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There's a quick and simple way President Trump could immediately help Americans addicted to opioids.
Here it is: allow Medicaid to start paying for treatment at large institutions for mental disease (known as IMDs). Under a current policy known as the “IMD exclusion,” people on Medicaid can't get substance abuse treatment at facilities with more than 16 beds.
This policy shift isn't explicitly part of the emergency declaration Trump issued yesterday at the White House, but the president did make a brief mention of it in his address.
"As part of this emergency response, we will announce a new policy to overcome a restrictive 1970s-era rule that prevents states from providing care at certain treatment facilities with more than 16 beds for those suffering from drug addiction," Trump said.
Treatment advocates, governors and medical providers have lobbied heavily to remove this exclusion, which has been in place since the Medicaid program was created half a century ago. Back then, there was a big push to deinstitutionalize mental-health patients in favor of integrating them into communities.
But now — as the nation grapples with an opioid abuse crisis that claims the lives of around 100 people every day — the overriding concern is how to help these patients break from their addictions, which often requires 24-hour monitoring over a period of several weeks, rendering residential settings crucial to the overall effort.
Trump’s opioid commission, led by New Jersey Gov. Chris Christie (R), identified removing the IMD exclusion as the top way to make treatment available to patients immediately. “This is the single fastest way to increase treatment availability across the nation,” the report said.
Yesterday, the president declared opioid abuse a public health emergency — a move that allows the federal government to more quickly direct resources toward the effort by giving states more flexibility in how they use federal funds and expanding the use of telemedicine treatment, my colleagues Jenna Johnson and John Wagner reported.
“Addressing it will require all of our effort, and it will require us to confront the crisis in all of its real complexity,” Trump said during a speech in the East Room of the White House. “As Americans, we cannot allow this to continue. It is time to liberate our communities from the scourge.”
But “liberating” residential facilities from Medicaid’s bed limits is, to the people who run them, a no-brainer way to combat the opioid abuse epidemic. Even before the Affordable Care Act expanded Medicaid, the federal health insurance program for the poor was the country’s single largest source of coverage for those with substance abuse disorders.
For example, the Gateway Foundation, which bills itself as the country’s largest nonprofit provider of addiction treatment, could treat opioid abusers at its chain of clinics across Illinois and Delaware if the exclusion were lifted. Right now, none of its 43 clinics meet the bed limitations; its smallest center has 44 beds and its largest has 125 beds.
“The type of person who needs to go residential is too sick to do [treatment] in the community," the group’s president, Tom Britton, told me.
Trump couldn’t erase the exclusion, because it’s written into law. But he could direct the Department of Health and Human Services to issue all 50 states waivers from it. West Virginia obtained just such a waiver this month, and New Jersey, Illinois, Indiana, Kentucky and Michigan are still awaiting word on their applications.
Of course, Congress could also vote to repeal the IMD exclusion — although the Congressional Budget Office has estimated it would cost an additional $40 billion to $60 billion over a decade. A bipartisan group of eight senators — led by Sen. Dick Durbin (D-Ill.) introduced legislation in May that would somewhat ease it by raising the 16-bed limit to a 40-bed limit.
“By maximizing Medicaid coverage gains and offering treatment for people suffering from addiction — rather than simply arresting them or turning them away from help — we can reduce crime, save money, improve health, and save lives,” the senators wrote.
Correction: An initial version of this story stated that Trump didn't refer to the IMD exclusion in the emergency declaration he signed yesterday. While the exclusion isn't mentioned in the declaration itself, the president did state an intention to issue more state waivers from the exclusion during a speech. The Health 202 has been changed to clarify this.
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--So now the opioid abuse epidemic is officially a "public health emergency." But what does that even mean? Our colleague Lenny Bernstein explains that Trump's declaration will help the government speed any available resources to communities and eliminate some obstacles that stand in the way of providing assistance. A huge part of this is getting more naloxone -- the drug that reverses the effects of an overdose -- into communities and training first responders to use it.
“Unless you keep people alive, you can’t get them into treatment,” Elizabeth Van Nostrand, an assistant professor of health policy at the University of Pittsburgh told Lenny.
"Naloxone, which is administered in several ways, can be expensive; Baltimore Health Commissioner Leana Wen said that city is paying $70 to $90 for a two-dose pack," Lenny writes. "It often takes several injections or nasal sprays to revive a single victim, especially if the individual has overdosed on the powerful street drug fentanyl....The emergency allows the federal government to speed more people and resources to the streets where naloxone is needed. Acting Health and Human Services Secretary Eric Hargan could negotiate lower prices for government agencies. And he could put out model instructions for states and cities to issue “standing orders” that make the antidote more readily available in pharmacies around the country, as jurisdictions like Baltimore already have done."
--But expanding use of naloxone also requires more money -- and that was notably not part of the president's announcement yesterday. "At this point in the nation's opioid epidemic, fighting back is mainly about quickly making money available: Money for treatment. Money for the overdose antidote naloxone. Money to hire more people to help overwhelmed cities and states battle a crisis that killed an estimated 64,000 Americans last year," Lenny writes.
Critics noted that the president stopped short of declaring the opioid epidemic a "national emergency" -- a different legal categorization that would have unleashed more funding to fight the epidemic, including buying more naloxone. The announcement fell well short of what many health-care advocates had urged and was also roundly criticized by Democrats.
From HuffPost's Jennifer Bendery:
For all this tough talk from Trump right now about fighting the opioid crisis, remember he's not directing any new $ for this. So...— Jennifer Bendery (@jbendery) October 26, 2017
Andy Slavitt, who headed the Centers for Medicare and Medicaid Services under Obama:
Trump claims we will "end the opioid epidemic," but has committed no $, named no leader & has no plan he can articulate. 2/— Andy Slavitt (@ASlavitt) October 26, 2017
This isn't political. We want a POTUS who can be effective here.— Andy Slavitt (@ASlavitt) October 26, 2017
But this is 1/2 baked at best, cynical lip service at worst. pic.twitter.com/lFmK2zu5Ux
Here's House Minority Leader Nancy Pelosi's (D-Calif.) response, via MSNBC's Kyle Griffin:
Pelosi to Trump on declaring the opioid epidemic a public health emergency: "Show me the money." (via ABC) pic.twitter.com/4zJPX6V0Yq— Kyle Griffin (@kylegriffin1) October 26, 2017
From the New York Attorney General:
If @POTUS really believes that the opioid crisis is a public health emergency (it is), he needs to dedicate real funding to the response.— Eric Schneiderman (@AGSchneiderman) October 26, 2017
Sen. Bernie Sanders (I-Vt.) referred to past GOP health-care plans -- which Trump backed -- that would have cut future Medicaid spending:
Millions depends on Medicaid for opioid treatment. Trump's solution is to cut Medicaid by $1 trillion. That is a disgrace.— Bernie Sanders (@SenSanders) October 26, 2017
--The president showed a rare, emotional side during yesterday's highly anticipated speech. Standing in the East Room of the White House, he briefly mentioned his brother, Fred, who struggled with alcoholism and who he said always warned him against alcohol and drugs.
“I learned myself. I had a brother, Fred. Great guy, best-looking guy, best personality — much better than mine,” Trump said. “But he had a problem. He had a problem with alcohol. And he would tell me: ‘Don’t drink. Don’t drink.’ ”
The president’s older brother, Fred Trump, was an airline pilot who died in 1981 at age 43. Talking about him seems to be the only time the president shows emotion, The Post’s Callum Borchers points out.
“To this day, I’ve never had a drink,” Trump continued. “And I have no longing for it. I have no interest in it. To this day, I’ve never had a cigarette. . . . He really helped me. I had somebody that guided me. And he had a very, very, very tough life because of alcohol. Believe me — very, very tough, tough life. He was a strong guy, but it was a tough, tough thing that he was going through. But I learned because of Fred. I learned.”
Jenna Johnson writes that Trump’s experience with his brother, and his brother’s death “seems to have shaped the way the president thinks about substance abuse and addiction." The president stressed the "just say no" approach, saying that “teach young people not to take drugs — just not to take them.”
It's a similar approach to Nancy Reagan’s “just say no” campaign, which just wasn't very effective. “Scores of researchers since that era have concluded it doesn’t work very well, however, and some advocates say the approach often deepens the stigma of addiction and suggests that those with a problem should be able to stop easily,” Jenna writes.
From the New York Times's Maggie Haberman:
Trump describes a latter-day version of the Just Say No campaign as a key to discouraging a new generation of opioid addicts.— Maggie Haberman (@maggieNYT) October 26, 2017
From Politico's Jack Shafer:
Fred Trump's alcoholism teaches us nothing about the opioid story.— Jack Shafer (@jackshafer) October 26, 2017
From MSNBC's Joy Reid:
Hey, I know: they could call the campaign “Just Say No...” the first lady could voice the ads! No one has ever thought of that before.— Joy Reid (@JoyAnnReid) October 26, 2017
Chairman of the American Conservative Union:
For those who say Pres Trump lacks discipline think about his avoidance of alcohol which is tough. It also means he is #tweetingsober— Matt Schlapp (@mschlapp) October 26, 2017
--The face of the crisis: This isn't the first time disenfranchised communities have seen an opiate devastate their communities. The Post's Nick Miroff wrote that “lesser waves of opiate abuse, especially heroin” were notable in large cities during the 1970s, in his piece about the history of opioid abuse in America going back to the Teddy Roosevelt administration. "What's most notable to some Americans is just how differently Washington is responding to the current crisis now that the face of the current epidemic is often a white one," The Post's Eugene Scott writes.
“Despite how much the current conversation has centered on rural, white Americans, the impact of the drug is not limited to those spaces. Opioid addiction is more widespread ethnically and geographically than some Americans realize,” Eugene writes. “Many Americans are relieved Trump appears to be moving forward on a campaign promise that made him popular with so many in his base. Others are just wondering whether that investment will arrive in the urban areas he promised black and Latino voters he'd ‘straighten out.’
AHH: Congress has passed a budget resolution which, while not law, signals that Republicans are willing to dramatically pare down the government's health-care spending, Vox reports. All non-Medicare health programs would get nearly 30 percent less spending by 2027, according to the Center on Budget and Policy Priorities. Medicare would be cut too, by $473 billion over that same period. The budget also includes $1 trillion over a decade in mystery cuts to mandatory programs, cuts which would probably affect programs helping the low income.
"It’s possible this plan is cheap talk, that if the rubber hit the road and these policies were actually in danger of being enacted, some GOPers would defect and the plan wouldn’t pass," Vox's Dylan Matthews writes. "But simply as a piece of rhetoric, the budget is important. It suggests that basically every Republican in each chamber...is comfortable aligning himself or herself with an agenda that radically cuts the social safety net, for the poor but also retirees and the middle class more broadly."
OOF: Stand by. Stanford University Medical Center's Hannes Vogel is awaiting the brain of Stephen Paddock, who killed 58 concertgoers in Las Vegas earlier this month in a rampage without any clear motive, the New York Times reports.
"While law enforcement officials attempt to understand the mass shooting by gathering evidence and interviewing those who crossed the gunman’s path, Dr. Vogel is preparing to look for clues in the remains of Mr. Paddock’s brain," reporter Sheri Fink writes.
“The magnitude of this tragedy has so many people wondering how it could have evolved,” Vogel said. "That includes whether any one of more than a half-dozen neurological diseases proposed to the coroner’s office might have played a role," Sheri writes. "Even though the chances of finding answers in the brain tissue to the mystery of Mr. Paddock’s act are slim, Dr. Vogel said, 'all these speculations out there will be put to rest, I think.'"
OUCH: Drug overdoses have risen to that point that they're now the top cause of injury-related death in the United States, the Centers for Disease Control says in a new report issued as the president declares opioid abuse an emergency. More than 52,000 Americans died of a drug overdose in 2015 -- a more than 200 percent increase from 16 years ago, the agency said.
The epidemic is especially centered outside cities and among Native Americans and whites. Deaths rose by 325 percent over the same period when you look only at rural areas, and by more than 500 percent among Native Americans and native Alaskans. Death rates among black Americans have more than doubled, though they have risen at a lower rate than among other races.
Officials blamed much of the increases on doctors overprescribing opioids. “Reducing the number of persons initially exposed to prescription opioids might reduce the illicit use of opioids, the subsequent risk of addiction, and the use of illicit drugs,” CDC researchers said.
--House GOP leaders announced yesterday they'll hold a long-awaited vote on extending funding for the Children's Health Insurance Program next week, the Hill reports. Lawmakers had allowed funding for the program to officially expire on Oct. 1. The situation has worried stakeholders as states are running out of cash for the program that provides coverage to around 9 million American kids.
"The reason why we're bringing it up next week is not because next week was the date we wanted to. We wanted to get this done long ago, but the reason why we're doing it next week is because Minnesota's about to run out of money," Majority Leader Kevin McCarthy (R-Calif.) said on the floor.
A few more good reads:
- The NIHCM Foundation hosts a briefing on Capitol Hill on “Transforming Health Care to Drive Value
- Kaiser Health News holds a discussion on advance care planning on November 8.
Watch President Trump’s full speech on opioids:
Trump declares opioid crisis a national public health emergency:
From The Daily Show with Trevor Noah: "How Trump is mishandling the opioid crisis:"
Watch Stephen Colbert's fake interview of Lou Dobb's interview of President Trump: