insurance company to pay for drug treatment than the health complications that come with addiction.

For instance, it would be cheaper to pay for three years of drug treatment than for a heart valve replacement for a drug user who got a heart infection related to intravenous drug use, he said.

Debrin Jenkins, executive director of the West Virginia Rural Health Association, said striking down the law would cause some of West Virginia’s small rural hospitals to shut their doors.

“The rural hospitals who are working on very small margins, some of them negative budgetary constraints will probably go under,” Jenkins said.

Rural hospitals have been closing in states like Kansas, Oklahoma and Alabama, Haeder said.

“One thing that’s keeping [rural hospitals] open in West Virginia is Medicaid expansion,” he said. “Those 200,000 individuals who gained coverage, they have a payer for the hospital services.

“Once a rural hospital closes that’s just not just poor people [who are affected], that’s the entire community that’s losing access to important services. So that’s a problem.”

Jenkins said striking down the ACA would make West Virginia’s rural health care shortage even worse.

“We have a shortage of physicians and nurse practitioners and [physician assistants] now in rural areas,” Jenkins said. “I believe that that will negatively affect their practice and they may move, because again they’re working on very small margins. They can only do so much uncompensated care.”

As of March 25, about 159,000 West Virginians were enrolled in expanded Medicaid, according to the state Department of Health and Human Resources.

The ACA allowed states to expand their Medicaid programs to offer health coverage to people who make up to 138 percent of the federal poverty line.

About 22,600 West Virginians signed up for a plan this year under the state’s health insurance marketplace, another provision of the ACA.

Jenkins said because hospitals are often the largest employers in their counties, their closures would have a negative effect on local economies as a whole.

“If that hospital closes, that county dies, that tax base just plummets,” Jenkins said. “All those subsequent businesses that make their money off of hospital employees — which could be anything from restaurants to dry cleaners to grocery stores to whole medical delivery — all of that just goes down the tube.”

Jenkins said the loss of expanded Medicaid could hurt also the state’s economy.

“For West Virginia to grow economically, sustainably you have to have good medical infrastructure and you have to have a healthy workforce or companies don’t come and set up businesses,” Jenkins said. “If you close the hospitals, you’re not going to have that infrastructure and you’re not going to have that healthy workforce, so we’re shooting ourselves in the foot that way.”

Repealing the law would also put those with pre-existing conditions, like diabetes and cancer, at risk of losing their health care coverage. The ACA requires that insurance companies cover those with pre-existing conditions.

“The state has some of the highest rates of disabilities and illnesses and cancers and childhood obesity,” Haeder said. “And you take the pre-existing conditions protections out of the ACA, those people will not be able to access services because they will be priced out of the market.”

The law also makes it easier for black lung patients and their families to get benefits and requires health insurance plans to cover preventive care like vaccines and well child visits, Haeder pointed out.

“A lot of people think the ACA is something for poor people to gain coverage, but it’s really everyone,” Haeder said.

The Associated Press contributed to this report.

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