“There were two children who had called the police because they found their parents dead in the house,” explained Cincinnati Ohio Health Department Interim Health Commissioner Dr. Marilyn Crumpton at a meeting in late April. She continued: “We had another situation in nearby Montgomery County, where three other children found their parents dead at home and had to call police. The trauma we’re seeing for children, it is burdensome to even think about it as an adult.”
The opioid crisis is having a devastating human toll. But the full consequences of this epidemic will continue to unfold for years as the children of parents with addiction cope with the effects of trauma known as adverse childhood experiences (ACEs). These stressful or traumatic events, including abuse and parental substance abuse, are strongly related to poor health outcomes throughout the lifespan. Children with exposure to multiple ACEs are more likely to have social, emotional or cognitive impairments, to develop chronic diseases, and to adopt risky behaviors including substance use. As the opioid epidemic illustrates, children of parents with addiction are likely to be exposed to multiple ACEs, such as neglect, homelessness, and parental incarceration among others.
Ohio, where Ms. Crumpton works, has been hit especially hard by the opioid epidemic. It has the highest rate of overdose fatalities in the nation. As a result of fatalities and the inability of parents battling opioid addiction to care for their children, the number of children in foster care in Ohio has risen nearly 20% since 2009. The state doesn’t have enough foster parents to handle the increased need with just 7,000 licensed foster homes for the 14,000 children in care. Compounding the problem is the fact that children are staying in care longer as their parents struggle to beat addiction. Furthermore, because of parental deaths due to overdose, more children are waiting for adoption.
In Hamilton County, where Cincinnati is located, 50% more children are waiting to be adopted than before the opioid crisis began. Learning from people on the front lines, like Cincinnati’s Dr. Crumpton, I’ve begun to understand just how devastating the short- and long-term consequences of Congressional leaders’ plans to slash Medicaid would be to families and children impacted by opioids. Crumpton is a partner in our Building Community Resilience (BCR) work, which has its academic home at the Sumner M. Redstone Global Center for Prevention and Wellness at the George Washington University’s Milken Institute School of Public Health. BCR works to align community support systems for children and families in order to develop the resilience necessary for positive health, educational, and life outcomes. Our premise is that children can be buffered from the negative impacts of ACEs and build resilience through positive supports, stable relationships, and a healthy community.
“Spitting in the Ocean”
As the opioid crisis has begun to overwhelm child welfare systems in Ohio and other states, the various iterations of health care legislation under consideration in Congress threaten to make matters much worse. Medicaid funds 50% of all opioid addiction treatment in Ohio and nearly the same proportion in neighboring Kentucky and West Virginia. Yet the Senate’s Better Care Reconciliation Act (BCRA), which would “repeal and replace” the Affordable Care Act (ACA), includes nearly $800 billion in cuts to Medicaid and makes profound changes to the way Medicaid operates. In an attempt to “get to yes” on passage, Senate leaders will add $45 billion to address the nation’s opioid epidemic, but maintain the deep Medicaid cuts from earlier versions of the legislation. However, the added funds are miniscule compared to the $800 billion cut in Medicaid and the estimates that an additional $183 billion to $220 billion will be needed over the next 10 years to fully address the epidemic. As Ohio’s Republican Governor John Kasich recently said, the $45 billion amounts to “spitting in the ocean.”
How many more children in Ohio will enter the foster care system if Medicaid, the largest source of treatment for parents battling addiction is slashed by nearly $800 billion — or 26% over the next 10 years? The proposed Medicaid cuts not only threaten help for adults, but care for children down the line. Almost all children in foster care receive health coverage through Medicaid and their health needs are often extensive. Children exposed to ACEs, especially those that enter the foster care system, often need robust health care supports to help heal the underlying traumas they’ve been exposed to. Young children in foster care are 4 times more likely to need treatment for a developmental disorder than their non-foster care peers, and adolescents in foster care are 3.5 times more likely to need treatment for ADHD, conduct, and disruptive behavior disorder than their peers.
Former foster youth also face significant challenges, including suffering from PTSD at double the rate of war veterans. That’s why the ACA’s provision that former foster youth can automatically remain on Medicaid until they are 26, just like other young adults can remain on their parent’s insurance, and cannot be denied coverage due to a pre-existing condition have been critical to help former foster youth build stable and productive lives. There’s also a growing body of evidence that trauma increases susceptibility to addiction. That susceptibility makes robust health care and other supports to children impacted by their parent’s addiction essential, so those children do not become a new generation to suffer from substance abuse.
Powerful, impactful, and innovative work is going on around the country — including that of our BCR teams — to mitigate and prevent the negative outcomes that result from traumas like the opioid epidemic. This work, and the children and families that are benefiting from it, is clearly threatened by the Medicaid cuts in the BCRA. It is uncertain what will be required to end the opioid epidemic. However expanding treatment and ensuring that children in and those leaving the foster care system have access to comprehensive physical and mental health care will be critical pillars. The proposed ACA replacements would destroy those key supports in places like Cincinnati, producing more traumatized children, an over-burdened child welfare system, and strained state budgets incapable of picking up the pieces.
