Donald Trump’s win over Hillary Clinton Nov. 8 was a surprise and, for many, an unpleasant one as they considered the possibility that the gains of the Affordable Care Act (ACA) will be wiped out. Medicaid expansion and the subsidized marketplace insurance plans are likely to be done away with by President-elect Trump and Congress, where both sides have said ACA repeal and replacement are top priorities. Many treatment programs have spent the past five years treating more and more people who now have health insurance. These patients have been treated with medications, in residential treatment programs and in emergency departments, and even the criminal justice system has figured out that it is cost-effective to use Medicaid to provide treatment services.

But ACA repeal isn’t going to happen overnight. Nobody seems to have a clear idea — not in Congress, and so far not Trump — about what to replace it with, and as politicians have realized in states, taking away people’s health insurance is not a popular move.

By now, people have had time to adjust to the new reality. When we interviewed them last week, they were just getting over the shock. For federal employees who were unsure about whether they should retire, this sealed the deal. It’s hard to be inspired to go into public service when the core tenet of the new president has been the negative aspects of government.

The House of Representatives and the Senate are now solidly Republican, so there will be little opposition to Trump’s initiatives.

Other initiatives of Trump and Congress are likely to affect the treatment field and patients. First, criminal justice reform is likely to be halted, as Trump’s “rule of law” philosophy plays out with the support of law enforcement. President Obama’s executive orders will be undone, according to Trump, who specifically cites the one banning federal prisons from being operated by private for-profit companies (Corrections Corporation of America stock went up 45 percent Nov. 9). One of the possible picks for attorney general is Rudolph Giuliani, who as mayor of New York City vowed to abolish methadone clinics there.

Trump has also said he would like Medicaid to be a block grant program, which would put a cap on the amount of money the federal government puts into it.

Marijuana

In other election results, marijuana — medical and recreational — had big wins on Nov. 8. California, Massachusetts and Nevada legalized recreational marijuana (Maine and Arizona were still too close to call), and Florida, Arkansas, Montana and North Dakota approved medical marijuana. In what the Drug Policy Alliance (DPA) termed a “watershed moment,” marijuana prohibition is on the verge of ending — except for Trump, whose administration may threaten marijuana.

“Marijuana reform won big across America on Election Day — indeed it’s safe to say that no other reform was approved by so many citizens on so many ballots this year,” said Ethan Nadelmann, DPA executive director. “But the prospect of Donald Trump as our next president concerns me deeply. His most likely appointees to senior law enforcement positions — Rudy Giuliani and Chris Christie — are no friends of marijuana reform, nor is his vice president.”

Uncertainty

“The theme is uncertainty,” said Robert Morrison, executive director of the National Association of State Alcohol and Drug Abuse Directors. It’s unclear what aspects of the ACA will be kept, if any. But in Congress, the work on opioids is ongoing, with the proposed budget for Fiscal Year 2017 expected Dec. 9, to be finalized before Christmas.

In a Trump administration, “everything is on the table,” said Morrison. “The power of the administration is its ability to set the agenda and put out a recommended path to get there.” So far, despite broad-brush characterizations such as repealing the ACA, there are no specifics, said Morrison.

And opioids, including more money in the FY 2017 budget, are still a top priority for the field. “I don’t see a stop in the intensity of the opioid problem,” said Morrison. “Parents and others affected are still very much for action.”

“A Trump presidency is going to be interesting to say the least, because I’m not sure anyone knows where he stands on many domestic issues, including drug abuse,” Andrew Kessler, principal with Slingshot Solutions, a behavioral health advocacy firm, told ADAW. “This is a man who was fairly centrist earlier in his career, and it’s really anybody’s guess as to whether he will be amenable to positive changes for prevention, treatment and recovery.” Noting that most of Trump’s attention has been focused on drug trafficking in terms of drugs, he did attend an opioid policy roundtable in New Hampshire last month, which, said Kessler, “indicates his willingness to discuss the issue.” Kessler will do what he always does when there is a new administration: “educate him and his team on the complexities of the issue, and get them to include us in discussions that create positive changes moving forward.”

Other voices

“Since January the Addiction Policy Forum has worked diligently to bring addiction and the opioid epidemic to the attention of every presidential candidate, and to review each candidate’s plan to address addiction,” said Jessica Nickel, executive director of the Addiction Policy Forum. “While each candidate’s plan had flaws, almost all showed a significant shift in how to address addiction, reduce current barriers to addiction treatment such as the Medicaid Institutions for Mental Diseases (IMD) exclusion, and the need for additional resources and education,” she told ADAW. “President-elect Trump’s plan included key pieces on prevention, treatment, law enforcement and overdose reversal.” Nickel also cited the New Hampshire roundtable event, at which Trump “focused on prevention and curbing the inflow of illegal drugs into the country.” The Addiction Policy Forum is “committed to working with the new administration to help expand resources to communities at the forefront of the opioid epidemic.”

The National Association of Addiction Treatment Providers (NAATP) “appreciates that President-Elect Trump has expressed his belief that substance use disorder (SUD) is a serious health issue in America,” according to a statement from the Colorado-based group. “We are encouraged that Mr. Trump has publicly discussed the impact of SUD in his own family and has supported treatment for affected employees.” NAATP encourages Trump “to appoint individuals who understand SUD and are committed to the enforcement of the bipartisan Mental Health Parity and Addiction Equity Act as well as the White House Parity Task Force recommendations to fully implement the law.” In addition, SUD is an essential health care benefit under the ACA, which NAATP urges Trump to continue.

“We welcome the opportunity to work with President-Elect Trump and the Republican Party on improving mental health in this country,” said Maria A. Oquendo, M.D., Ph.D., president of the American Psychiatric Association. “Mental health is a bipartisan issue that affects millions of Americans from all walks of life, and we pledge to work with President-Elect Trump’s administration to ensure those Americans get the care they need.”

“As we transition to a new President and Congress, the National Association of Psychiatric Health Systems (NAPHS) and our members are committed to our longstanding, bipartisan advocacy for policies that will improve the lives of the millions of Americans of all ages whose lives are affected by mental illnesses and drug and alcohol use disorders,” said Mark Covall, president and CEO of NAPHS. “The stakes are high for all Americans, with the impact of behavioral health conditions having a wide impact on individuals, families, and communities,” he said. “Alcohol is killing Americans at a rate not seen in at least 35 years, and the United States is experiencing an epidemic of drug overdose deaths.” Lives are at stake, said Covall, adding, “With lives at stake, this is an opportunity for our leaders — both Republicans and Democrats — to come together to take meaningful action on mental health and substance use policies.”

A battle call

And Linda Rosenberg, president and CEO of the National Council for Behavioral Health, provided these words — which are healing and a call to battle at the same time — on her Nov. 10 blog: “I love this quote from Hillel the Elder, one of the most important figures in Jewish history, because I often find myself asking, ‘If not us, who? If not now, when?’ as I think about the National Council’s role in ensuring access to effective care for people with addictions and mental illnesses and in supporting the people in their lives who love them. The outcome of the presidential election doesn’t change the National Council’s answers to the two questions that Hillel the Elder asked. Easily available, effective services is still our true north.” Less than five years ago, most Americans thought of addiction as a “moral failing,” she said. “The response to that failing was incarceration. Acute treatment and belief in a higher power were the primary interventions to what science has taught us are chronic disorders. But over the years together we pushed for change. Because you — the on-the-ground providers of mental health and addiction services in communities across America — believed in a new direction. You applied science to treatment. You created outpatient and rehabilitation programs, incorporating case management, peer and recovery supports, and housing. You worked long and hard to bring behavioral health disorders into health care to integrate the mind and body.”

The outcome of the election “doesn’t change our goal of effective, accessible care and it won’t change or limit the passion and intelligence that our community brings to work with a new administration and Congress,” she said. “But it can mean being prepared to change strategy and tactics and the National Council community is ready to do that.” The meeting will likely be controversial, she said. “Bills may be passed that use the ‘new’ language — reform, value-based, population health — but offer no expansion of service capacity nor invest in quality. We may see proposals that limit entitlements, and that continue to build the gulf between the haves and have nots. We’ve seen it all before and we are prepared to say no loudly and strongly.”

Bottom Line…

President Trump — the field gets used to the reality and what it means for treatment and patients.