Dreamland by Sam Quinones talks a little about the economics of America’s opiate epidemic. On one side was the evil Purdue Pharma, which collected tens of billions of dollars in revenue for OxyContin. But who was on the other side? Most drug addicts don’t have a lot of money. The answer turns out to be that you the taxpayer were on the other side:
And so the Medicaid card entered our story. The card provides health insurance through Medicaid, and part of that insurance pays for medicine—whatever pills a doctor deems that the insured patient needs. Among those who receive Medicaid cards are people on state welfare or on a federal disability program known as SSI (Supplemental Security Income). In Scioto County, annual SSI applicants almost doubled in the decade ending 2008—from 870 to 1,600. An untrained observer of Portsmouth’s bleak economic landscape might have understood; jobs, after all, were scarce. People needed money and that check helped. That was true, but by then pills and pain clinics had altered the classic welfare calculus: It wasn’t the monthly SSI check people cared so much about; rather, they wanted the Medicaid card that came with it. If you could get a prescription from a willing doctor—and Portsmouth had plenty of those—the Medicaid health insurance cards paid for that prescription every month. For a three-dollar Medicaid co-pay, therefore, an addict got pills priced at a thousand dollars, with the difference paid for by U.S. and state taxpayers. A user could turn around and sell those pills, obtained for that three-dollar co-pay, for as much as ten thousand dollars on the street.
Combined with pill mills, the Medicaid card scam allowed prolific quantities of prescription medication to hit the streets. The more pills that sloshed around the region, the more people grew addicted, and the bigger the business grew, and the more people died. The Oxy black market might never have spread and deepened so quickly had addicts been forced to pay for all those pills with cash at market prices.
“Twenty years ago they were drawing SSDI and full workers’ comp—say, eighteen hundred dollars a month,” said Brent Turner, the commonwealth prosecutor for that part of eastern Kentucky, whose career began in 2000, just as OxyContin became a business for impoverished families across Appalachia. “The checks were higher because they’d go work in the mines and pay into their [SSDI] disability. Now we’ve got people who aren’t working, who are drawing SSI, maybe five hundred dollars a month. We’ve got people who have kids and wives and the whole family trying to survive on five hundred dollars. I’m not making excuses for them. Many haven’t had a job. But it is what it is. When you don’t work, and never have had a job, or paid into the system, you don’t qualify for much. We have boatloads of people who qualify only for SSI. You wouldn’t believe the number of people we see, twenty or thirty years old, have never had a job and are drawing checks since they were teenagers. “That was one of the driving factors when pills exploded. We can talk morality all day long, but if you’re drawing five hundred dollars a month and you have a Medicaid card that allows you to get a monthly supply of pills worth several thousand dollars, you’re going to sell your pills.”
Other families, though, had been unemployed for generations and on government assistance. Up to then, they had resorted to small-time criminal activities, but remained minor irritants in holler life. When Oxy came along, however, the sorriest families were transformed into dominant and unruly forces.
Back home, [the pill dealer] made a killing on the first of the month when the SSI checks arrived in Floyd County.
He watched capable young people get themselves declared “simple” to get SSI and the Medicaid card, and thus access to pills.
The author elsewhere praises liberal Democrats and condemns conservative Republicans, so I don’t think the above passages were driven by a bias against government welfare programs. And in fact the author directly praises anyone working for the government as implicitly altruistic:
As I tried to chart the spread of the opiate epidemic, one thing dawned on me: Other than addicts and traffickers, most of the people I was speaking to were government workers. They were the only ones I saw fighting this scourge. We’ve seen a demonization of government and the exaltation of the free market in America over the previous thirty years. But here was a story where the battle against the free market’s worst effects was taken on mostly by anonymous public employees. These were local cops like Dennis Chavez and Jes Sandoval, prosecutors like Kathleen Bickers, federal agents like Jim Kuykendall and Rock Stone, coroners like Terry Johnson, public nurses like Lisa Roberts, scientists at the Centers for Disease Control, judges like Seth Norman, state pharmacists like Jaymie Mai, and epidemiologists like Jennifer Sabel and Ed Socie
The author lives in California so he is presumably aware that government workers do get paid (examples). He doesn’t explain why a police officer, DEA agent, prosecutor, judge, or prison guard would be upset to have a job, steady paycheck, and pension due to the existence of opiate addicts.