Trump county worries Medicaid cuts could throw them back into opioid spiral

HARLAN, Ky. – Candice Fee isn’t sure who’s right in the debate over the future of Medicaid: the Republican president whose party says it will leave federal health funding intact as it seeks to slice billions in government spending or the Democrats who warn that the broad cuts the president has promised can’t happen without carving into one of the government’s most costly programs.

But if Medicaid is axed, Fee knows exactly what will happen to the life she has pieced back together after decades of addiction.

“If it were to go away today, I would be homeless tomorrow. I would lose everything. All my counseling, all my treatment. I would absolutely be homeless tomorrow,” said Fee, 42, who has lived in Harlan all her life, most of it spent in a cycle of addiction and rehabilitation. A Medicaid-funded treatment program she entered last year has her feeling, for the first time, optimistic about not living a life dominated by substance abuse.

In group meetings, she and other recovering addicts talk about the benefits of an injection that reduces the desire for opioids. They mull the role of talk therapy in their rehabilitation. And, increasingly, they worry over a Washington funding debate that has left their future uncertain.

“I am stepping out onto my own, getting my house with my kids sooner or later, but if I lost (Medicaid-funded treatment) today, I would lose my job, I would lose everything that I’ve worked so hard to rebuild over the last year,” said Fee, who can’t vote because she has a felony conviction, but is not a supporter of Donald Trump. “If (Trump) takes the things that they’re saying, it’s going to be devastation for Eastern Kentucky for sure. We’re scraping off the bottom already.”

Almost 90 % of voters in this Appalachian county in Kentucky’s southeastern corner voted for Trump, who has said his party’s effort to eradicate waste, fraud and abuse will culminate in a “big beautiful bill” that will lay the groundwork for slicing at least $1.5 trillion from the federal budget in the next decade. The president has repeatedly said entitlement programs like Medicaid, Medicare and Social Security will remain untouched, even as he pushes for a contraction of broader federal spending.

But Democrats, including the governor of Kentucky, warn that the kind of cuts the GOP is considering are impossible without cutting essential services like Medicaid, which provides health care to low-income people. The Congressional Budget Office agreed, saying this month that Republicans cannot cut their desired amount of federal spending without cutting Medicaid or Medicare benefits.

And despite Trump’s assurances that the programs are safe, some Republicans have advocated that reform is needed.

Three members of the ultraconservative House Freedom Caucus recently penned an op-ed on Fox News saying “lawmakers must reform Medicaid. To do anything less borders on malfeasance.”

“Medicaid was never meant to be this expansive,” the opinion piece says, echoing concerns that have been expressed by other Republicans.

The intensifying debate hangs over Harlan County and illustrates a disconnect – even a contradiction – in Trump’s efforts to remake the federal government. He has vowed to reduce waste, fraud and abuse, and to extend a suite of tax cuts he signed into law in 2017. But reducing federal funding, particularly in places with large percentages of Medicaid users like Harlan, can threaten the livelihoods and even the lives of some of Trump’s most ardent supporters.

Containing the opioid epidemic has featured prominently in the political rhetoric of the Trump administration. Trump justified high tariffs on Mexico, Canada and China by saying the three countries didn’t do enough to stem the flow of opioids, particularly fentanyl, across American borders. “They’ve allowed fentanyl to come into our country at levels never seen before,” he said during his address to a joint session of Congress, “killing hundreds of thousands of our citizens and many very young, beautiful people destroying families.”

Almost half of people in Harlan County receive Medicaid, which is administered by the state of Kentucky but funded largely by the federal government. Those funds help pay for doctor visits and prescriptions, but Medicaid also subsidizes a burgeoning industry of rehabilitation facilities and treatment centers in a state that has one of the country’s highest rates of opioid abuse.

“The substance abuse treatment industry in Eastern Kentucky employs more people than the coal mines ever thought about,” said the owner of one facility, who spoke on the condition of anonymity to avoid fraying professional relationships. “With Medicaid expansion, if you need help, you can get it now. You can get medication, you can get counseling, you can get therapy. Basically, you can get almost any service that you need, more services than you ever could have before.”

Harlan County Judge Dan Mosley, the county’s chief executive, said Medicaid has helped countless people in his county recover from opioid abuse, transforming from repeat offenders who siphon finite resources to working taxpayers, including some who help others through addiction.

“I have seen firsthand the people behind those statistics who have went and rehabilitated their bodies and their lives and are now productive members of society, and I worry what would have become of them had they not had Medicaid,” said Mosley, a Republican who voted for Trump in 2024 and thinks congressional Republicans will deliver a plan that cuts waste but also helps his community stay afloat, even if it includes tweaks to Medicaid or other entitlements.

“Medicaid in that arena has enabled us to return people to a productive workforce setting and make them a taxpayer again,” he said.

The state of Kentucky has seen similar strides. In 2023, drug overdose deaths in the state fell almost 10%, marking a second straight year of declines in the fight against the addiction epidemic. In an interview with the Washington Post, Democratic Gov. Andy Beshear said he worries what Medicaid cuts would do to people in his state, framing his fears in humanistic and economic terms.

“Any substantial impact to either (Medicaid reimbursement) rates or the overall amount coming in to the state will have a significant impact that no state in the country would be able to escape,” Beshear said. Further reductions could mean some rural hospitals would have to reduce services and staff, or even close. “If these cuts go too deep, it’s a risk to every piece of progress we’ve made in the last 10 years.”

Last month, Harlan residents were reminded of what those cuts could look like. Harlan’s hospital, a branch of Appalachian Regional Healthcare, announced that it was closing its labor and delivery unit. That means people giving birth in Harlan have to drive 40 miles to Middlesboro, Tennessee, or 50 miles to Whitesburg, Kentucky, or else give birth in the hospital’s emergency department. In announcing the reduction in services, the hospital said not enough women had opted to give birth at the hospital, and keeping the labor and delivery unit open was not economically feasible. Local leaders worry it’s the first of a cascade of closures for an area sorely in need of health care.

“We have a lot of unhealthy people here, and the statistics show that we have high rates of cancer, high rates of obesity, high rates of diabetes, high rates of heart disease,” Mosley said. “Kentucky was one of the least healthy states in the nation, and Harlan County was listed as one of the least healthy counties in the state. We’re trying to reverse that cycle.”

But despite Democratic warnings about what, exactly, could happen to Medicaid, some in Harlan don’t think Trump and Congress will whittle too much of the program away, said Paul Browning, one of the magistrates for Harlan County. He said many of his constituents never considered that Medicaid would be on the chopping block – some still don’t.

Medicaid has continued to exist, and even expand, through Democratic and Republican administrations, and regardless of the makeup of the state government.

“It’s been through Jimmy Carter, been through Ronald Reagan, been through Clinton, Obama, both Bushes, Trump’s (first term) – through everything, Medicaid has just been there and folks here consider that would continue. You know, history is the best indicator of the future,” he said.

Keiley Harrison, 40, of Harlan, a recovering addict who is working toward a degree in counseling and also got clean with the help of Medicaid, said she remains a Trump supporter despite the threat to programs that have helped people like her. In the end, she trusts that Trump will rightsize Medicaid and get rid of waste and abuse. Harrison said she’s seen that abuse firsthand, both by people purportedly seeking treatment and by companies offering inadequate services that do little to help addicts.

“Let’s get real – there is Medicaid fraud. There’s a lot of Medicaid fraud. People are taking advantage of it,” Harrison said. She said she would favor an effort similar to Trump’s pause on grants and loans disbursed by the federal government. “I think that maybe it’s going to be something like that again, and I’m hoping he gets out the people that aren’t really about helping others and just looking at people as a money source.”

Little has been released about how much, exactly, would be cut. The Republican House’s budget resolution instructs a key U.S. House committee to cut $880 billion in spending over the decade, something that will help extend the Trump tax cuts. The vast majority of funds are in the Medicare and Medicaid buckets, and Republicans have said that Medicare is off the table.

House Speaker Mike Johnson , R-Louisiana, has not ruled out the cuts. Others have been more explicit: “Let me tell you, we cannot get to where we need to go without Medicaid,” Rep. Keith Self , R-Texas, said recently on Fox Business.

Fee, who has two jobs, but is also seeking training to become a peer support specialist, has said she encouraged people to shut out the noise and to focus on their own recovery, but she is not always successful.

“I’ve also noticed it through a lot of people in the recovery world, not knowing what we’re going to do, not knowing what our next move is going to be, not knowing how things are going to turn out. I’ve seen a lot of relapses, because a lot of people they’re just like, ‘Forget it. It’s not going to happen. They’re going to take it away.’”

But even as she counsels people to stick with a program that has worked for her, she said she is worried about her own future.

“I couldn’t be more happy with my life today. … But I absolutely am worried about my future, because I’m not sure how it’s going to go if Medicaid is gone. If you remove all that back, then am I simply going to go push play on my old life again?”

Marianna Sotomayor and Jacob Bogage in Washington, D.C., contributed to this report.