ASHINGTON — The House spent much of the last two weeks passing dozens of bills aimed at addressing the opioid crisis, an effort top lawmakers from both parties have long identified as a priority.
Many are consensus proposals, though a few have generated controversy. Some are substantial in their scope, though many fund pilot programs or studies, or enact grants for which funding will expire within years.
Outside experts, while applauding Congress for its focus on the issue, say they believe the current package fails to match the scope of the current crisis.
Politics, too, have played a role, with midterms looming this November. Republicans have been criticized for dividing the package into 57 bills with, accordingly, 57 or more GOP lawmakers who can claim credit for working to address the epidemic.
It also remains unclear exactly how and when the Senate will craft its own legislation. A spokesman for Senate Majority Leader Mitch McConnell (R-Ky.) said the legislation was a priority but acknowledged the Senate does not have a specific timeline for opioids legislation.
Lobbyists and Democratic congressional staffers have predicted that McConnell will wait until November — so that the roughly one dozen vulnerable Democrats in hard-hit states like West Virginia can’t advertise a “yes” vote on opioids legislation.
The House is expected to finish its opioids work this week. Here’s a look at some of the most impactful bills, and which proposals or policy ideas didn’t make the cut.
What’s in the package:
1. Evidence-based treatment: One bill, lawmakers and outside experts have said, is a common-sense proposal that has never formally been enacted: a requirement that any addiction treatment program funded by the Substance Abuse and Mental Health Services Administration exclusively fund evidence-based treatment. Such legislation is likely to shift federally funded treatment toward addiction medicines coupled with counseling and away from abstinence-based programs. A large majority of Americans with opioid addiction do not receive medication-based treatment, which is shown to substantially reduce overdose deaths.
2. Waiving the IMD exclusion — kind of: Many behavioral health advocates have long pushed to waive a restriction known as the institutions for mental diseases (IMD) exclusion, which prevents Medicaid from reimbursing for inpatient mental health or addiction treatment at facilities with more than 16 beds. Many believe the restriction has proven a bottleneck to addiction treatment; others have expressed concern that care delivered in many such facilities is not effective and that appropriate addiction treatment, more often than not, takes place in outpatient settings.
The House package makes it easier for states to waive the IMD exclusion, but the bill expires in five years.
3. Expanded access to buprenorphine: A controversial House bill would preserve the right of nurse practitioners and physician assistants to prescribe buprenorphine. Buprenorphine is a controlled substance, meaning it requires special permission to prescribe, and the bill also allows doctors to prescribe the drug to up to 100 patients immediately after they obtain a waiver.
4. A movement away from opioids for pain treatment: A bill passed by the House Ways and Means Committee aims to ensure there are no “misaligned financial incentives” to prescribe opioids via Medicare — a challenge for physicians, given the low cost of generic opioids and the many pricier options for medical devices or non-opioid medicines to treat pain.
5. Changes to medical privacy laws: After intense debate that had little to do with partisan politics, the House voted to authorize the disclosure of a patient’s history with a substance use disorder without the patient’s consent — a policy change specific to addiction treatment. The legislation’s backers say it could prevent doctors from prescribing opioids to patients with a history of addiction. Groups that favor stricter privacy standards have expressed concern that the change could prevent some individuals from seeking treatment.
1. Harm reduction: The package does little to further some of the most progressive ideas championed by some cities in the United States and Canada.
Namely, it does not expand syringe exchange services, which have been shown to reduce infectious disease transmission among injection drug users. It also does not change laws prohibiting supervised injection sites, though cities including San Francisco, New York, and Denver have expressed interest in pilot programs aimed at reducing overdoses. And the bill does not include a requirement that the overdose-reversal drug naloxone be co-prescribed with opioids, an increasingly popular concept for pain patients viewed as at high overdose risk.
2. Methadone treatment expansion for Medicare and Medicaid: A recent study found methadone to be the most effective drug in reducing mortality related to opioid addiction, followed by buprenorphine. Medicare programs as a whole historically have not covered methadone treatment for opioid use disorder, and a number of state Medicaid programs similarly cover buprenorphine but not methadone. The bills passed by the House allow more flexibility for Medicare, but do not fully address the Medicaid gap.
3. More parity enforcement: A proposal endorsed by Labor Secretary Alex Acosta would have given the federal government the authority to fine insurers who violate parity law — which requires equivalent coverage for physical and behavioral health conditions. An effort in the Senate to introduce such a provision fizzled, and the House did not address the issue.
4. Mandatory prescriber education: A House committee at one point had discussed the prospect of stricter limits on first-time opioid prescriptions and mandatory prescriber training for doctors. Neither policy is included among the House bills, though some legislation would create stricter oversight for opioid prescriptions and better monitoring for at-risk patients.