As the Republican-led 115th Congress gets to work in Washington, Americans are asking what’s in store for addiction policy, especially concerning opioid issues. The incoming administration and Congressional leaders have a bold agenda for health care reform, but many of the details with big impacts on topics like who can access treatment for opioid use disorder and even what treatment looks like, still remain to be seen. From what’s been said and teed up for action so far, it looks like there will be several opportunities for further progress on the opioid epidemic as well as a few threats to the progress we’ve already made.
In 2016, the passage of the Comprehensive Addiction and Recovery Act (CARA) and the inclusion of $1 billion for opioid addiction treatment in the 21st Century Cures bill were possible legislative wins due to this issue’s strong bipartisan support. The epidemiology of the opioid addiction epidemic – hitting both red states and blue states hard – means that neither party can turn a blind eye to the suffering it’s causing. They see its impact every time they return home.
We also have a fresh springboard for our work, The Surgeon General’s Report on Alcohol, Drugs and Health, released in November. The report marked a major advancement in the public understanding and dialogue about addiction by framing it – correctly – in terms of individual and public health. By reviewing and collecting all the neuroscience and health services research we have on addiction in one place, and giving it the Surgeon General’s stamp of approval, the report has given our field an even stronger foundation and justification for continued improvement to our treatment system.
Of course, we also know that expanding access to quality addiction care is the cost-effective thing to do for our health system and economy. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), investing $1 in mental health care and addiction treatment yields returns to the tune of $3 to $5 in new economic contributions and years of health life. And the Surgeon General’s report noted that every dollar spent on addiction treatment saves $4 in health care costs and $7 in criminal justice costs. People who can access treatment and enter recovery are able to return to productive work, take care of their families, contribute to their communities, and avoid further criminal justice involvement. Those are the kind of outcomes that will make America great again.
Yet, despite bipartisan support on the issue, access to care is now at risk with the pledge to repeal and replace the Affordable Care Act (ACA). The ACA mandates that new small group and individual market plans, as well as plans offered to individuals as part of Medicaid expansion, offer addiction treatment benefits. It also expanded the reach of the 2008 Mental Health Parity and Addiction Equity Act to the individual and small group markets, meaning that many more individuals could access mental health and addiction treatment services in the same way they do general medical care. Rolling back those assurances of non-discriminatory access to addiction treatment would be devastating in the middle of an epidemic.
As an example, a recent article in USA Today analyzed the effect of ACA repeal on mental health care and addiction treatment access, noting that according to data from SAMSHA, previously uninsured individual eligible for coverage under the ACA’s Medicaid expansion had a higher prevalence of mental illness and addiction. This offered examples of states that would be particularly hard hit by repeal. In one of those states, my home state of Kentucky, overdose deaths rose 17 percent between 2014 and 2015. While Kentucky did expand Medicaid under the ACA, we still have inadequate evidence-based treatment infrastructure to provide care, and remuneration for providers is too low to encourage clinicians to include addiction treatment in their practices. Any new reforms must not only protect access but should include incentives for strategies and approaches that have demonstrated good outcomes, not just sustain funding for more of what is not working.
With the looming possibility of coverage losses or changes in patient protections or benefit requirements, the American Society of Addiction Medicine (ASAM) is working with the American Psychiatric Association (APA), the American Academy of Addiction Psychiatry (AAAP) and the American Osteopathic Academy of Addiction Medicine (AOAAM) to call for preservation of non-discriminatory access to mental health care and addiction treatment services in any plan to replace the ACA.
While the Republicans’ ACA-replacement plan may indeed preserve the gains in access to addiction treatment that the ACA included, a bigger challenge will be preserving and even expanding access under efforts to reform Medicaid. Proposals to block grant or otherwise cap funding for Medicaid are very concerning. We already know that Medicaid beneficiaries can struggle to access all levels of recommended care for addiction, not to mention medications approved by the Food and Drug Administration to treat addiction involving opioid use. We also know of anecdotal reports that indicate Medicaid payment for addiction treatment in many states is too low to incentivize clinicians to provide those services. Limits on federal funding would only exacerbate the access issues we already see.
The opioid epidemic shows no signs of stopping. We certainly have no shortage of work to do this year to fight back. We plan to work hard with the 115th Congress as they tackle their ambitious health care agenda to make sure that patients needing treatment for opioid addiction can access quality care.
Dr. Kelly Clark is President-elect of American Society of Addiction Medicine. Representing over 4300 physicians specializing in Addiction Medicine. Dr. Clark is board certified in both addiction medicine and psychiatry and has practiced extensively in private practice, emergency, acute, sub-acute, and chronic institutions; community, county, state, federal sites; and voluntary, involuntary and penal settings.