By Ronald Brownstein / Bloomberg Opinion
President Donald Trump says the opioid epidemic is such a clear and present danger that it justifies extraordinary actions against the foreign nations he accuses of facilitating the flow of fentanyl into the U.S. Meanwhile, his Republican allies in Congress are about to hobble the federal government’s most important domestic tool for fighting opioid addiction: the Medicaid program.
The result is that, just as Trump is demanding that other countries do more to fight the opioid epidemic, Congress is poised to do less.
Trump has portrayed drug smuggling as “a national emergency” and “public health crisis” to justify his initial round of tariffs on China, Mexico and (implausibly) Canada. Congressional Republicans, by contrast, appear willing to treat the opioid struggle as collateral damage as they seek spending cuts to offset the cost of extending (and enlarging) Trump’s 2017 tax cuts. Though Trump has sent conflicting signals on what he would accept, the House Energy and Commerce Committee voted Tuesday afternoon on a plan to cut about $700 billion from Medicaid over the next decade.
A scholar at the Brookings Institution estimates that Medicaid accounts for about $29 billion of the roughly $33 billion the federal government spent to treat opioid addiction in 2023. Medicaid funds opioid addiction treatment for more than 1.8 million people, federal figures show. Lisa Clemans-Cope, a senior research fellow at the Urban Institute, estimates that’s about half of all Americans receiving such treatment.
If Medicaid is the key federal tool to fight opioids, the key tool within Medicaid is the eligibility expansion to the working poor approved under the Affordable Care Act.
The expansion (which now provides health insurance for about 20 million people in all) opened Medicaid to precisely the kind of people most likely to fall into addiction: younger to middle-aged, low-income people working irregular jobs. Before the expansion, single, working-poor men — an especially high-risk group — were ineligible for Medicaid at any income level.
The result has been transformative. Nationwide, just over half of the 1.8 million Americans receiving opioid treatment through Medicaid are eligible for the program through the ACA expansion. In many purple and red-leaning states that voted for Trump in 2024, the share is even higher.
Now that Medicaid (specifically, the expansion of it under the ACA) guarantees that more people with opioid addictions can pay for their treatment, the network of providers, clinics and hospitals has grown enormously. Christina Andrews, an associate professor of public health at the University of South Carolina, says the expansion of Medicaid under the ACA has done more to increase the availability of care than any change since the modern system of drug addiction treatment was developed in the 1970s.
These efforts are producing results: Opioid deaths declined nationwide in 2023 for the first time since 2018. Gov. Andy Beshear of Kentucky, which expanded Medicaid eligibility in 2016, recently noted that after smaller declines in 2022 and 2023, opioid overdose deaths in the state plummeted more than 30 percent last year. The Medicaid expansion “has been a huge part” of Kentucky’s success, Beshear said in a conference call with reporters: “This is a day that we have been praying for, a system that is working, and we need it to continue.”
The House Energy and Commerce committee plan avoids the direct measures to undo the Medicaid expansion that conservatives sought. But it creates new work requirements, heightened eligibility checks and cost-sharing mandates targeted mainly at the expansion population. The Congressional Budget Office projects that the bill would cause at least 8.6 million people to lose Medicaid coverage; many of whom, says Allison Orris, director of Medicaid policy at the Center on Budget and Policy Priorities, were likely added through the expansion.
The committee draft likewise exempts people with “chronic” drug addiction from the new work mandates, but significant numbers of them could be ensnared anyway by the bill’s other new requirements on the expansion population. Those additional burdens will make it harder for people in drug treatment to get and keep the coverage they need, Orris says.
In earlier budget fights, Republicans showed little hesitation about cutting Medicaid because they viewed it primarily as a program for the urban poor. But the politics of Medicaid have changed.
The ACA expanded Medicaid eligibility up the income ladder precisely as Trump’s political realignment extended the GOP’s reach down the income ladder. So Congressional Republicans can’t cut the program nearly as much as they are contemplating without hurting many of their own voters. That’s especially true when it comes to opioid addiction, which is often most prevalent in rural areas.
In the immortal words of Neil Young, “Every junkie’s like a setting sun.” But addicts are also like black holes, pulling those around them into addiction. The ripple effect of revoking Medicaid coverage, and with it access to treatment, could again send the epidemic raging “out of control and really scourge communities,” Clemans-Cope warns.
In a drug war that Trump himself describes as a pressing threat to U.S. national security, rescinding Medicaid coverage for millions of low-income people amounts to nothing less than unilateral disarmament.
Ronald Brownstein is a Bloomberg Opinion columnist covering politics and policy. He is also a CNN analyst and previously worked for The Atlantic, The National Journal and the Los Angeles Times. He has won multiple professional awards and is the author or editor of seven books. ©2025 Bloomberg L.P., bloomberg.com/opinion.
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