In the past two years, deaths related to drug overdoses have contributed to an unprecedented decline in life expectancy in the United States. In 2017, there were more than 70,000 drug-related deaths, accounting for more fatalities than HIV, auto accidents, and gun violence combined. The opioid epidemic has played a major role in the escalation of these deaths and was designated a National Public Health Emergency in 2017.
Next week the United States Senate is poised to pass its sweeping response to the opioid crisis. The bipartisan legislation includes more than 70 individual bills that fall within the jurisdiction of five Senate committees (Health, Education, Labor, and Pensions; Finance; Judiciary; Commerce; and Banking). The size and scope of the legislation is a testament to the problem’s complexity and the need for multifaceted solutions, as well as the political pressure felt on both sides of the aisle.
The Senate bill, the Opioid Crisis Review Act (OCRA) of 2018, offers state and local resources and flexibility for combating the epidemic. The legislation provides for expanded treatment and recovery options, including some changes to Medicaid and Medicare, and promotes prevention by addressing prescriber practices and patient and caregiver education. It takes steps to accelerate and support research and innovation; a number of provisions aim to enhance data-collection capacities and the secure tracking of drug use and trends. Other provisions address drug packaging and safety, law enforcement, and the reauthorization of the Office of National Drug Control Policy and Department of Justice funding for drug courts.
Recovery and treatment is a significant area of focus, with provisions establishing comprehensive opioid recovery centers and expanding access to medication-assisted treatment. There is emphasis on family-focused treatment and recovery and assistance for youth.
To support the state response, the bill provides $500 million a year through 2021 to reauthorize and build on a state-targeted grant program created under the 21st Century Cures Act. The Cures Act funding has been used by states to expand methadone treatment, provide medication-assisted treatment in criminal justice settings, connect individuals to community-based treatment, support an opioid crisis helpline, and expand the availability of naloxone, a medication used to reverse overdoses.
Additional funding could further enhance these efforts and support prevention and treatment programs aimed at youth, culturally appropriate services for disproportionately affected groups like American Indians and Alaska Natives, data-sharing between public health and law enforcement, and flexibility to quickly pivot to emerging issues, such as spikes in overdose deaths linked to fentanyl.
Providing such resources is critical as the epidemic has had a very real impact on state and local budgets. In 2016, Medicaid, which is jointly funded by federal and state governments, paid 24 percent of all costs associated with medication-assisted treatment; in the hardest-hit states, Medicaid paid 41 percent of these costs. Governors from across the country, regardless of political affiliation, have been united in their calls for the enactment of comprehensive solutions for individuals and families coping with and recovering from substance-use disorders.
The legislation does make some changes to how Medicaid resources can be used to combat the epidemic. One key provision included in the House bill, passed in June (but not in the Senate bill), is lifting the exclusion for the institutions for mental disease (IMD), which has historically prohibited states from using federal Medicaid dollars to pay for mental health treatment in a facility with more than 16 inpatient beds. The policy was originally constructed in an attempt to move treatment away from psychiatric hospital wards. More recently, experts have raised questions about the impact this policy is having on adult Medicaid beneficiaries’ access to inpatient mental health services.
The unprecedented increase in drug-related deaths and the resulting demand for substance use disorder and mental health treatment options have led many to call for this prohibition to be lifted. The legislation passed in the House allows a state Medicaid program to lift the ban for adult beneficiaries with opioid use disorders. This will permit Medicaid to pay for up to 30 days of care per beneficiary per year until 2023. It’s expected that this provision will be negotiated when the House and Senate bills are conferenced.
The bill also includes provisions designed to reduce the risk of opioid use disorder by people in Medicare. It expands the use of telehealth services for treatment of opioid use and other substance disorders and mandates a comprehensive screening for opioid use disorder in the “Welcome to Medicare” visit. The legislation also requires that physicians and other providers use electronic prescribing for controlled substances to improve tracking.
On the research and innovation front, the bill includes provisions that allow for the discovery and development of new nonaddictive painkillers, call for studies to address the effects on the economy and workforce, and improve pain management.
The next step for the legislation will involve negotiating differences between the Senate bill and the House bill. Final negotiations on bills of this size and magnitude are always delicate and fraught with opportunities for breakdown, but in this case, momentum is on the side of action. The scale of the epidemic and its impact on families, communities, and our nation are simply too great to ignore.