Abstract
An over‐reliance on federal block grants and “one‐off” funding initiatives has left the addiction treatment system under‐resourced to respond to an addiction crisis that stands to be at least as deadly as COVID‐19 during the span of the Biden administration, a trio of prominent researchers argue in a newly released policy paper. The authors suggest that the new administration and Congress should prioritize efforts to build on what they consider the most impactful developments in improving access and quality in addiction treatment, such as Medicaid expansion and parity mandates.
Bottom Line…
Authors of a new policy paper believe the Biden administration and Congress have an opportunity to improve addiction treatment access and quality if they move away from traditional grant financing.
An over‐reliance on federal block grants and “one‐off” funding initiatives has left the addiction treatment system under‐resourced to respond to an addiction crisis that stands to be at least as deadly as COVID‐19 during the span of the Biden administration, a trio of prominent researchers argue in a newly released policy paper. The authors suggest that the new administration and Congress should prioritize efforts to build on what they consider the most impactful developments in improving access and quality in addiction treatment, such as Medicaid expansion and parity mandates.
Published online Jan. 22 in the Journal of Health Politics, Policy and Law, the article warns against embracing new funding initiatives that repeat patterns of the past. “Candidate Biden promised greater investment in addiction treatment and prevention. That's welcome and necessary,” the paper states. “Yet if that new money follows tradition and takes the form of targeted set‐aside grants, it will not promote the long‐term investments in treatment infrastructure America needs.”
One of the paper's co‐authors told ADAW that many of its recommendations are realistic for a couple of key reasons: They carry a reasonable price tag, and rare bipartisanship can coalesce around addressing the opioid crisis and other drug problems. “There is room to get appropriations if they are modest,” said Richard G. Frank, Ph.D., the Margaret T. Morris Professor of Health Economics in Harvard Medical School's Department of Health Care Policy.
Frank and his co‐authors, Stanford University's Keith N. Humphreys, Ph.D., and the University of Chicago's Harold A. Pollack, Ph.D., argue that financing reform alone will not suffice to combat an opioid epidemic that again has worsened during the COVID‐19 crisis. They advocate robust mechanisms for accountability in service delivery, with some of their criticism targeted to those who perpetuate ineffective treatment approaches.
“We spend a lot of money on stuff that not only doesn't work but is dangerous,” said Frank, a former administrator in the U.S. Department of Health and Human Services (HHS). Atop that list, he says, is inpatient detoxification with no follow‐up care for a substance use disorder (SUD). “That's the poster child,” Frank said.
Financing, delivery recommendations
Much of the paper is devoted to strategies for improving addiction treatment financing and delivery, with an emphasis on integrating financing within mainstream public and private insurance. The authors advocate channeling most new federal money through Medicaid, Medicare and other federal systems such as the Veterans Health Administration and the Indian Health Service (IHS). Frank says there should be a pivot in emphasis that would ultimately result in the provider and advocacy communities becoming as adept in Medicaid and Medicare funding as they now are in state‐managed grants.
“We spend a lot of money on stuff that not only doesn't work but is dangerous….[inpatient detoxification with no follow‐up care is] the poster child.”
Richard G. Frank. Ph.D.
On the private insurance side, the authors see expanded enforcement of the federal parity law as further integrating behavioral health into mainstream insurance. They recommend the formation of a high‐level “fusion center” made up of the Department of Labor, HHS and the Treasury Department that would educate and monitor insurers and establish criteria for auditing health plan practices on utilization review, medical necessity, provider reimbursement and other key areas.
Also, HHS should partner with stakeholders to launch a national public education campaign on consumer rights under the parity law and how to file complaints over violations, the researchers suggest. The most recently adopted COVID‐19 relief package already authorizes some additional spending for parity enforcement efforts, Frank said. “These are building blocks,” he said.
Another advantage to moving away from dependence on block grants or one‐time grant programs, Frank said, is “insurance programs and Medicare/Medicaid come with a set of national accountability standards that you don't see in grant programs.”
Regarding specific treatments for opioid use disorder, the paper proposes a series of incentives for wider use of agonist medications. These include:
increasing Medicaid's Federal Medical Assistance Percentage for states that adequately reimburse addiction treatment providers, “clawing back funds from states that do not raise reimbursement levels,” the paper states (this would require federal legislation);
eliminating access barriers to medication treatments within Medicare Part D drug plan formularies;
targeting resources to guarantee in‐house addiction treatment expertise within all federally qualified health centers and IHS facilities; and
expanding the use of medication treatment in the criminal justice system, such as through legislation allowing for Medicaid reimbursement for addiction treatment services commencing 30 days prior to one's release from custody. Also, “The Attorney General could restore the Obama administration's directive that no federal funds be provided to drug courts that fail to offer participants all three FDA‐approved [medications for opioid use disorder],” the report states.
The authors argue that weak accountability demands on providers allow for the perpetuation of ineffective SUD treatment. They cite in their paper a 2020 “secret shopper” study published in the Journal of the American Medical Association that found fewer than four in 10 residential treatment programs offer any opioid agonist treatment, and 21% actively discourage admission of patients who are receiving an agonist medication.
Don't disregard supply
The other component of the policy paper offers suggestions for reducing the population's exposure to addictive drugs. Frank admits that if he had been told several years ago that he would be co‐authoring a policy paper recommending several supply‐side initiatives, he would have seriously questioned that. What has changed the equation since? The presence of fentanyl in the drug supply.
The paper, then, recommends that the United States enter multilateral agreements to gain more international control over fentanyl and other opioid shipments. “The U.S. also has much to offer, including as the home base for some pharmaceutical companies aggressively pushing prescription opioids overseas using tactics now outlawed in the United States,” the authors wrote.
They added that the highest priority in international efforts should focus on Mexico, where they say the U.S.'s commitment to assisting with public health challenges such as COVID‐19 would build trust toward cooperative activity on drug supply control.
Other recommended strategies for reducing the population's exposure to substances include adjusting for inflation the flat federal excise tax rates on alcohol, and reforming or repealing a 2016 federal law that inhibits the Drug Enforcement Administration's authority to respond to entities that fail to report suspect opioid shipments.
“The Biden administration faces many policy challenges,” the paper concludes. “None — including the immediate threat from COVID — is likely to take more lives than opioids over the full Biden presidency.”