By declaring the country’s opioid crisis a 90-day national public health emergency on Oct. 26, President Donald Trump set in motion his administration’s response to the country’s deadly overdose epidemic.
While Trump’s October announcement did direct national attention toward the crisis and open temporary access to a small amount of federal funds, the president did not divert any new permanent funding toward a federal response. With the temporary emergency status set to expire at the end of January, Trump now faces the challenge of financing and implementing long-term policies that will have a lasting impact on ending the American addiction scourge.
The dilemma at the crux of this public health challenge is that effective medical treatment exists for opioid addiction but is largely inaccessible to addicts in need. Medication-assisted treatment (MAT) combines services like counseling with the controlled administration of opioid agonists that bind to brain receptors to lessen withdrawal symptoms. MAT has been shown to reduce relapse and fatalities. Yet over half of the two million Americans addicted to opioid medications in 2015 lacked access to treatment, an outcome of insufficient resources and obstructive policies.
The president’s task lies in spearheading the policy and funding strategies that will make this medical treatment more available to Americans in need. A national effort to improve treatment coverage would carry a high price tag, particularly in light of the Republican administration’s commitment to cutting government health spending. Yet the White House’s Council of Economic Advisors’ recent finding that the opioid epidemic cost the U.S. $500 billion in 2015 underscores that financing a federal response now would save government dollars – and American lives – down the road.
Officials in state governments that have exhausted their resources for fighting opioid abuse have argued that the emergency declaration must be Trump’s first step in the public health response to the crisis, not his only step. These officials urge the president not just to acknowledge the extent of the crisis as he did in his announcement, but also to push for an infusion of federal cash to expand access to life-saving treatment.
The Limited Power of Rhetoric
The designation of the opioid epidemic as a public health emergency holds significant symbolic power. Stigma surrounding drug use has long muffled dialogue about addiction and prevented addicts from seeking the care they need. Trump’s announcement sparked a national conversation about the overdose epidemic and affirmed that the epidemic has afflicted Americans across the country of all incomes, genders, races, and ages.
The national conversation could not come at a more urgent time. With 142 Americans dying of overdoses every day, the president’s commission reported that the country suffers “a death toll equal to September 11th every three weeks.”
While the public health emergency declaration brought the crisis to national attention, the announcement bears minimal substantive significance beyond its rhetorical impact. Unlike a national emergency declaration, the public health emergency designation provides no new permanent federal funding for alleviating the crisis. Instead, the declaration opens the already-drained public health emergency fund for the 90 days after the announcement. If the less than $57,000 remaining in this fund were distributed to the country’s two million addicts, each addict would receive an average of two cents worth of aid.
The remaining funds will likely fall short of backing even the lower-cost facets of a federal response. Trump proposed an advertising campaign as a fixture of the federal response during his press conference about the emergency declaration. Similar national advertising campaigns have cost millions of dollars in the past. Other proposals called for by public health leaders—including expanding access to treatment, funding provider education for safe prescription of opioids, and creating nationally connected databases for tracking prescriptions—require significantly more federal investment, with many citing multi-billion dollar estimates for expanding treatment alone.
The Pressing Need for Federal Funds
Expanding treatment access tops the list of public health interventions most in need of federal funding. For the growing number of opioid addicts, multiple barriers block their access to treatment. Only 10 percent of conventional drug treatment centers offer medication-assisted treatment. And with waiting lists up to 18 months long, treatment centers must turn away addicts who have asked for help. Federal funds could help lessen these obstacles by rewarding centers that offer medication-assisted treatment and by better subsidizing care.
The Trump administration could endorse legislation that would fund expanding access to treatment. Last December, Congress approved spending $1 billion on combating the opioid epidemic through 2018 as part of the 21st Century Cures Act. The nationwide sense of urgency surrounding the crisis in the wake of Trump’s announcement opens the door for the current administration to ask to extend federal funding for the epidemic through at least the remainder of Trump’s term.
Few issues have received more bipartisan support than increasing funds to combat the epidemic, which has harmed blue and red states alike. Cash-strapped states have issued pleas to the federal government to provide more funds. The state of Ohio alone spent nearly $1 billion on fighting its opioid epidemic in 2016. In D.C., congresspersons across party lines have pushed for increased federal funding. During the congressional efforts to repeal and replace the Affordable Care Act in the summer of 2017, Republican senators supported allotting $45 billion to state-level responses. These funds were intended to hold together state health systems that would lose Medicaid funding due to ACA repeal.
In the aftermath of the failed ACA repeal efforts and Trump’s subsequent public health emergency declaration, Senate Democrats have introduced the Combating the Opioid Epidemic Act that also proposes $45 billion in funding to states over ten years for addressing the crisis. Yet, no Republicans have supported the bill as co-sponsors. Democratic sponsors argue that the bill provides Trump with the opportunity to show his commitment to his public health emergency declaration by encouraging his party to support the funding increase. The difficulty lies in getting both parties to unite on legislation related to healthcare, which has become increasingly politicized during the ACA debates.
Although Trump administration officials bent on cutting spending may balk at spending billions on a problem that is unlikely to be resolved within the next few years, inaction would prove even costlier as the crisis worsens. The number of Americans using more dangerous substances like fentanyl continues to increase. As addiction spreads through the American workforce, the mounting costs of the epidemic stem from spikes in overdose-related emergency room visits and lost worker productivity. Federal investment would not only save lives but save future spending by restoring the country from the grips of addiction.
Potential Policy Levers
Translating federal funds for the epidemic into improved health outcomes will also require accompanying policy interventions to lessen the regulatory obstacles to treatment.
One potential area of policy reform involves regearing regulations of drug treatment centers. The president’s commission recommended that the White House back legislation that would provide federal incentives for offering MAT and would require that all MAT-licensed facilities offer all forms of the treatment.
State officials, the president’s commission, and Congresspersons have also criticized a Medicaid provision that restricts access to treatment beds. The statute in question in the Social Security Act – the Institutes for Mental Disease exclusion – prohibits federal reimbursement for treatment at substance abuse inpatient centers with more than 16 beds. As it stands, when Medicaid patients arrive at these centers, they are either turned away or the cost for the treatment is passed on to already overextended state budgets. Since Trump’s public health emergency declaration, the Center for Medicare and Medicaid Services has started to provide waivers to states looking to work around this provision. Officially striking this provision from the law will require federal legislation, which Trump could push as a priority.
Finally, all efforts to increase insurance coverage also make it easier for Americans to receive the treatment they need. The simple equation is that without health insurance, Americans suffering from addiction cannot afford treatment.
The Trump administration’s ongoing efforts to dismantle and strategically weaken the ACA have concerned officials working to respond to the opioid crisis. The National Institutes of Health view the ACA as a critical component of the country’s ability to fight the opioid epidemic. NIH research assessing the ACA’s impact on the opioid crisis emphasizes that more Americans than ever before have insurance under the ACA, including those covered by expanded Medicaid programs. Not only does the ACA increase overall access to healthcare for Americans who may be affected by the opioid epidemic, but it also mandates that insurance policies cover substance use disorder treatment as an “essential health benefit.” In states that expanded Medicaid, 1.6 million people who struggle with substance use disorders have gained insurance that makes addiction treatment more affordable. Crippling the ACA would undermine any progress toward expanding treatment options, as Americans without insurance would lose access to treatment.
Trump’s public health emergency declaration takes the first step down a long road toward combating the opioid epidemic. In the weeks after the temporary public health emergency status expires, the administration’s funding and policy decisions have the potential to determine whether Trump leads the country out of a health crisis or leaves a legacy of neglect.
The authors, Natalie Swartz and Caroline Diggins, are co-presidents of the Harvard Undergraduate Global Health Forum.
Image Credit: Flickr / Senate Democrats