On Thursday, February 28, 2019, the Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, held a hearing to discuss how federal funding has helped state and local governments tackle the opioid epidemic. Subcommittee Chairman Roy Blunt of Missouri explained that the hearing would help Congress to identify where funding should be directed and what strategies from individual states can perhaps be applied nationwide.
At the hearing, Subcommittee members heard from a panel of researchers as well as state and local experts. By and large, the witnesses emphasized the importance of maintaining Medicaid expansion and state flexibility in how federal support is used to ensure access to treatment. Members of the Subcommittee were in agreement that the states should continue to control their own funds and took time to discuss the “hub and spoke” model in Vermont. All witnesses also agreed that fentanyl and other addictive substances were causing the epidemic to evolve and stressed that future funding should be able to be broadly applied to all addiction services.
Opening Statements
In his opening statement, Chairman Blunt unequivocally stated that it is clear that, in spite of improving access to treatment and declining deaths, the opioid crisis is not over. He called for behavioral health issues to be treated like any other physical health issue to ensure addiction treatment include mental health services, as well as expanded surveillance to reduce the number of individuals who become addicted in the first place. He also asked that future solutions target better pain management and access to non-addictive pain medications or alternative treatments.
Ranking Member Patty Murray mentioned the annual cost of the opioid crisis, $500 billion, but also stated that it does not include the emotional cost the opioid crisis has brought to families and communities around the country. She said the costs of the epidemic are also seen in health providers treating babies born addicted to opioids, kids placed in foster care, parents who have lost children to an overdose, and veterans in chronic pain who struggle with addiction.
Witness Testimony
Mark Stringer, Director of the Missouri Department of Mental Health, explained his belief that bigger, longer-term investments are needed to make a significant impact on the opioid crisis. He also advocated for federal addiction initiatives to continue to perform work through state substance use agencies for flexibility.
Karen Cropsey, Psy.D., Conatser Turner Endowed Professor of Psychiatry at the University of Alabama at Birmingham, asked for expanded access to quality addiction treatment through increased reimbursement parity for addiction treatment and reduced regulations and cost to prescribe buprenorphine.
Charissa Fotinos, MD, MSc, Deputy Chief Medical Officer at Washington State Health Care Authority, opined that maintaining pre-existing protections and essential health benefits under the Affordable Care Act, as well as Medicaid expansion, was critical to fight the epidemic.
Beth Tanzman, MSW, Executive Director of the Vermont Blueprint for Health at the Department of Vermont Health Access, explained that the state treats those with opioid use disorder through a “hub and spoke” model to provide Medication Assisted Treatment (MAT), which has been replicated in other states due to its success. She pushed for solutions that require insurance to cover MAT, as well as primary care participation in MAT.
James Berry, DO, Associate Professor and Vice Chair, Director of Addiction Services for the Department of Behavioral Medicine and Psychiatry at West Virginia University, noted that addiction is a treatable condition and advocated for expanded access to evidence-based treatment. He also highlighted the importance of multifaceted solutions addressing the biologic, psychologic, social, and spiritual manifestations of the disease.
Daisy Pierce, PhD, Executive Director of Navigating Recovery of the Lakes Region, requested that the federal government commit to consistent, long-term funding support so that state resources can effectively plan and implement prevention and treatment programs. She stated that federal support should shift its focus to all substance addiction, and remain flexible to encourage innovative, targeted response.
Hearing Discussion
Medicaid Expansion
According to Dr. Fotinos, those being treated for addiction and covered by Medicaid in Washington were all considered part of the expansion population. She noted eliminating the expansion, and thereby their coverage, would increase the burden on hospitals, the criminal justice system, and child welfare system. Dr. Fotinos believes that eliminating the Medicaid expansion would start a cycle of increased health care costs. Ms. Tanzman also testified that 80 percent of those treated for opioid addiction in Vermont were covered under the Medicaid expansion, and that funding through Medicaid had been incredibly important to implement the home health program and support additional nurses and counselors. She noted that most commercial plans didn’t cover the “hub and spoke” model treatment and Medicaid resources were being stretched to include commercial-covered patients in the program.
CDC Guidelines
The CDC guidelines were a hot topic of discussion on both sides of the aisle, with Senator Lamar Alexander questioning them, saying that leading doctors offer higher recommendations for dosages. Dr. Fotinos responded, noting that the issue is more complicated than it may seem because physicians are receiving the brunt of the blame for the opioid epidemic and have slowly stopped prescribing opioids altogether. She further stated that it has been shown that opioids do not actually work for chronic pain, but worried that due to public opinion, the pendulum swung too far in the other direction, leading to confusion over what constitutes a medically necessary and correct dosage of opioids for different situations. Senator Marco Rubio discussed with the witnesses morphine equivalence calculators and how they can be used to ensure patients are prescribed safer, less-addictive opioid dosages.
Best Practices
Multiple ideas and discussions centered on best practices, as that was one of the major reasons behind holding the hearing. Dr. Cropsey referenced MAT and behavioral therapy as critical tools in treating addiction but also said that future strategies should incentivize treatment facilities and health providers to collect and report data on what happens to patients when they leave inpatient or intensive outpatient programs. That additional information may help to form more effective and innovative treatment plans.
When it comes to mothers, Mr. Stringer discussed his state’s specialized treatment programs that allow children to accompany their mothers, instead of being separated, as tends to be the norm. Dr. Cropsey explained the way her state targets mothers while they’re pregnant by connecting with OBGYN and community providers, as ages zero to five is a critical window for children who are exposed to opioid addiction.
Dr. Pierce noted that addiction has to be treated throughout life, not just in one single instance and she explained the way her state offers recovery coaches before, during, and after treatment. She clarified that the coaches are billable through Medicaid, although free to the patient, and can map out and assist a patient’s life plan and goals. All witnesses reported that a lack of federal funding would devastate efforts to tackle the epidemic, close many non-profit support centers, and increase the death toll from overdoses.
Conclusion
A variety of topics were discussed at the Subcommittee hearing, and it will be interesting to see if the discussions and opinions given at the hearing make their way into any legislation during this Session.