But addiction treatment specialists warn that sum of money is far from enough to address a crisis that has escalated across the United States in recent years,ÌýÌýtens of thousands of people.

The federal money would be spent over about a decade, and is part of a bill that also dramatically cuts Medicaid, which is helping many people get treatment now. Those cuts willÌý — those living in states that expanded the Medicaid program under the Affordable Act.

In Pennsylvania in 2016, Medicaid expansion helped 124,000 people get treatment for their substance use disorder. Democratic Gov. Tom Wolf has said his state won’t be able to maintain Medicaid expansion if the federal government cuts back its share of spending. Without the program, many of those people would have limited access to help for their addiction.

Edley did some back-of-the-envelope math, and is really concerned at what he found.

If $45 billion is distributed to all 50 states by population, Pennsylvania would get about $1.8 billion, spread out over nine years. Depending on other variables, that could range from somewhere between $1,000 to $2,000 per person per year who might need treatment, based on how many people got treatment under expanded Medicaid in Pennsylvania last year.

By contrast, one year of maintenance treatment with methadone costs about $4,700 per year, according to theÌý. Methadone is an evidence-based treatment that makes it possible for a person with opioid addiction to work and lead a normal life.

But the cuts to Medicaid would amount to billions of lost dollars in Pennsylvania.

The state says it can’t make up the difference. So, many of the people who get opioid treatment through Medicaid could lose coverage and then turn to the grant that’s specifically meant for opioid treatment.

And, like any chronic disease, opioid treatment takes many steps — medication and, perhaps, a lifetime of management.

“Your typical individual doesn’t get treatment right in 10 days on their first try,” said Jennifer Smith, Pennsylvania’s acting secretary for the Department of Drug and Alcohol Programs.

“[The funding] doesn’t even come close. Doesn’t even come close,” Smith added. “We can piece together some solutions that might help get us a little closer to where we had been, but the end result is more people are going to die.”

Every day in Pennsylvania an average of 13 people die from a drug overdose.

And there also would be ripple effects from that drop in funding, Smith said —Ìý, bankruptcies because of treatment costs, and more work for each county’s department of children and youth services. Smith also worries that less treatment would mean more people would be desperate to support their habit.

“And they end up with a criminal record,” she said. “Nobody wants to hire them.”

So they drop out of the workforce.

Experts like Smith and Edley are concerned that if the federal government pulls back spending on Medicaid, the costs simply will be shifted somewhere else.

“You stop funding for [treatment and] they don’t go away” said Edley. “People end up in emergency rooms. They end up in uncompensated care, homelessness. You talk to people in the criminal justice system — you see increased incarcerations.”

He expects that if the Senate GOP health bill is approved, lawmakers will have to come back to this issue in six months or a year.

“They’re going to be back at the drawing board,” Edley said, “realizing, ‘All right, that didn’t work, and there are too many people being hurt.'”

Edley and Deb Shoemaker, executive director of the Pennsylvania Psychiatric Society, also see a double standard with how the Senate GOP bill treats people who have a substance use disorder.

Shoemaker is very active on substance use issues in Pennsylvania, and said she often tries to personalize her pitch to lawmakers.

“Would you want to say, ‘Hey, I’m sorry that you have cancer but you can only get treatment once a week,’ or ‘you can only get dialysis once a week,'” she said, pointing to the disparity in the way the proposal treats substance abuse versus other physical conditions.

“So think about it that way,” she said. “Yes, [treatment for substance use disorder] is a cost, but in the long run, they’re healthier. They’re alive.”

Sen. Pat Toomey (R-Pa.) has defended the proposed cuts.

“If it’s not worth it to the state to buy this coverage at 43 cents on the dollar [about what the state contributes to non-expansion Medicaid recipients], then how is it worth it to those very same taxpayers — who, at the end of the day, have to provide the funding for the federal program — why is it worth it to them to pay 90 cents on the dollar? It just doesn’t make sense,” he told NPR inÌý.

In a written statement, Toomey has said “fighting the scourge of opioid and heroin abuse remains a top priority of mine.” His office also says current Medicaid funding is unsustainable.

An earlier version of the bill included just $2 billion in grants for substance use disorder treatment. Senate GOP leaders included the $45 billion as a concession to moderate Republicans like Sen. Rob Portman of Ohio and Sen. Shelley Moore Capito of West Virginia, who represent states that have been hit particularly hard by the crisis.

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Charlene Yurgaitis is one of the people who’s been helped. She’s 35 and lives in Lancaster, Pa., and once supervised 17 people at an insurance company. But when some college students moved in next door to her about a decade ago, she started doing oxycontin with them. Then she moved onto heroin and harder drugs.

Earlier this year, Yurgaitis finally had enough of that life and went into recovery. It’s been difficult.

“I’ve been doing everything that I can possibly do to stop using,” she said. “My normal thought is to just do it. Nobody will ever know.”

To support her determination to stay sober, Yurgaitis gets a monthly shot of , also known as naltrexone.

“That stops me,” she said.

Pennsylvania expanded Medicaid under the Affordable Care Act, and the state pays no more than 10 percent of the bills for the people who gained coverage under the expansion; federal funds contribute the other 90 percent. Toomey says states should have to pay a higher share.

“If it’s not worth it to the state to buy this coverage at 43 cents on the dollar [about what the state contributes to non-expansion Medicaid recipients], then how is it worth it to those very same taxpayers — who, at the end of the day, have to provide the funding for the federal program — why is it worth it to them to pay 90 cents on the dollar? It just doesn’t make sense,” Toomey said.

If federal Medicaid money gets cut, that would leave states to either fill in the financial gap, limit access to care or drop some people’s coverage.

At a clinic in Harrisburg, Dr. Sarah Kawasaki said recovering from opioid addiction is so physically difficult that people need access to medication like naltrexone to help them break free.

If they can’t get that medicine, she said, “I think that by necessity, they would probably have to go back to using heroin or any other medications they could find on the street to avoid getting sick. And I would worry about that.”

If Medicaid funding is reduced, Kawasaki said she expects more people to die from overdoses, and predicts a rise in hepatitis C and HIV infections because of dirty needles.

Yurgaitis, the patient in recovery, gets emotional thinking about the potential cuts.

“Why are you trying to change something that’s working? You know, that’s what I don’t understand,” she said. “If I don’t have those places to go to, I don’t have anything else. I need to have that safe place to go to, and when I’m in my counseling session, that’s my safe place. That’s where I can unleash my demons, and clear my head out.”

Yurgaitis hopes she’ll be able to get treatment for years to come, so that at some point she can go back to work — perhaps helping other people recover from addiction.

This story is part of a partnership that includes , and Kaiser Health News.

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The couple spent December trying to decide whether to buy health insurance or skip it for 2017. They voted for Trump because they were fed up with how much they are paying for health insurance.

In mid-December in the couple’s kitchen, Abra was sizing up their health insurance options. She showed off a thick notebook, along with a file folder with policy documents and notes piled as high as a stack of pancakes. “Don’t touch my paperwork — don’t even try to touch it,” Abra joked to Matt. “I get so stressed out about it. I’ll not pick one until the very last minute, like that deadline day.”

Matt makes good money, but he usually gets laid off in the winter when construction slows down. For the past few years, he and Abra have bought coverage on Healthcare.gov, the Affordable Care Act exchange.

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He’s warm and open as he talks about his past few years. HeÌýstarted using drugs like Xanax and Valium during his freshman year of high school, and at age 18, Casanova turned to heroin. About two years later, the rehab shuffle began.

“I relapsed and then I was just getting high. And then I went to treatment again in February of 2015,” said Casanova. “Then I relapsed again and went back to treatment.”

Now 23, Casanova hasÌýsuffered and caused suffering with his addiction. His criminal record is long, and he has hurt people close to him. By his ownÌýcount, he has been through eight stays in inpatient rehabs.

“I did 30 days, and after that I came here,” he concludes, talking about his latest visit. Earlier stints ranged from about 18 to 45 days.

A month’s stay is typicalÌýforÌýpeople who go to an inpatient facility to treat drug or alcohol addiction.

But why?

“As far as I know, there’s nothing magical about 28 days,” saidÌý, director of the Center for Substance Abuse Treatment atÌý, the federal agency that studies treatment services.

“It certainly is not scientifically based,” she said. “I live in Minnesota where the model was developed and a lot of treatment across the country really stemmed from that.”

Fletcher saidÌýthe lateÌýÌýwas one of the primary architects of the “Minnesota model,” which became the prevailing treatment protocol for addiction specialists. At aÌýÌýin Minnesota in the 1950s, Anderson saw alcoholics living in locked wards, leaving only to be put to work on a farm.

To find a path for them to get sober and leave the hospital, he came up with the 28-day model. Later Anderson became the president of what is now theÌý.

Marvin Ventrell, executive director of theÌý,Ìýhas studied the model’s history. He says the month-long standard comes from the notion that when “someone is suffering from addiction — and in the days that this began, we’re pretty much talking about alcoholism — it made sense to people that it took about four weeks to stabilize somebody.”

Later, Ventrell said, “it became the norm because the insurance industry was willing to pay for that period of time.”

The model is being used to treat opioid addiction, even though recovering from addiction to those powerful drugs may be quite different from recovery from alcoholism.

Ventrell acknowledgedÌýthere isn’t enough research about the most effective length for an inpatient stay for opioid addiction.

“Treatment centers have to step up and say, ‘Just like cancer or heart disease, we’re going to measure our outcomes and show them to you,'” he said.

The federal government estimates spending on treatment for all substance abuse will hit a high ofÌýÌýby 2020. Some people pay tens of thousands of dollars out-of-pocket, desperately hoping inpatient treatment will work.

But there’sÌýÌýthatÌýÌýwith theÌýÌýor Suboxone can help those addicted by relieving symptoms of withdrawal and reducing cravings. It is especially effective when paired with strong outpatient counseling and other support.

Fletcher said it’s important for treatment to move away from the default month-long model.

That may be enough for some people, she said, but it “isn’t the case for most people. It’s like any other chronic disorder, it waxes and wanes.”

For his part, Casanova said he preferred longer stays because it gave him more time to learn from other patients in a supportive environment.

After aÌýrecent relapse, he had to serve some jail time. But he’s back in the recovery house, and hoping to soon make the leap to the next stage — a house with more independence.

This story is part of a partnership that includes , and Kaiser Health News.

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Many states — including some that have been hardest hit by the opioid crisis — don’t know how many of their youngest residents each year are born physically dependent on those drugs.

Pennsylvania is one of those states. , head of Pennsylvania’s Department of Human Services, calls the information he’s working with “reasonably good.”

“Data is never pristine when you’re dealing with 2.7 million people,” he said. “Do I think it gives you a good picture of the issues that are out there? Yes.”

Between 2013 and 2014, about 3,700 babies on Medicaid in Pennsylvania were born with neonatal abstinence syndrome, Dallas said. The statistics show that 31 died before their first birthday — and neonatal abstinence syndrome likely played a role in at least some of those deaths.

But it’s not all the data Dallas would like to have. The statistics are two years old, he said, and only deal with babies who are covered by Medicaid, the government’s health insurance for the poor and disabled. That’s just a slice of Pennsylvania’s nearly 13 million people. More comprehensive, statewide numbers, he said, would have to come from Pennsylvania’s Department of Health — and that agency isn’t keeping track.

Cuddling or rocking the babies nearly nonstop is key to successful treatment, Wolf said, along with adjusting medication doses frequently in the first 48 hours of the child’s life, to wean these newborns off opioids with as little discomfort as possible.

Each infant’s stay in the hospital can stretch past two or three weeks, and can cost $10,000 or much more. Then the babies need follow-up visits.

Pediatricians say that if the right agencies get real-time information, the babies areÌý, and it’s more likely that hidden roots of the epidemic can be identified and addressed.

To make good decisions, health officials need basic information: Which infants are affected? How many, where, and why?

Pennsylvania might look to Tennessee’s tracking efforts. Tennessee reacted quickly when doctors started seeing a lot more cases of neonatal abstinence syndrome in 2012, recalledÌý, a pediatrician and public health specialist with the Tennessee’s Department of Health.

“We were hearing from hospitals across the state, that they were really, really full,” Warren said, “and in some cases, bursting at the seams.”

It’s now mandatory for doctors and hospitals to report cases of neonatal abstinence syndrome within 30 days, and Tennessee made it simple for them to do so.

“If you’ve ordered from Amazon or an online service and you’ve been able to do that, you can navigate this system with ease,” Warren said. “And truly, at the end of it, you click ‘submit’ and that case is reported to us at the Department of Health.”

The data that started rolling into Tennessee shattered a number of stereotypes, Warren found.

“I think sometimes there’s a tendency to say these are just those moms who are using illicit drugs or buying those drugs on the street,” he said. “But what the surveillance system has actually allowed us to see, is that, in the majority of our cases, Mom is getting at least one substance that is prescribed to her by a health care provider.”

As a result, the state alerted doctors to the issue, recommending they try to change their prescribing habits, and more often offer alternatives to opioids, especially to pregnant patients. The evidence-based shift in prescribing recommendations only came about because health officials had solid data they could share.

When a public health crisis emerges, real-time data are especially important. Policymakers can use the information just as Tennessee did — to tailor solutions to the root causes. Otherwise solutions may miss the mark, or, if the data are old, come after the problem has festered and grown.

Pennsylvania Department of Human Services Secretary Ted Dallas acknowledged his state is missing out.

“If we had better data, generally, my theory would be we could make better decisions,” he said.

Just as I was wrapping up this story, Pennsylvania’s health department called. Starting in July, officials there plan to start collecting data about all babies who are born dependent on opioids.

The system to collect the information is still being developed, but neonatal abstinence syndrome will be added to the Pennsylvania’s list of , meaning that every time doctors diagnose a baby with the condition, they’ll be required to the state.

This story is the fourthÌýin our four-part series, “Treating the Tiniest Opioid Patients,”Ìýa collaboration produced by Kaiser Health News, NPR andÌýlocal NPR member stations.

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Now, in a dramatic shift, the federal government is considering chipping in, too. The agency that governs Medicaid is proposing to cover 15 days of inpatient rehab per month for anyone enrolled in a .

But in Pennsylvania, those who work in the addiction field are not happy with that news. While it’s a good start, they say, 15 days of residential care isn’t nearly enough time for many people addicted to heroin, opioids, alcohol or other drugs to get clean and stay that way.

“Where they came up with the 15 days, I don’t know, but it’s not based on research,” saidÌý, head of the nonprofit treatment program Gaudenzia, which serves about 20,000 patients a year in Pennsylvania, Maryland and Delaware. In just 15 days, he said, you can’t expect to achieve a positive outcome.

“Do you know how expensive that would be, with no outcome?” Harle said. “We wouldn’t want to do it. We would not want to do it.”

Up until now, the state of Pennsylvania has used an obscure provision in the federal law to get federal reimbursement for much longer rehab stays for some people. Pennsylvania officials worry that the loophole will likely go away if the new Medicaid proposal is enacted.

In its , the National Institute on Drug Abuse says:

Individuals progress through drug addiction treatment at various rates, so there is no predetermined length of treatment. However, research has shown unequivocally that good outcomes are contingent on adequate treatment length.

, a professor at Boston University’s Clinical Addiction research unit, saidÌýthere’s been little funding for research that gets at the optimal length of an inpatient stay, in terms of effectiveness. And in the absence of good data, private insurance plans are all over the map in terms of how many inpatient days they will cover.

“Maybe it’s half a loaf for someone who needs 30 days,” saidÌýMann, who now works for Manatt Health Solutions, a law and consulting firm. “But it’s half a loaf of new federal dollars that could be available.”

Chris Benedetto, a 30-year-old who started using heroin when he was 13 years old, in Scranton, Pennsylvania, says he needed much more than 15 or even 30 days in rehab to kick his drug habit.

“I was really young,” Benedetto said. “I actually was arrested in school.” He bounced from school to probation to jail to rehabilitation. Benedetto saidÌýhe knew how to play the treatment game, fooling his family and others that he was doing well, even when he was still using drugs, or about to slip.

“I’m good at putting on that mask,” he said.

Eventually, in 2009, Benedetto got into an inpatient facility and stayed there for five months of supportive therapy, thanks to Pennsylvania’s looser interpretation of federal restrictions. Benedetto saidÌýthe longer rehab stay is what finally enabled him to kick his drug habit.

“For that amount of time, in that environment, I will show up,” Benedetto said. He’s now been clean for more than five years and works as an assistant to an addiction counselor.

Samet saidÌýhe likes the idea that Medicaid will start covering at least some inpatient treatment. But he also wants to make sure that doctors and patients consider outpatient programs, which can be highly effective for some people and are less expensive.

“It’s the challenge of public policy,” he said. I think this is why the feds go into this kind of work — because a lot of good can be done.” But, he added, he doesn’t want residential programs to become the default style of treatment, just because the option is now available.

“The risk of it being taken advantage of is real,” by both patients and providers, Samet said.

Mann saidÌýthe proposed change still allows state governments to pay for as much treatment as they think a patient needs — just as they have been doing all along.

“The state and the locals are completely free to finance that stay if they think it’s the right place for somebody to be,” she said.

And if they’re still not happy, she added, states can put together to apply for more federal money.

This story is part of a partnership that includes , and Kaiser Health News.

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