Trump's America
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Shockingly, fewer than 3 percent of treatment programs offer all three of the medications available to help fight opioid addiction.12 This is a problem because each of the three recovery medications in the market has its own benefits and drawbacks. There is not a one-size-fits-all opioid addiction medication.
Breaking down barriers that keep medication-assisted treatment away from patients will save lives.
Imagine if our health care system told a heart attack survivor that talk therapy and exercise was their only medical option to prevent a second heart attack. What if insurance companies did not cover insulin for diabetics until a patient experienced a diabetic-induced coma at least twice? These situations would be absurd, illegal, and unethical. Yet, this is how the health system treats most people with opioid addiction in the United States today.
People suffering from addiction are frequently denied medicine that would help them cope with and eventually conquer their addictions. And many insurance companies do not cover opioid recovery medications until someone has overdosed multiple times.
These barriers exist for various reasons, but a main one is simple bias.
Stigma around addiction and the belief that someone can “will themselves out of it” keeps our society trapped in a vicious, deadly, wasteful cycle of relapse and overdose.
This bias exists at the highest levels of public and private bureaucracy and continues to shape insurance coverage, dictate policy, and perpetuate regulations not based on evidence.
Widespread bias even exists in the recovery and medical community itself. Faith-based and abstinence-only programs—such as Alcoholics Anonymous—have helped millions of people, including many close personal friends of mine. However, opioid addiction and alcohol addiction are fundamentally different.
Proponents of abstinence-only support group programs believe them to be the only legitimate way to treat opioid addiction. To them, the use of a recovery medication is just “replacing one drug with another.” Tragically, patients getting medication-assisted treatment would not be welcome in these support groups, if they were honest about their treatments.
Imagine being an opioid-addicted patient in the early days of recovery. While you are battling the disease minute by minute, you build up the courage to attend your first support group meeting. After standing up and discussing your treatment plan (which includes a recovery medication), the leadership tells you that you are really not in recovery at all because you are getting medication-assisted treatment—essentially cheating.
At this critical time when peer support and encouragement are most needed, you feel shame, embarrassment, and confusion. This is no way to help someone who is suffering from opioid addiction.
Widespread bias isn’t the only major barrier to curing opioid addiction today. Our own rules are in the way.
Currently, any health care provider can prescribe an opioid for pain management, but when it comes to prescribing two of the three opioid recovery medications that exist, special circumstances and training requirements must be met. These requirements are contributing to the massive shortage of medication-assisted treatment providers.
For example, a law passed by Congress in 2000 (known as DATA-2000) forced health care providers to pass an eight-hour course and meet other qualifications to be granted a special waiver to treat people battling opioid addiction with buprenorphine. Congress’s rationale was that because buprenorphine was opioid-based, it needed to be closely monitored to ensure it would not be used for unintended illegal use, which law enforcement refers to as diversion.
Think about this: Buprenorphine—which is designed to help get people off of opioids—is held to a stricter standard than the multitude of pain management opioids that have an unlimited capacity for abuse and helped cause this epidemic.
Furthermore, this law arbitrarily capped the number of patients that physicians can treat at any one time. The Obama administration did raise the cap from 100 to 275 in 2016, and the Republican-controlled Congress extended the eligible prescribers to include nurse practitioners and physician assistants through 2021. However nonphysician providers still have a 100-patient cap.
Fundamentally, this cap makes no sense. No other medications have such restrictions—including the pain management opioid prescriptions that have helped cause this problem.
Our rules also keep methadone—the oldest, most researched, and most inexpensive recovery drug—out of the hands of most patients. It must be administrated in federally regulated facilities called opioid treatment programs. Patients must visit their opioid treatment program for a daily dose. This daily disruption to their family and work routine puts this option out of reach for many people with opioid addiction. The facilities are often too far away to visit for patients to maintain their jobs, or they cannot find transportation. Again, the current situation is absurd. Methadone can be prescribed for home use to treat pain, but when used for addiction treatment, it needs special oversight and more stringent regulatory control.
TRUMPING ADDICTION WITH MEDICATION-ASSISTED TREATMENT
The unintended consequences of these well-intentioned, but misguided, policies are significant. The current treatment capacity falls far short of the number of Americans suffering from substance use disorders.
For example, 60 percent of rural counties in America lack physicians who have DATA-2000 waivers to prescribe buprenorphine. The same is true for more than a quarter of urban counties.
Even in areas that appear to have providers able to prescribe medication-assisted treatments, some providers are at capacity and other providers are not treating for various reasons—one being that doctors doubt patients have access to the behavioral counseling and social support necessary for successful recovery.13
Similarly, there are simply not enough opioid treatment programs in the United States. Although there has been a 26 percent increase in the number of opioid treatment facilities from 2003 to 2015 and a nearly 60 percent increase in the number of patients being treated,14 the opioid overdose death numbers have grown more than 250 percent in the same time frame. Clearly, we are still badly under-resourced.15
We would never consider keeping proven medications away from patients suffering from diabetes or cancer. There is no reason we should cap the number of people who can be helped with opioid recovery medications. President Trump and Republicans must act swiftly to end treatment caps for physicians, physician assistants, and nurse practitioners who are authorized to treat opioid addiction with medication.
The administration should also work to make treatment available to those in underserved areas through technology.
With too few licensed clinics and too few doctors with medication-assisted treatment waivers, rural communities face the highest barriers for access to treatment.
Telemedicine could help us immediately close part of this gap.
Telemedicine, also referred to as telehealth, allows people to consult their doctors remotely through videoconferencing or other technologies. Federal agencies should review and revise regulations and reimbursement policies to make telemedicine more available for opioid addiction treatment.
At the same time, we should offer incentives for providers to use the technology. While telemedicine has limitations, the greater availability and advancement of this kind of technology has the potential to expand access to care.
THE PARITY PROBLEM
When I was Speaker of the House, we took the first step toward mental health equality in passing the Mental Health Parity Act of 1996.16 It was improved upon in 2008 with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, which sought to ensure that insurance companies cover treatments for mental illness and addiction the same as they would treatments for physical ailments.
Under this law, a patient provided unlimited doctor visits for a chronic condition like diabetes would also be offered unlimited visits for a mental health condition such as depression or schizophrenia.
Lack of insurance parity
is contributing to the opioid epidemic by limiting access to both medications and providers.
Each of the three recovery medications in the market have varying degrees of availability.
Many insurance plans don’t cover all three medications. Additionally, some plans that do cover all three impose dangerous fail-first protocols, onerous and frequent prior authorization requirements, and dosage and lifetime limits.
When it comes to the opioid epidemic and enforcing insurance parity, the first step President Trump and Republicans should take is to fix the government-sponsored health plans Americans pay for.
Take Medicare for example:
Medicare, the insurance program for America’s seniors, is the largest single health insurance program in the country. Despite the clear public health endorsement of medication-assisted treatment, Medicare does not cover all three recovery medications.
Individuals who have successfully stayed in recovery with methadone reach the age of 65 and panic that they cannot continue their treatment. This is more common than you would think.
According to data from the CDC’s National Health and Nutrition Examination Survey, nearly four in ten people above age 65 use five or more prescriptions,17 which increases the risk of drug misuse or abuse.18
In 2016, one out of every three Medicare beneficiaries received at least one prescription opioid through Medicare Part D, but Part D does not cover all three of the recovery medications.
Strangely, methadone, the cheapest of the three, is not paid for by Medicare for opioid addiction recovery—only as a pain treatment. It has fallen through the cracks of the bureaucracy—a victim of the siloed Medicare billing system. It can’t be covered as a recovery drug under Part D because you can’t get it at the pharmacy.
Further, it is not covered in Medicare Part B because it is administered through outpatient opioid treatment program (OTP) centers, and Part B only covers inpatient drugs.
This system’s failure means that Americans who may have been treated at an OTP for years are forced to switch to more expensive medication and lose the OTP services when they are Medicare eligible. It’s nonsensical and destructive.
Considering that insurance coverage parity is the law of the land and the administration and every major public health organization supports medication-assisted treatment, it is shocking that Medicare does not cover these treatments. The oversight is so irrational and the solution so undeniable that fixing this disparity will be a litmus test on the seriousness of any effort to combat this epidemic.
Congress should review Medicare, Medicaid, Veterans Health, the Military Health System, the Indian Health Program, and the Federal Employee Health Benefits Program. They should modify policies to ensure that these insurance programs support access to all three recovery medications and are using evidence-based treatment guidelines.
Additionally, every governor should audit his or her Medicaid program to see if it provides for meaningful medication-assisted treatment coverage for all three medications. Aggressive clinical management practices such as arduous prior authorizations, and dosage and lifetime limits may make sense for insurance actuaries and bureaucrats, but they have no place in a serious response to solving this crisis.
The Trump administration should also enforce parity in reimbursement rates by insurance companies.
Millikan, Inc., published a report that was released by a group of American’s top mental health and addiction treatment organizations in December 2017. The report found that insurance companies in 46 states have been paying physical health care providers about 20 percent better than they were paying addiction and mental health providers for the same types of services. In many states, the disparities in payment rates were two to three times greater.19 Additionally, the report showed people seeking addiction and mental health treatment had to use “out-of-network” providers far more often than patients seeking treatments for physical ailments. This results in higher costs to patients and indicates the networks are much narrower for addiction treatment services.
Existing addiction and mental health care providers won’t stay in business very long if they don’t get properly paid for their work. This will put treatment further out of reach for those battling opioid addiction.
A key recommendation by President Trump’s Commission on Combating Drug Addiction and the Opioid Crisis was to fully enforce the parity law. President Trump should ensure the Department of Labor has real authority and resources to enforce this law, audit violators, and impose fines.
DECRIMINALIZE ADDICTION: MORE PATIENTS, FEWER PRISONERS
According to the Surgeon General’s report, substance use disorder costs the country $442 billion annually in health care costs, criminal justice spending, and lost productivity.20
The criminal justice system is often the first institution to encounter those suffering from addiction. As a result, jails have become warehouses for those struggling with mental illness and substance use disorders.
To relieve prison populations and keep people with addictions or mental illness out of jail, we should invest more in treatment courts and ensure they are using evidence-based treatments. These courts are already profoundly successful in some states for combating addiction and keeping jail populations low. These courts offer people in need of long-term help a far better option than incarceration and can help them find the best treatment programs. These programs also provide people with addictions or mental illness a path of accountability, compassion, and assistance in getting the treatment they need.
Georgia Governor Nathan Deal has achieved tremendous success using treatment courts to help people with drug addictions stay out of jail and get the help they need.
As the Atlanta Journal-Constitution (AJC) reported on January 25, 2018, Governor Deal’s focus on treatment courts, along with a lowered crime rate and a legislative push to adjust the state’s property crime laws, have made a significant impact.21
The overall incarceration rate has dropped by 19 percent in the last eight years—and the incarceration rate for African Americans in Georgia has fallen by 30 percent to the “lowest level in decades,” according to the AJC.
However, medication-assisted treatment is only used in half of drug courts operating around the country. This means that these jurisdictions are wasting money. Diversion programs favor evidence-based treatment over incarceration save more than $2 for every dollar spent.22
Courts that do not support medication-assisted treatments often cite the potential for diversion. However, if these courts are properly funded and staffed, they could easily put accountability measures in place and support evidence-based treatments.
The criminal justice system can hold people accountable for their actions, but it can also help them become productive and healthy members of society. Isn’t that the point of a corrections system?
DOLLARS AND SENSE
The opioid epidemic is larger and more devastating than any natural disaster we have seen. Leaders have a moral imperative to help solve it.
When Hurricane Harvey hit, $15 billion was quickly approved in the weeks to follow. Yet, Congress has only allotted $1 billion over two years to combat the opioid crisis. This is not enough. For those who are unmoved by the moral argument, it also makes economic sense to invest in fighting this epidemic. Every dollar we invest saves money:
• $1 for brief primary care addiction intervention saves $27 across the system;
• $1 for addiction intervening at a hospital saves over $36, or $9 in the emergency room;
• $1 for treating substance abuse saves $4 in overall health care costs, and $7 in criminal justice costs by preventing the cycle of recidivism that often accompanies addiction.23
As current funding is appropriated and new funding is granted, Congress should ensure the funding is going toward evidence-based treatments. This will help ensure taxpayer money is being spent on treatments that work.
Now, to summarize:
Addiction is not a moral failing or
a lack of strong will. It is not a choice, it is a disease.
No healthy person would willingly put themselves and their families through the horror and destruction caused by opioid addiction.
If opioid addiction wasn’t such a stigmatized illness, immediate action would be taken to address this clear public health emergency. Instead, many of our policies and programs have been based on the flawed stigma.
This must change.
Americans seeking treatment should be supported for their efforts, not shamed and dismissed.
Real, evidence-based treatments must become more widely available, or the death toll will continue to rise. If we fail, people all over the world will look back in 10 years and say a generation of Americans died because their fellow Americans refused to help them.
That America would be far from great.
CHAPTER FOURTEEN
HELPING AMERICANS RETURN TO WORK
The keys to reaching President Trump’s goal of a sustained 3 to 4 percent economic growth are for the United States to dramatically ramp up its productivity and expand its workforce.
Through the passage of the Tax Cuts and Jobs Act and the administration’s massive deregulation efforts, President Trump and Republicans have already laid the groundwork for companies to be able to expand and create more jobs. A vital second step will be passing a significant infrastructure bill that will create jobs at nearly every skill level in virtually every state and infuse local communities with commerce.
However, unemployment is already at 4.1 percent—a 17-year low. This is certainly a good thing, but it creates a key hurdle for boosting productivity. To fill all the jobs that the Trump economy is creating, we need an ample supply of Americans willing and able to work. And as new technology and new productivity tools become available, we will need a lot of retraining for the workforce to achieve its full potential.