The Health 202: Trump's budget shows he is serious about tackling the opioid crisis

Tuesday , February 13, 2018 - 11:20 AM

Paige Winfield Cunningham

(c) 2018, The Washington Post.

Many parts of President Donald Trump’s budget proposal are just pie-in-the-sky wishes. But the proposal unveiled yesterday does contain this: some strong hints about how the administration might tackle the burgeoning opioid epidemic with $6 billion in new funding that is already in hand.

The budget proposal the White House released contains Trump’s first official request for more opioid abuse funding, which is significant. It’s possible to glean some clues about how Health and Human Services Secretary Alex Azar views the sweeping problem and where he might put billions of newly appropriated dollars provided by Congress in last week’s budget agreement.

Congress’ spending bill - which lays out how the government will be funded for two years - contains few directives for how the opioids money should be spent, instead granting broad authority to the HHS secretary. But Trump’s proposal, which seeks nearly $17 billion in opioid-related spending in 2019, fleshes out more details about how the president and his appointees think the crisis should be tackled.

In other words, even though Congress doesn’t have to pass any part of Trump’s budget, the proposal is still relevant if you want a better picture of how the administration expects to combat opioid abuse. The report acknowledges the epidemic’s magnitude, noting there are now two-and-a-half times more overdose deaths than in 1999, and fatalities from heroin overdoses have tripled since 2010.

“This budget is profoundly significant because the [budget bill] came before and articulated priorities very congruent with the priorities in this budget,” Dan Mendelson, CEO of Avalere Health and former associate health director at the White House Office of Management and Budget during the Clinton administration, told The Washington Post.

Broadly, the budget says new opioid funding will “support efforts to prevent opioid abuse and help those who abuse opioids get access to overdose reversal drugs, treatment and recovery support services” and also bulk up prevention efforts and disrupt the supply of illicit drugs. Here are some specific ways the administration proposes to spend the dollars:

- Expand grants to states for prevention, treatment, and recovery support services.

- Expand Medicaid coverage of comprehensive and evidence-based medication-assisted treatment. The Centers for Medicare and Medicaid Services will issue guidance creating minimum standards for state “Drug Utilization Reviews” to reduce overprescribing and will require states to track and act on high prescribers and users of prescription drugs.

- Test and expand nationwide a Medicare bundled payment for community-based medication-assisted treatment, including reimbursement for methadone for the first time. Prevent prescription drug abuse in Medicare Part D by requiring plan participation in a program to prevent prescription drug abuse.

- Request $381 million for the Department of Veterans Affairs to reduce over reliance on opioids for pain management, promote the safe and effective use of opioid therapy, and to treat addiction.

- Request $12 million for the Justice Department for state-based prescription drug monitoring programs.

- Request $253 million for Customs and Border Protection’s National Targeting Center to better concentrate on illicit goods, including illicit drugs.

- Request an additional $31 million for the Drug Enforcement Administration to add eight new heroin enforcement teams and bolster staffing at field divisions.

- Request $500 million for the National Institutes of Health to support a public-private partnership with the pharmaceutical industry to develop prevention and treatments for addiction, overdose reversal, and nonaddictive pain therapies.

The budget’s mention of medication-assisted treatment was especially pleasing to Medicaid plans and health advocates, who have long fretted that drugs proved to be extremely helpful in treating addiction aren’t used nearly often enough by providers or covered by insurers.

“We are happy to see the White House and HHS address the opioids crisis, especially calling out medication-assisted therapy as an important tool to help those who are addicted, and that they enlist the help of Medicaid health plans to tackle these issues at the state level,” said Jeff Myers, president of Medicaid Health Plans of America.

But these advocates are still ambivalent about the budget proposal. That’s because it also incorporates a rollback of the Affordable Care Act’s Medicaid expansion, as well as suggests block-granting Medicaid and placing a per-person spending cap on it. Those are all moves that would sharply reduce future Medicaid spending and almost certainly reduce health coverage for many low-income Americans.

This in turn could work against combating drug abuse because Medicaid covers nearly four in 10 non-senior adults who are addicted to opioids, according to the Kaiser Family Foundation. That means that increasing access to addiction treatment while rolling back Medicaid could be the policy equivalent of cutting off your nose to spite your face.

“While I’m glad that the proposal requires Medicaid to cover medication-assisted treatment, its overall weakening of the Medicaid and Medicare programs will hurt Americans struggling to overcome substance use disorders,” said Gary Mendell, founder of the group Shatterproof.


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