As the chief medical officer at a downtown hospital, William Goodman has seen how opioid abuse can ravage a community. He’s also seen what a robust response to addiction looks like, from creating safe spaces for users to seek help to seeding a network of long-term treatment centers across the Granite State.

But this public-health response depends on federal health dollars. Until 2014, able-bodied adults living just above the poverty line in New Hampshire didn’t qualify for Medicaid. Now they do, and that expansion has undergirded a rollout of services for substance abuse and mental illness.

Under health-care legislation being crafted by Senate Republicans, the Congressional Budget Office has estimated that 15 million Americans would lose Medicaid coverage over the next decade. For Dr. Goodman, any retrenchment in coverage could be a body blow in New Hampshire’s battle against opioid abuse.

“We’re trying to catch up. If we lose this kind of support and we go back to standard Medicaid [eligibility] I think it would be devastating on many levels.... Programs would wither on the vine,” he says.

His worry, shared by others here including the Republican governor, is emblematic of how grass-roots concern about opioid addiction is altering national debate over health-care policy. Although pledges to repeal Obamacare helped Republicans win control of Congress, Senate efforts to follow through on that promise have faltered because of the politics of coverage cuts, including for addiction treatment.

New Hampshire is the kind of low-tax, small-government state that Republicans love to champion. Until the opioid crisis hit, it spent only a fifth per capita of the average of New England states on treating substance abuse. A surge in opioid deaths and related illnesses forced a rethink in spending priorities during the rollout of the Affordable Care Act (ACA), which mandates coverage for substance abuse as an “essential” benefit in private insurance plans. It led to a bipartisan law that expanded Medicaid to an additional 53,000 residents and added substance abuse to traditional Medicaid plans.

Republican governors push back

Gov. Chris Sununu has criticized the Senate bill, joining other Republican governors from states that accepted more Medicaid dollars under the ACA. In a letter to Senate majority leader Mitch McConnell, Governor Sununu said the bill would jeopardize the state’s investment in Medicaid coverage. “Taken as a whole, we believe that the changes proposed in the BCRA will lead to cuts in eligibility, loss of coverage or significant increases in state taxes,” he wrote. The letter was made public on June 27 after Senator McConnell delayed hearings on the controversial bill.

The initial Senate bill offered about $2 billion in extra money for states fighting opioid abuse. A revision, in the works as Congress heads out for a week-long recess, may offer more money to get moderate Republicans on board. But critics say even $45 billion for the next decade, sought by Republican senators from West Virginia and Ohio, wouldn’t compensate for deep cuts in subsidies for the poor at risk of opioid abuse.

“Slashing and burning Medicaid and saying the states will find the money is the most gargantuan case of buck-passing in the history of American politics, and one that will cripple Medicaid financing ... for people plagued by opioids” and for many others, says Alan Sager, a professor of health law, policy, and management at Boston University.

Drug abuse cuts across class lines; not all those seeking help are on Medicaid. But its expansion in New Hampshire has eased the financial strain on hospitals like Catholic Medical Center (CMC), where Goodman oversees an emergency room that can see multiple drug overdoses in a single night when a potent batch of fentanyl, a synthetic opioid, hits the streets.

A rise in coverage

On a recent weekend, four extended family members were driven to the emergency room by an unknown fifth person after overdosing on fentanyl. All survived. “We all know someone who’s suffered, and it’s usually someone very close to you,” says Goodman.

Today fewer patients arrive at CMC with no means to pay for care. In 2011, 16 percent of opioid-related admissions were uninsured. Last year that share fell to 3 percent. Statewide, the rate of uninsured is 6 percent, down from 11 percent in 2011 before the Affordable Care Act.

Just as important as hospital care, say health officials and policy experts, is the flow of public money to outpatient clinics and detox centers for recovering addicts.

“We are developing a substance use disorder treatment network that can actually care for people with addiction. This is the first time we’ve been able to do that and that’s due to the coverage requirements in the Affordable Care Act,” says Lucy Hodder, director of health law and policy at the University of New Hampshire.

When Goodman’s team saves an overdose patient, he wants to know that there’s a place to refer the patient for long-term rehabilitation. That wasn’t a given before, which only added to his frustrations when the same patient would show up again in the ER. “It’s much more cost-effective to keep them sober and prevent them from getting sick,” he says.

Between 2009 and 2015, the number of non-residential mental health and substance abuse centers in New Hampshire grew from 52 to 70, according to New Futures, an advocacy group. It estimates that substance abuse cost the state $2.36 billion in 2014, of which lost productivity made up the largest share, following by medical care and law enforcement.

The uncertainty factor

The network of treatment centers still lags behind the rising demand in a state that saw 478 opioid-related deaths last year, up from 300 in 2014, the second-highest rate per capita behind West Virginia. But the uncertainty hanging over future Medicaid coverage puts operators in a bind, says Courtney Gray-Tanner, who heads an association of drug and alcohol treatment centers.

“These entities are hesitant to build up, because they’re not sure about the level of resources,” she says.

Should the Senate bill become law, states that expanded Medicaid could try to fill the gap in federal funding from their own budgets. In his letter to McConnell, Sununu said the state would receive $1.4 billion less over 10 years under the Senate’s Medicaid funding formula.

New Hampshire’s Medicaid expansion program automatically ends if the federal matching changes, says Ms. Hodder, a former adviser on health policy to Maggie Hassan, the two-term Democratic governor who signed the expansion into law.

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Like many here, she’s unsure if a low-tax state could muster the resources to maintain the Medicaid coverage. “New Hampshire just isn’t prepared for that kind of investment that quickly,” she says.

Staff writer Mark Trumbull contributed to this report from Washington.