Evidence is all around that the country is facing another drug abuse crisis.  Not surprisingly that crisis is impacting the number of children entering foster care.  Child welfare will continue to be effected by increased drug epidemic and that could become even more significant if Congress repeals the ACA, block grants Medicaid and does not have an adequate replacement.

Based on a CDC report, Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015.Opioids are continuing to dramatically impact health and society. The CDC reports that drug overdose deaths nearly tripled during 1999–2014. During 2013–2014, deaths associated with the most commonly prescribed opioids (natural/semisynthetic opioids) continued to increase slightly; however, the rapid increase in deaths appears to be driven by heroin and synthetic opioids other than methadone. That pattern continued in 2015, a total of 52,404 persons in the United States died from a drug overdose increasing from 47,055, among these deaths, 33,091 from opioids which is an increase from 28,647 in 2014.

The largest absolute rate change in deaths from synthetic opioids other than methadone occurred in Massachusetts, New Hampshire, Ohio, Rhode Island and West Virginia. The largest percentage increases in rates occurred in New York (135.7%), Connecticut (125.9%) and Illinois (120%). Connecticut, Massachusetts, Ohio, and West Virginia experienced the largest absolute rate changes in heroin-related deaths, while the largest percentage increases in rates occurred in South Carolina (57.1%), North Carolina (46.4%), and Tennessee (43.5).

Building on the CDC report the Journal of the American Medical Association Pediatrics provided new documentation, Rural and Urban Differences in Neonatal Abstinence Syndrome and Maternal Opioid Use, 2004 to 2013 that there has been an increase in infant dependence with a bigger increase in rural areas of the country.   Incidence rates for neonatal abstinence syndrome (NAS) and maternal opioid use increased nearly 5-fold in the United States between 2000 and 2012. The study indicates increasing maternal opioid use and growing numbers of newborns with withdrawal symptoms in rural areas.

Examining research, the National Council for Behavioral Health has outlined a picture of what may happen if the ACA is repealed.

  • Research indicates that there are 21.6 million people that have substance use disorder with 9.3% receiving treatment. These numbers are based on data from SAMSHA.


  • Medicaid accounts for a large amount of substance use disorder spending with people with a substance use disorder or mental health diagnosis accounting for 29 percent of the Medicaid expansion population under the ACA.


  • Health insurance reforms includes an essential health package that requires substance use disorder treatment at parity with medical and surgical coverage provided.


  • An ACA repeal will take $5.5 billion from the treatment system and 2.8 million will lose substance use disorder coverage.

By comparison the Substance Abuse Prevention and Treatment Block Grant totals $1.8 billion.  Last year’s new “Cures” legislation provides $500 for this year and, if appropriated, next year. Before the Cures Act and in the past decade, state and local funding for behavioral health was cut by $4.5 billion due to the recession (National Council for Behavioral Health).

Some states that chose to expand their Medicaid coverage under the ACA have been particularly hard hit by the opioid epidemic.  Death rates due to drug overdose in expansion states include: West Virginia, 41.5 deaths per 100,000, Kentucky 29.9 per 100,00, Ohio 29.9 per 100,000, Pennsylvania 26.3 per 100,000, Tennessee 22.2 per 100,000 and Maine at 21.2 per 100,000.

The research and data on the impact of the ACA on expanded drug treatment services is based on the work of Richard G. Frank and Sherry A. Glied of the Harvard Medical School and the Wagner School of Public Policy at NYU.  They provided an opinion piece in The Hill, Keep Obamacare to Keep Progress on Treating Opioid Disorders and Mental Illnesses  

And how does this effect child welfare? The last AFCARS data, released late last year indicated clear data that foster care numbers are trending upward.  A third consecutive increase in foster care to 427,910 children in care represents an eight percent increase since 2012.  In publishing the information HHS released a statement and press release that said,

“[we]…interviewed child welfare directors in states experiencing the highest increase in foster care numbers, and state officials informed ACYF what the data suggest: a rise in parental substance use is likely a major factor driving up the number of children in foster homes. Citing opioid and methamphetamine use as the most debilitating and prevalent substances used, some state officials expressed concern that the problem of substance use is straining their child welfare agencies.  

State child welfare directors also emphasized that recent trends in substance abuse are sometimes affecting entire families and neighborhoods, making a child’s placement with relatives an unviable option. Increased collaboration across service providers and community leaders will be necessary to address this rising challenge.”