A missed opportunity to report on the rural opioid crisis

Columnist Salena Zito wasn’t very candid with me in a recent Twitter exchange. That’s annoying. More important, she’s missed a real opportunity to contribute genuine reporting on the rural opioid crisis.

Twitter generally conveys the emotional warmth of a contentious economics seminar without the intellectual rigor. Still, I’ve come to value my Twitter engagements with kindred spirits and others with whom I deeply disagree whose insights I value.

Ms. Zito is one person I hoped to learn from across the usual partisan and ideological lines. She is a conservative reporter and commentator who writes for the Washington Examiner, New York Post, CNN, and other outlets. Ms. Zito is most famous for her aphorism that “the press takes [President Trump] literally, but not seriously; his supporters take him seriously, but not literally.” This is a genuinely valuable insight into how political professionals underestimated Trump’s electoral appeal. (It is also a profound moral evasion, but that’s another matter.)

Her main beat is Trump country. Liberal professors like myself are not her target demographic. She’s not one for nuance or policy reporting that might complicate her political thesis. I’m stuck by the wee-bit-too-perfect quality of her anecdotes and man-on-the-street interviews. Everyone she encounters ruefully explains why Democrats just don’t get it, why out-of-touch bicoastal elitist liberal look down on rural conservative white people as rubes and racists, and so on.

For all these defects, Zito writes with insight and connection to older conservative white voters in places like rural Ohio or Pennsylvania. Many of the men and women she profiles remind me of my in-laws, who lived their entire lives in rural upstate New York.

Given her chosen reportorial terrain, Ms. Zito unavoidably encounters the opioid epidemic. I’ve encountered this epidemic, too. I interact with many Democratic and Republican officials, public health and law enforcement practitioners, and treatment professionals at the front lines of this awful thing. Thirty years ago, Randy Shilts commented that HIV/AIDS cut like a scythe through the gay community. That’s what opioids are now doing to parts of rural America.

I recently found an article by Ms. Zito engaging the topic: “The opioid crisis: No one’s fault, and everyone’s fault.”

I’ll give you one guess what went undiscussed. Men and women with opioid disorders urgently need addiction treatment. There is a desperate shortage of such services, particularly in hard-hit rural areas. Poor insurance coverage is fundamental to that.

This reality has provided surprisingly strong political impetus to expand insurance coverage. It’s also produced unexpected cooperation across partisan lines. Eight years ago, ACA’s addiction and mental health parity components passed with unanimous Republican support in the Senate Finance Committee. Since then, Democratic and Republican officials in states such as Indiana, Ohio, Kentucky, West Virginia, and New Hampshire spent years implementing policies that fundamentally rely on the Affordable Care Act, often through public or private negotiations with the Obama Administration.

The opioid crisis and high uninsurance rates among low-income rural white folk played a big role in many Republicans’ difficult decision to embrace the ACA’s Medicaid expansion. The same states became epicenters of opposition to repeal-and-replace efforts in Washington, which most governors publicly or privately opposed. Republican Senators from Ohio, Maine, and West Virginia were key holdouts. Among other things, they demanded a $45 billion opioid fund to (partly) offset the harms associated with deep Medicaid cuts. That fund was nowhere near adequate. That it was even requested to provide political cover suggests the extent that drug policy has evolved in recent years.

I responded to Zito over Twitter:

Zito succinctly responded over Twitter: “I have before.”

There’s only one problem. She apparently hasn’t. I asked her repeatedly over Twitter for pertinent links. She’s never provided anything. I scoured her columns. I can’t find any reporting on Medicaid, insurance coverage, and the opioid crisis.

What I did find was pretty dismaying. Here’s one piece: “The opioid epidemic tightens its grip on America.” Interviewing an Ohio police chief, John Lane, she reports:

Lane is dissatisfied with [Oho governor] Kasich, who has cut funding and hurt the chief’s ability to go after dealers and track down the sources.

He’s hopeful that President Trump will make good on his promises to solve the epidemic.

Opiate abuse kills 91 people a day in the US, according to the CDC, and much of the problem is concentrated in Rust Belt counties where Trump won big in the presidential election.

Many voters in these states switched their support from Barack Obama and the Democrats to Trump, hoping to shock the political class into noticing the problems in their communities.

“I told people I would help them, and I will,” [President Trump] said, pointing to the bipartisan task force on opioids he created, with New Jersey Gov. Chris Christie in the driver’s seat. Christie has earned high praise for his work on addiction in New Jersey. In his budget, Trump also proposed $500 million to fund addiction prevention and treatment and recovery services.

But there are still doubts about whether he can tackle the problem in time. Trump has not yet named a drug “czar,” and after news leaked that the White House was considering deep cuts to the Office of National Drug Control Policy, alarm bells went off in Congress. White House spokeswoman Sarah Huckabee Sanders dismissed that report, saying the budget is not in its final form.

Much is wrong here, in what’s said and what is not.

President Trump spoke humanely about the opioid epidemic in the 2016 campaign. As Alec MacGillis has reported, this was an often-overlooked factor in Trump’s political success. The President’s recent bipartisan task force on opioids is perfectly fine, too. Still, cutting through the rhetoric, President Trump isn’t doing much new or constructive to address this epidemic. He’s promised tougher measures against Mexican suppliers. There’s surprisingly little evidence that tougher supply-side enforcement will slow the epidemic or even raise street prices. The President appointed an HHS Secretary, Tom Price, who opposed mental health and addiction parity enacted under President Bush. The administration is not providing new resources that the Obama administration wasn’t providing through ACA, the bipartisan CURES Act, or system reforms pushed by Obama-era drug czar Michael Botticelli.

Quite the opposite. ACA’s Medicaid expansion is the single most important tool to address addiction and mental health disorders across rural America. Promising not to cut Medicaid before Election Day, President Trump then endorsed a $772 billion cut. He proposes to end Medicaid expansion, and, beyond that, to block-grant and cut Medicaid to well below its pre-Obamacare baseline.

There were other Republican models. Ohio’s Governor John Kasich, far from neglecting the epidemic, expended considerable financial and political capital to specifically address the opioid epidemic. He took a major risk by embracing Medicaid expansion to expand addiction and mental health services. (Since you’re too polite to ask, 71% of the 700,000 Ohioans newly-insured by its Medicaid expansion are low-income white people. Many of these men and women likely voted for President Trump.)

Zito did produce one puff interview on health reform: “[Iowa Senator] Jodi Ernst on health insurance: “We’re in a world of hurt in Iowa”. (Iowa’ss marketplace has major challenges. More on this issue here and here.)

Here are Zito’s questions on repeal-and-replace:

Regarding healthcare, the heat is on right now, but the process is just in the beginning for you in the Senate. There’s a lot of things that you have to go over. What are some of the key things you’re watching as this bill unfolds in the upper chamber?

Iowa is down to one provider in the state, correct?

What are some of your frustrations in how the process has been handled by those who do not support changing Obamacare?

Do you think the genie’s out of the bottle, that people just have this expectation that they’re just going to get free healthcare?

Is that your biggest uphill battle? That people believe everyone should have free healthcare?

There is no analysis of why Iowa is having its current difficulties, the impact on Iowa of actual Republican legislation which was ultimately defeated, no discussion of why every patient, provider, and disability advocacy group opposed the Republican bills.

Before election day, Zito advised Republicans:

If they are wise, congressional candidates-as well as the nominee-should adopt House Speaker Paul Ryan’s consistent push of not only being against Obamacare and calling for its repeal, but reminding voters the House has consistently offered replacement proposals that would lower premiums by providing consumers with a wider choice of health-plan options.

A few months later, Speaker Ryan unveiled his repeal-and-replace legislation. When nonpartisan experts got a look at it, the numbers were almost unbelievable. (One might even say his proposal was a classic example of America’s political class ignoring the desperate needs of rural communities.) The Congressional Budget Office’s analysis of the House bill determined that a 64-year-old with an annual income of $26,500 would see a $12,900 increase in annual net premiums. The Senate repeal bill differed in the fine print. It, too, catastrophically raised insurance costs for near-retirees in addition to inflicting deep cuts in Medicaid.

These bills amounted to the Republican political class’s betrayal of its own white working-class core constituents who decided the 2016 election. This one hits close to home, too. My now-departed in-laws might have voted for President Trump. They would not have voted to block-grant and cut the Medicaid benefits they used for 38 years to care for their disabled son.

Adding insult to injury, Republican bills would have channeled much of the money saved from program cuts into large tax cuts for affluent bicoastal elites. Many Republican office-holders across the states wisely opposed this effort, as did every advocacy group for patients, providers, the elderly, and the disabled.

Ms. Zito might have checked out the Kaiser Family Foundation’s web portal and explored the impact of House and Senate bills on insurance premiums for working-class 60-year-olds in the rural areas she covered. Spoiler alert: It isn’t good.

Areas such as rural Ohio need ACA’s good parts retained, the bad and broken parts genuinely repaired. Ironically, one person in American politics understood this. Hillary Clinton’s campaign didn’t sufficiently connect with rural rustbelt communities, and she paid dearly. These communities didn’t sufficiently recognize that Clinton’s policy proposals offered much that would have helped them. They’re paying dearly for that, too.

The health reform story in Trump country doesn’t neatly fit a liberal or conservative narrative. People’s political allegiances sometimes collide with economic realities and real human divisions within struggling rural communities. Alec MacGillis and Sarah Kliff, among others, provide excellent coverage of these matters.

The story includes devastation wrought by opioids, the genuine anger among residents of local communities towards their neighbors and acquaintances who go on disability programs or Medicaid. It includes the real costs and disappointments of ACA marketplaces, particularly in rural areas. And it includes growing nervousness among low-income Trump voters who started to realize that they might lose critical health benefits and protections they receive through ACA. ACA’s marketplaces are a genuine disappointment in sparsely-populated areas. I suspect that Medicaid or a Medicare buy-in are ultimately necessary to properly cover people in these communities.

Ms. Zito was well-positioned to put a human face on this intricate and evolving story, to map the disconnect between grand Washington, DC policy pronouncements and the on-the-ground reality. She might have linked shoe-leather and policy journalism regarding communities she obviously cares about. It’s wise to speak with a predictably-sympathetic local cop about the opioid epidemic. Speaking with others on the ground such as opioid treatment providers would have provided a much deeper account.

It’s annoying to be misled over Twitter. The missed opportunity bothers me more. Repeal and replace was an economic guided missile aimed at the heart of Trump country. Fortunately, the missile was so badly designed that it collapsed on the launch pad before people were harmed. If Ms. Zito has tried to get beyond partisan bromides to really report on this story over the months that it was front-page news, I certainly haven’t seen it. If she’s attempted to inform herself or her readers about the actual consequences of repeal-and-replace policies for the communities she covers, I haven’t seen that either.

Ms. Zito might have contributed much to this conversation. She chose not to. That’s her loss and ours.

Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect, tnr.com, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.