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

with Paulina Firozi


Many parts of President 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’s 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 me.

Sen. Pat Toomey (R-Pa.): 

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.

Here's a sampling from critics on Twitter. New York City's First Lady Chirlane McCray: 

Sen. Sheldon Whitehouse (D-R.I.): 


--Like Trump's budget last year, the White House is again proposing dramatically cutting HHS's budget -- this year, by nearly $18 billion, or 21 percent less than it currently gets. The spending plan also proposes major cuts to entitlement programs -- including Medicare and Medicaid -- and ways to improve veterans’ health care. Some top-lines:

  • Cuts spending on Medicare by $237 billion as part of $1.7 trillion in reductions to entitlement programs. 
  • Provides $85.5 billion in funding for veterans' health services, education, and vocational rehabilitation.
  • Slashes the Supplemental Nutrition Assistance Program (SNAP), also known as food stamps, by $17.2 billion in 2019, per our colleagues Tracy Jan, Caitlin Dewey and Jeff Stein, who write that it's one of the ways the budget “hits the poorest Americans the hardest."
  • Instead of food stamps, gives low-income families boxes of canned goods that Mulvaney described as a “Blue Apron-type program,” Caitlin reports.
  • Cuts future Medicaid spending by $250 billion over the next 10 years.

The budget includes several strategies for discouraging drug manufacturers from hiking prices, but doesn't do much that would directly and quickly lower the list price of drugs -- something hard to do without government price-setting, an idea the White House has rejected. The budget suggests:

  • Allowing up to five states to join together to negotiate drug prices directly with manufacturers and to set up their own drug formularies.
  • Cutting Medicare Part B reimbursements for hospital administered drugs.
  • Passing on discounts and rebates negotiated by pharmacy-benefit managers for seniors who buy drugs through Medicare Part D. Seniors would pay less out-of-pocket under the proposal, though insurance premiums could increase as a result.
  • Capping out-of-pocket costs for beneficiaries who pass through the “donut hole” coverage gap, and makes it so low-income seniors don’t pay for generic drugs.
  • Moving some drugs now under Medicare Part B into Medicare Part D, which would allow for price negotiations.

As you can imagine, Twitter was aflutter with responses to the budget, even though the vast majority of Trump's suggestions probably won't ever become law:

From HuffPost’s Arthur Delaney:

Politico’s Joanne Kenen:

From House Democrats:

Former senior Obama adviser Dan Pfeiffer:

ThinkProgress’s Judd Legum:

Sen. Bernie Sanders (I-Vt.):


AHH: The Post's Sari Horwitz digs deeper into the $28 billion budget proposal for the Justice Department, which reflects Attorney General Jeff Sessions’s priorities to fight the opioid crisis and crack down on illegal immigration with millions of additional dollars going toward new immigration judges and attorneys working on border security. The proposal, roughly the size of last year's budget request, includes an additional $295 million to fight the opioid epidemic and support law enforcement safety.

“The Department of Justice has the noble task of keeping the American people safe from drugs, gangs and terrorists, and this budget proposal reflects our commitment to do just that,” Sessions said in a statement.

OOF: An investigation led by Sen. Claire McCaskill (D-Mo.) finds pharmaceutical companies selling some of the most lucrative prescription painkillers funneled millions of dollars to advocacy groups who then promoted use of the medications, the AP reports. The investigation "sheds light on the opioid industry’s ability to shape public opinion and raises questions about its role in an overdose epidemic that has claimed hundreds of thousands of American lives."

Senate staff obtained financial information from makers of the top five opioid painkillers showing they spent more than $10 million between 2012 and 2017 to support 14 advocacy groups and affiliated doctors. Representatives of some of the drug makers named in the report contend they did not set conditions on how the money was to be spent or force the groups to advocate for their products.

"While the new report provides only a snapshot of company activities, experts said it gives insight into how industry-funded groups fueled demand for drugs such as OxyContin and Vicodin, addictive medications that generated billions in sales despite research showing they are largely ineffective for chronic pain," the AP writes.

“It looks pretty damning when these groups were pushing the message about how wonderful opioids are and they were being heavily funded, in the millions of dollars, by the manufacturers of those drugs,” Rutgers University and opioid expert Lewis Nelson told the AP.

OUCH: Molina Healthcare, formerly one of the best-faring insurers selling in the Affordable Care Act marketplaces, said yesterday the Trump administration's decision to stop making extra subsidy payments to insurers for cost-sharing discounts they're required to offer cost the company $73 million in the final three months of last year, Axios reports. Molina had already reduced its participation for 2018, citing losses in 2017 it hadn't previously anticipated.

"The $73 million loss shows the magnitude of Trump's move to stop paying the subsidies to insurers, and indicates Molina had to pay out a lot of medical claims for that subset of enrollees," Bob Herman writes. "Centene, another large ACA insurer, recently said it lost $22 million from the nonpayment of cost-sharing subsidies."


--The research and consulting firm Altarum is out this morning with a new projection showing the opioid crisis will cost an additional $500 billion over the next three years, on top of its $1 trillion projected cost from 2001 to 2017. According to the report, the biggest economic costs result from lost wages because of Americans either dying from overdoses or dropping out of the workforce and costs to the health-care system in caring for them.

Study author Corey Rhyan told me the projection is probably on the conservative side because it's extremely difficult to comprehensively estimate the epidemic's toll on society. But he also stressed that future costs could be mitigated with a robust response to abuse from the government and private industry. "I think if we see a robust response to reduce the impacts and engage in prevention activities, I would say there is the capacity for us to decrease the rate we’re projecting," Rhyan said.

--A few more good reads from The Post and beyond:

This little-known medicine could help fight the opioid crisis (Vox)

Trump Jr. says his wife is ‘safe and unharmed’ after opening letter containing unknown substance (Mark Berman)


She thought the weird sensation was a stray eyelash. It was eye worms. (Lena H. Sun)

Ovarian Cancer Doesn’t Begin in the Ovaries, Researchers Say (Wall Street Journal)


U.S. files complaint against three biggest dental supply firms (Reuters)

A Long Era of Low Health Care Inflation May Be Coming to End (Bloomberg)



  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on reauthorization of FDA animal drug user fees.
  • Kaiser Health News holds a discussion on living well with dementia.

Coming Up

  • The Hill, Faces & Voices of Recovery and Indivior hold an event on the opioid crisis and supporting recovery on Wednesday.
  • The Substance Abuse and Mental Health Services Administration holds a meeting of the Advisory Committee for Women's Services on women experiencing homelessness with behavioral health needs on Wednesday.
  • The USC-Brookings Schaeffer Initiative for Health Policy holds an event on patient cost sharing for prescription drugs on Friday.



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