Republicans in both the House and the Senate are considering big . But those cuts endanger addiction treatment, which many people receive through the government health insurance program.

Charlene Yurgaitis is one of the people who’s been helped. She’s 35 and lives in Lancaster, Pa., and once supervised 17 people at an insurance company. But when some college students moved in next door to her about a decade ago, she started doing oxycontin with them. Then she moved onto heroin and harder drugs.

Earlier this year, Yurgaitis finally had enough of that life and went into recovery. It’s been difficult.

“I’ve been doing everything that I can possibly do to stop using,” she said. “My normal thought is to just do it. Nobody will ever know.”

To support her determination to stay sober, Yurgaitis gets a monthly shot of , also known as naltrexone.

“That stops me,” she said.

The medication blocks receptors in her brain so she can’t get high off opioids, but it also costs about $1,000 a dose. The monthly shots are paired with weekly therapy sessions, and regular visits with a recovery coach. Medicaid in Pennsylvania pays for all of the treatment.

Having this health insurance is how she’s managed to break her addiction over the past few months, Yurgaitis said.

“I would never be able to afford counseling,” she said. “I would never be able to afford psych meds. I would never be able to afford the Vivitrol shot.”

Yurgaitis is one of more than 124,000 Pennsylvanians who depended on Medicaid to get help for their drug or alcohol addiction last year. The Republican health care bill that passed the U.S. House of Representatives in May would reduce spending on Medicaid by more than $800 billion across 10 years. The Senate is modifying that bill but has been deliberating in secret. Deep cuts to Medicaid are expected in the Senate version of the bill, too.

Yurgaitis’ congressman, , a Republican, voted for the GOP bill in the House; in the Senate, Pennsylvania Republican has said he agrees that Medicaid should be cut.

Pennsylvania expanded Medicaid under the Affordable Care Act, and the state pays no more than 10 percent of the bills for the people who gained coverage under the expansion; federal funds contribute the other 90 percent. Toomey says states should have to pay a higher share.

“If it’s not worth it to the state to buy this coverage at 43 cents on the dollar [about what the state contributes to non-expansion Medicaid recipients], then how is it worth it to those very same taxpayers — who, at the end of the day, have to provide the funding for the federal program — why is it worth it to them to pay 90 cents on the dollar? It just doesn’t make sense,” Toomey said.

If federal Medicaid money gets cut, that would leave states to either fill in the financial gap, limit access to care or drop some people’s coverage.

At a clinic in Harrisburg, Dr. Sarah Kawasaki said recovering from opioid addiction is so physically difficult that people need access to medication like naltrexone to help them break free.

If they can’t get that medicine, she said, “I think that by necessity, they would probably have to go back to using heroin or any other medications they could find on the street to avoid getting sick. And I would worry about that.”

If Medicaid funding is reduced, Kawasaki said she expects more people to die from overdoses, and predicts a rise in hepatitis C and HIV infections because of dirty needles.

Yurgaitis, the patient in recovery, gets emotional thinking about the potential cuts.

“Why are you trying to change something that’s working? You know, that’s what I don’t understand,” she said. “If I don’t have those places to go to, I don’t have anything else. I need to have that safe place to go to, and when I’m in my counseling session, that’s my safe place. That’s where I can unleash my demons, and clear my head out.”

Yurgaitis hopes she’ll be able to get treatment for years to come, so that at some point she can go back to work — perhaps helping other people recover from addiction.

This story is part of a partnership that includes , and Kaiser Health News.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

The couple spent December trying to decide whether to buy health insurance or skip it for 2017. They voted for Trump because they were fed up with how much they are paying for health insurance.

In mid-December in the couple’s kitchen, Abra was sizing up their health insurance options. She showed off a thick notebook, along with a file folder with policy documents and notes piled as high as a stack of pancakes. “Don’t touch my paperwork — don’t even try to touch it,” Abra joked to Matt. “I get so stressed out about it. I’ll not pick one until the very last minute, like that deadline day.”

Matt makes good money, but he usually gets laid off in the winter when construction slows down. For the past few years, he and Abra have bought coverage on Healthcare.gov, the Affordable Care Act exchange.

But they’re in a tough spot. They make too much money to get a subsidy to help them pay for insurance. Subsidies are available only to those who make under 400 percent of poverty, or about $97,000 for a family of four. But while the Schultzes don’t qualify for help, paying full price for health insurance stretches their budget to the limit.

Two years ago, when they first signed up for insurance on the exchange, they were paying $530 a month for a plan they liked, Abra says. The price rose a little for 2016, but the options for 2017 went up a lot — about 30 percent on average in Pennsylvania.

“We have one for $881, one for $938, one for $984, like the deductibles are — look, these are insane,” Abra said, as she checked the exchange website for monthly premiums. “The one that we would be stuck with would be the silver. This is $881.50, and our deductible would be $7,000.”

It’s frustrating, she said, because she and her husband are relatively healthy and haven’t needed that much care. Add to that the cost of a separate partially subsidized insurance policy for their two children, and the family is expecting to pay at least $14,000 in health premiums.

Abra resented the mandate to buy health insurance from the beginning. And she liked what Trump said about the Affordable Care Act on campaign stops, like one in King of Prussia in November, just before the election.

“Obamacare has to be replaced, and we will do it and we will do it very, very quickly,” Trump said in his speech. “It is a catastrophe.”

Abra said she wouldn’t mind being in health insurance limbo while Trump and lawmakers debate the future of Obamacare.

Larry Levitt, with the Kaiser Family Foundation, said he understands her frustration with the law. “These are people who are playing by the rules, and doing the right thing, and they feel like they’re getting the shaft,” he said. (KHN is an editorially independent program of the foundation.)

No one likes higher and higher premiums, he said, but there’s a trade-off. “Before the ACA, to get insurance on your own, you had to fill out a medical questionnaire, and an insurer would only take you if you were reasonably healthy,” Levitt said. “That kept premiums down, but it’s because sick people were excluded from the market altogether.”

Levitt said the law’s goal was to to get insurance to a point where premiums only increase slightly every year while everyone can still get coverage, no matter their pre-existing condition. And, he says, any replacement plan devised by Republicans will have upsides and downsides, just like the Affordable Care Act. “If this were easy, it already would have happened,” he said.

Abra said she understands the broader picture, but she needs to focus on what’s best for her family — affordable health insurance.

“[Trump] just wants to fix what needs to be fixed, which I think is wonderful news,” she said.

Abra did decide on a policy for her and her husband — she selected the plan that costs $938 a month because she wants to keep her current doctor. But if lawmakers eliminate the penalty for people who don’t get insurance, she might take a risk and drop the coverage.

This story is part of a partnership that includes , and Kaiser Health News.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Many states — including some that have been hardest hit by the opioid crisis — don’t know how many of their youngest residents each year are born physically dependent on those drugs.

Pennsylvania is one of those states. , head of Pennsylvania’s Department of Human Services, calls the information he’s working with “reasonably good.”

“Data is never pristine when you’re dealing with 2.7 million people,” he said. “Do I think it gives you a good picture of the issues that are out there? Yes.”

Between 2013 and 2014, about 3,700 babies on Medicaid in Pennsylvania were born with neonatal abstinence syndrome, Dallas said. The statistics show that 31 died before their first birthday — and neonatal abstinence syndrome likely played a role in at least some of those deaths.

But it’s not all the data Dallas would like to have. The statistics are two years old, he said, and only deal with babies who are covered by Medicaid, the government’s health insurance for the poor and disabled. That’s just a slice of Pennsylvania’s nearly 13 million people. More comprehensive, statewide numbers, he said, would have to come from Pennsylvania’s Department of Health — and that agency isn’t keeping track.

With more complete information, Dallas says, the state would be able to better deploy resources as it tries to solve a health problem that’s getting worse. With the right resources, there is an upside to this aspect of the opioid crisis: Babies with neonatal abstinence syndrome who get the right care usually do recover. But their care is expensive, and takes time.

“These babies are very work-intensive,” said , who works in the neonatal intensive care unit in Pinnacle Health’s Harrisburg Hospital. “Our nurses are on the front lines; they have to deal with the minute-to-minute symptoms.”

Cuddling or rocking the babies nearly nonstop is key to successful treatment, Wolf said, along with adjusting medication doses frequently in the first 48 hours of the child’s life, to wean these newborns off opioids with as little discomfort as possible.

Each infant’s stay in the hospital can stretch past two or three weeks, and can cost $10,000 or much more. Then the babies need follow-up visits.

Pediatricians say that if the right agencies get real-time information, the babies are , and it’s more likely that hidden roots of the epidemic can be identified and addressed.

To make good decisions, health officials need basic information: Which infants are affected? How many, where, and why?

Pennsylvania might look to Tennessee’s tracking efforts. Tennessee reacted quickly when doctors started seeing a lot more cases of neonatal abstinence syndrome in 2012, recalled , a pediatrician and public health specialist with the Tennessee’s Department of Health.

“We were hearing from hospitals across the state, that they were really, really full,” Warren said, “and in some cases, bursting at the seams.”

It’s now mandatory for doctors and hospitals to report cases of neonatal abstinence syndrome within 30 days, and Tennessee made it simple for them to do so.

“If you’ve ordered from Amazon or an online service and you’ve been able to do that, you can navigate this system with ease,” Warren said. “And truly, at the end of it, you click ‘submit’ and that case is reported to us at the Department of Health.”

The data that started rolling into Tennessee shattered a number of stereotypes, Warren found.

“I think sometimes there’s a tendency to say these are just those moms who are using illicit drugs or buying those drugs on the street,” he said. “But what the surveillance system has actually allowed us to see, is that, in the majority of our cases, Mom is getting at least one substance that is prescribed to her by a health care provider.”

As a result, the state alerted doctors to the issue, recommending they try to change their prescribing habits, and more often offer alternatives to opioids, especially to pregnant patients. The evidence-based shift in prescribing recommendations only came about because health officials had solid data they could share.

In the majority of our cases, Mom is getting at least one substance that is prescribed to her by a health care provider.

Dr. Michael Warren

When a public health crisis emerges, real-time data are especially important. Policymakers can use the information just as Tennessee did — to tailor solutions to the root causes. Otherwise solutions may miss the mark, or, if the data are old, come after the problem has festered and grown.

Pennsylvania Department of Human Services Secretary Ted Dallas acknowledged his state is missing out.

“If we had better data, generally, my theory would be we could make better decisions,” he said.

Just as I was wrapping up this story, Pennsylvania’s health department called. Starting in July, officials there plan to start collecting data about all babies who are born dependent on opioids.

The system to collect the information is still being developed, but neonatal abstinence syndrome will be added to the Pennsylvania’s list of , meaning that every time doctors diagnose a baby with the condition, they’ll be required to the state.

This story is the fourth in our four-part series, “Treating the Tiniest Opioid Patients,” a collaboration produced by Kaiser Health News, NPR and local NPR member stations.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Now, in a dramatic shift, the federal government is considering chipping in, too. The agency that governs Medicaid is proposing to cover 15 days of inpatient rehab per month for anyone enrolled in a .

But in Pennsylvania, those who work in the addiction field are not happy with that news. While it’s a good start, they say, 15 days of residential care isn’t nearly enough time for many people addicted to heroin, opioids, alcohol or other drugs to get clean and stay that way.

“Where they came up with the 15 days, I don’t know, but it’s not based on research,” said , head of the nonprofit treatment program Gaudenzia, which serves about 20,000 patients a year in Pennsylvania, Maryland and Delaware. In just 15 days, he said, you can’t expect to achieve a positive outcome.

“Do you know how expensive that would be, with no outcome?” Harle said. “We wouldn’t want to do it. We would not want to do it.”

Up until now, the state of Pennsylvania has used an obscure provision in the federal law to get federal reimbursement for much longer rehab stays for some people. Pennsylvania officials worry that the loophole will likely go away if the new Medicaid proposal is enacted.

In its , the National Institute on Drug Abuse says:

Individuals progress through drug addiction treatment at various rates, so there is no predetermined length of treatment. However, research has shown unequivocally that good outcomes are contingent on adequate treatment length.

, a professor at Boston University’s Clinical Addiction research unit, said there’s been little funding for research that gets at the optimal length of an inpatient stay, in terms of effectiveness. And in the absence of good data, private insurance plans are all over the map in terms of how many inpatient days they will cover.

Considering that Medicaid hasn’t funded residential treatment programs at all, up until now, 15 days is a good start, said , a former top administrator at the federal Centers for Medicare and Medicaid Services, which governs Medicaid.

“Maybe it’s half a loaf for someone who needs 30 days,” said Mann, who now works for Manatt Health Solutions, a law and consulting firm. “But it’s half a loaf of new federal dollars that could be available.”

Chris Benedetto, a 30-year-old who started using heroin when he was 13 years old, in Scranton, Pennsylvania, says he needed much more than 15 or even 30 days in rehab to kick his drug habit.

“I was really young,” Benedetto said. “I actually was arrested in school.” He bounced from school to probation to jail to rehabilitation. Benedetto said he knew how to play the treatment game, fooling his family and others that he was doing well, even when he was still using drugs, or about to slip.

“I’m good at putting on that mask,” he said.

Eventually, in 2009, Benedetto got into an inpatient facility and stayed there for five months of supportive therapy, thanks to Pennsylvania’s looser interpretation of federal restrictions. Benedetto said the longer rehab stay is what finally enabled him to kick his drug habit.

“For that amount of time, in that environment, I will show up,” Benedetto said. He’s now been clean for more than five years and works as an assistant to an addiction counselor.

Samet said he likes the idea that Medicaid will start covering at least some inpatient treatment. But he also wants to make sure that doctors and patients consider outpatient programs, which can be highly effective for some people and are less expensive.

“It’s the challenge of public policy,” he said. I think this is why the feds go into this kind of work — because a lot of good can be done.” But, he added, he doesn’t want residential programs to become the default style of treatment, just because the option is now available.

“The risk of it being taken advantage of is real,” by both patients and providers, Samet said.

Mann said the proposed change still allows state governments to pay for as much treatment as they think a patient needs — just as they have been doing all along.

“The state and the locals are completely free to finance that stay if they think it’s the right place for somebody to be,” she said.

And if they’re still not happy, she added, states can put together to apply for more federal money.

This story is part of a partnership that includes , and Kaiser Health News.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .