Politics: Trump's opioid commission's recommendations fly in the face of Republicans' healthcare overhaul plans
Experts are praising the plan, but Republicans could be a roadblock to some of the biggest solutions to the opioid crisis.
The report was received with cautious optimism by drug-policy advocates and experts.
Bradley Stein, a senior natural scientist at the Rand Corporation who studies substance-use disorders, called the commission's primarily public health-based solutions a "broad, multi-faceted" approach to the crisis.
Here are a few of the main recommendations (see the rest here):
- Declare a national emergency under the under the Public Health Service Act or the Stafford Act (which a former CDC head told the New York Times is usually for natural disasters).
- Mandate opioid-prescribing training for all physicians seeking or renewing a DEA license to handle controlled substances.
- Expand access to medication assisted treatment, considered the "gold standard" for opioid use disorder, through funding initiatives and requirements for access at all federal facilities.
- Expand access to naloxone, which reverses overdoses by getting it to all law enforcement and requiring it be prescribed with "high-risk opioid prescriptions."
But while many, like Stein, are "highly encouraged" by the report, some of the most critical recommendations fly in the face of established Republican policy goals on healthcare reform.
“The commission’s report highlights how out of step this administration has been [with policy experts] in responding to the opioid crisis and implementing a drug strategy," said Grant Smith, deputy director of national affairs at the Drug Policy Alliance, a nonprofit that advocates drug-law reform. "There hasn’t really been a strategy.”
Eliminating a 'federal disincentive' to treatment
The commission's lead recommendation, following calls for declaring a national emergency, calls for altering an obscure Medicaid rule that has been around since the 1960s.
The Institutions for Mental Diseases (IMD) exclusion rule prohibits the use of federal funds for Medicaid patients in residential mental health or substance use disorder treatment centers with more than 16 beds.
The rule is a major roadblock to expanding overloaded treatment centers in hard-hit states, said Deb Beck, the president of the Drug and Alcohol Service Providers Organization of Pennsylvania, a coalition of drug- and alcohol-abuse prevention, addiction treatment, and education programs and providers.
Changing the rule, which Beck called a “federal disincentive to fund treatment,” would allow treatment centers to gain critical funding from Medicaid as well as expand their facilities to become more cost-efficient.
"It’s very exciting," Beck told Business Insider of the Commission’s recommendation to eliminate the exclusion. "Anything would be an improvement" from the current situation.
Several Republican and Democratic senators introduced legislation in May to eliminate the rule. But, as the commission said, the process could be expedited should Trump empower Health and Human Services Secretary Tom Price to issue waivers to states.
But doing so would effectively expand the use of Medicaid to treat those suffering from opioid use disorder, drawing more funds and resulting in more access to sorely needed inpatient treatment.
"It opens up the existing infrastructure and gives patients access to a far broader range of treatment" by allowing Medicaid to pay for treatment in more settings, Stein said.
Expanding Medicaid is a striking contrast to the administration's efforts to repeal the Affordable Care Act, the law better known as Obamacare.
A key tenet of both Senate and House Republicans’ plans to repeal Obamacare was a rollback of Medicaid and the expansion established under the law, which established that any adult living under 138% of the federal poverty level was eligible for states choosing to participate.
Overall, 1.29 million people are receiving treatment for substance use disorders or mental illnesses thanks to the Medicaid expansion, according to research conducted by Harvard Medical School Health Economics professor Richard Frank and New York University dean Sherry Glied. About 220,000 of those people are receiving treatment for opioid abuse.
"It’s ironic," Smith said. "It underscores how much the administration has been going in the wrong direction on healthcare … and mitigating the crisis."
Similarly, the commission calls for ramping up enforcement of the Mental Health Parity and Addiction Equity Act, which established that health insurers must provide mental-health or substance-use-disorder coverage equivalent to coverage for physical ailments. The law has been on the books since 2008 but still suffers from noncompliance.
That recommendation, too, flies in the face of GOP efforts on healthcare reform. Both Senate and House plans contained provisions to waive Obamacare's so-called essential health benefits, which mandate that all plans must cover 10 basic types of care.
If that happened, substance-abuse treatment was expected to be the benefit "most at risk" to be cut, Christine Eibner, a health economist for the Rand Corporation, told Business Insider in May.
An analysis conducted by Eibner and Christopher Whaley, a policy researcher at Rand, found that in places that waive substance-treatment benefits, the out-of-pocket cost for consumers who use those benefits could rise by $1,333 a year. For "high-need" consumers, like those who need an in-patient stay at a treatment facility, out-of-pocket costs could rise to $12,261 a year, the report said.
Wait and see
Though the recommendations have been lauded by many experts, nothing has yet been implemented and a final report isn't due until October 1. Assuming the final report isn't delayed — as the preliminary report was — it would still be nearly nine months before a plan on the issue even begins.
That's striking, considering many of the commission's proposed solutions have been bandied about both by experts and tuned-in politicians for years. A surgeon general's report released last year made many of the same reccomendations.
And as the commission's report said, the most recent data from the Centers for Disease Control and Prevention estimates that 142 Americans die every day from a drug overdose.
Given that many of the recommendations would require funding or legislation from a Congress divided not just between Democrats and Republicans, but amongst factions of Republicans as well, drug policy watchers are in a “wait and see” mode.
Still, Stein said there is reason to be optimistic.
"The opioid crisis is a bipartisan issue. It affects everyone throughout the country," said Stein. "The recommendations offer a whole variety of options that people have talked about. I hope that we can get bipartisan agreement to get some of these in place."
The commission itself, which was created by President Donald Trump in March, is bipartisan. New Jersey Gov. Chris Christie heads the commission, and it also includes Massachusetts Gov. Charlie Baker, a Republican; North Carolina Gov. Roy Cooper, a Democrat; Harvard Medical School professor Bertha Madras; and Patrick Kennedy, the former Democratic congressman from Rhode Island.
A good bellwether of how the Trump administration is proceeding with the recommendations may be how it handles enforcement of mental-health parity in health insurance. As Stein noted, most of the recommendations require legislation to effectively enact, but the law on mental-health parity was passed nearly a decade ago.
"It just needs to be enforced," Stein said.
Similarly, Beck said, the IMD exclusion rule could be eliminated at least in part by executive action from the president.