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Brandi, 30, depends on Medicaid expansion for opioid addiction medication. Courtesty of Brandi

For much of her twenties, Brandi was in a bad place: staying up all night to sniff OxyContin and dealing marijuana from her apartment in a dingy Rochester, New York, housing project to feed her insatiable painkiller addiction. Drug users were always coming in and out of her place, a nearly empty one-bedroom that smelled of cat pee. Dinners consisted of instant noodles or McDonald’s, where a friend would trade chicken nuggets for a gram of marijuana. “Any money would go directly into buying pills,” said Brandi, who requested to go by her first name.

A 30-year-old with piercing green eyes, Brandi hasn’t used drugs since January of 2015, when she started taking buprenorphine, a medication that treats opioid addiction. She lives in a townhouse with her fiancé, also a former drug user, and their cats. Thanks to the medications, she says, “both of our lives are a total 180 from what they used to be.” She works the night shift at the supermarket during the week, visits family on Sundays, occasionally splurges at Bonefish Grill or TGI Friday’s. Each day, the couple takes their medications: buprenorphine for her, methadone for him. She’s been reading the news about the potential repeal of Obamacare and Trump’s budget proposals, and she finds it “all terrifying”—because if Obamacare is repealed and Medicaid expansion is cut, she, like hundreds of thousands of Americans, could lose her ability to pay for buprenorphine. Without the medication, she worries, she’ll fall back into the cycle of drug abuse.

She’s been there before. Brandi first got her life back on track when she went on buprenorphine as a 22-year-old straight out of rehab. She did well for a few years: She got a job as a cashier, moved into a nicer place, started buying groceries and brushing her hair. But when she was 26, just before New York expanded Medicaid, she was kicked off her mom’s health insurance. Knowing she didn’t make nearly enough to be able to pay for her own coverage, she stretched out her buprenorphine supply as long as she could, stockpiling what she had in the months before her 26th birthday and weaning her dose down. But eventually there was none left, and within two weeks, she says, “I found pills and it was just done and over with.” She used for nearly two years before going back to rehab and realizing that, with Medicaid expansion, she could pay for the medication once again.

On the campaign trail, President Donald Trump promised to “spend the money” to tackle the nation’s opioid epidemic. Yet drug policy experts fear that passage of the American Health Care Act, also known as Trumpcare, would cut off former drug users from their addiction medications, making an already devastating epidemic even worse. That’s largely because the AHCA would dramatically cut funding for Medicaid—the federal program that provides health insurance to poor Americans and the largest federal funder of addiction services. It would also phase out Medicaid expansion, which expanded the eligibility requirements of the publicly-funded insurance program to include those who earn up to 138 percent of the federal poverty level in the 31 states that opted to expand it. Cuts to Medicaid would hurt most in many of the states that helped vote Trump in: in places like Ohio, West Virginia, and Kentucky, Medicaid pays for at least forty percent of buprenorphine prescriptions.

“People talk about being committed to doing something about drugs,” says Keith Humphreys, a Stanford University psychiatry professor who advised the Obama administration on drug policy. But “their Medicaid cuts would swamp anything else they could do.”

Nearly three million Americans with a substance use disorder, including more than 200,000 who were addicted to opioids, would lose some or all of their insurance coverage if Obamacare is repealed, according to an analysis by researchers Richard Frank of Harvard Medical School and Sherry Glied of New York University. In a report released last week, the Congressional Budget Office found that if the AHCA passes, addiction treatment services “could increase by thousands of dollars in a given year” for those who aren’t covered by insurance through their employers.

Both Humphreys and Frank worry that many politicians don’t understand just how critical addiction medications can be. Indeed, last month, Health and Human Services Secretary Tom Price said addiction medications were “substituting one opioid for another,” contradicting years of research by the agency he now runs. Buprenorphine and methadone, the two most common such medications, work by binding to the brain’s opioid receptors and decreasing craving for more harmful opioids like painkillers or heroin—without inducing the high. They come with some side effects: It’s still possible to abuse the medications, and coming off of them too quickly can result in a painful process similar to withdrawing from other opioids.

But a wealth of research has found that addiction medications like buprenorphine help curb opioid addiction and prevent relapse and overdose. Organizations from the Centers for Disease Control to the Substance Abuse and Mental Health Administration to the World Health Organization support access to the medications for opioid users. “I don’t think that there are any areas where the data is shaky,” said Dr. Nora Volkow, the head of the National Institutes on Drug Abuse, part of the National Institutes of Health, to STAT news. “It clearly shows better outcomes with medication-assisted therapy than without it.”

Brandi may be lucky: If the AHCA does pass, there’s still a chance that her home state of New York would find a way to fund treatment for people in her position. But many Americans may not be so fortunate. As Humphreys told me this spring, without Obamacare, “We’re back where we were before: bad access, low quality of care, and a lot of patients being turned away.”

For now, Brandi plans to keep taking the medication for as long as she can. “People I work with right now would never in a bajillion years picture me as a drug addict—ever.” The impact of the medication is “like night and day,” she said—and going back to the days without coverage would amount to “a nightmare.”

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Brandi Is Terrified That She’ll Fall Back Into Addiction if Obamacare Is Repealed