Elena Scotti/FUSION

It may not look like it at first glance, but in a country where almost 100 people die from an opioid overdose every day, Ashley* has been extremely lucky. First there’s the fact that her mom, Cindy Koumoutzis, is the kind of committed parent who would bring Ashley back to Ohio and put everything she had into keeping her from using drugs, tracking her movements and keeping her on lockdown. (It didn’t work.) There was the lenient judge who’d seen enough cases of addiction by the time the possession charge came up, years later, to mandate rehab over jail time. And, of course, there's the extremely fortunate circumstance of Ashley being a college-educated white person in America.

But according to her mother, there was also the fact that some of her kid's darkest days coincided with the expansion of Medicaid in Ohio, as part of the Affordable Care Act.

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“It saved her life,” Koumoutzis says. “Well, it saved her life or my house. One or the other.”

As of the middle of last year, more than 700,000 Ohioans, most of whom were previously uninsured, signed up for coverage under the ACA’s Medicaid expansion. According to government data, nearly a third of them, including Ashley, were diagnosed with a substance abuse disorder. The promise, as is stands from today’s press conference with President-elect Trump, is to swiftly “repeal and replace” the health coverage known as Obamacare—but there is still little semblance of a plan for what that would look like.

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And since the new Congress introduced a resolution early this year that could functionally gut the ACA, drug abuse counselors and their patients have begun to weigh the wide-ranging consequences for the millions of lower-income people receiving treatment for substance abuse in 31 qualifying states.

Medicare allows prisoners in states like Kentucky to receive monthly shots of Vivitrol, an opioid-blocking medication, upon their release. It gives addicts in New Hampshire access to high-quality, intensive outpatient programs so they can continue to work while kicking the habit. And it relieves the constellation of pressures that go along with drug and alcohol problems, among them depression and the long-lasting physical ailments that attend years of abuse.

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According to Beck Gee, a Boston-based counselor for LGBTQ youth struggling with drugs and alcohol, it’s nearly impossible to separate mental and physical health from addiction. “Addiction is a social justice issue,” he says.

The institutional stigma of mental health and addiction treatments could make it even harder to find reasonable care. In 2008, a federal law mandated that most insurers treat substance abuse and mental health conditions the same as, say, diabetes. That said, for many private insurance providers, those diseases still count as pre-existing conditions and command higher premiums, at the very least.

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Under the Affordable Care Act, insurance providers are prohibited from denying service for such pre-existing issues; the ACA also lists substance abuse as one of its 10 essential coverage areas. Mike Ferguson, a California-based addiction treatment specialist, worries that if such restrictions on basic insurance plans are lifted, the consequences will be “disastrous.” In his years of practice, he's spoken to people about their pre-ACA denials of health insurance. Some were denied coverage based on having been hospitalized in the past for mental health reasons. Some, he says, were denied simply for seeing an individual therapist.

The Koumoutzis family knows all this firsthand. Ashley’s sexual assault at the age of 15—far before Obamacare kicked in—both fueled the heroin habit she picked up a few years after she was raped and made it difficult for the cash-strapped family to find care at a price they could afford. For some private insurers, depression is considered a pre-existing condition: Ashley’s suicide attempts and extensive trauma counseling made it so “nobody wanted to touch her,” Koumoutzis says. And once Ashley turned 18 nearly 10 years ago, she was dropped from even her parents’ insurance plan. Given the depression she’d been treated for and the overdoses on her medical records, finding insurance on her own was nearly impossible.

Still, the family shelled out everything they could. Ashley’s mom estimates that between the drug counseling, the Suboxone (another medication that blocks opioid receptors), and the antidepressants, she and her husband were spending roughly $1,500 a month on treatment for Ashley—which isn’t to mention the lasting health issues she faced, including hepatitis C, which largely went untreated.

“We’ve got four kids,” Koumontzis says. “At what point do you go bankrupt, put your house up? Many people have.”

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The 2014 Medicaid expansion in Ohio kicked in just in time. Ashley did two back-to-back stints in a Medicaid-covered rehab program and locked down a prescription that helped her keep the addiction at bay. Ashley's been clean for more than a year. She’s lucky in that respect, too—it’s unclear just how devastating the effects of pulling treatment out from under addicts only now beginning the recovery process will be.

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“I don’t think [politicians] are thinking about people who are on methadone, who are on Suboxone,” says Koumoutzis. “There’s a lot of them, and it’s keeping them alive.” Even now, she says, a lot of overdose deaths in the state are people who are just coming out of prison or treatment.

John Ludice, who has been a drug counselor for 10 years, works at an extensive outpatient program in New Hampshire treating primarily alcohol and opioid abuse. For much of the program’s history, it only treated people with private insurance—that is, people with higher incomes. In the last year he’s been able to expand his program to treat people who, in his approximation, could need the services even more that his original client base.

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He estimates that since the Medicaid expansion in his state around 25% of his patients are lower-income people on state insurance. The influx helped them open a second office. Ludice is upfront about the limits of the Affordable Care Act: There are still waitlists for beds in rehab centers; Medicaid is imperfect. But when asked what might happen to the people in his program when Obamacare is repealed and new provisions are not put in place, he offers a grim progression of events, both for his patients and the public at large.

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“People would want help, look for it, not get it anywhere, become despondent, and spiral back into addiction—essentially for the rest of their lives,” he says.

*After 10 years of struggling with the stigma of addiction and sexual assault, Ashley would prefer this article not appear when someone Googles her. Her name has been changed.