ASHINGTON — The Senate is likely to pass a comprehensive bill to address the opioid crisis in the coming weeks. The House did so in June.
But the finish line on that long-discussed priority remains a long way off.
Lawmakers have left untouched many of the bill’s most contentious issues, like debates over patient privacy and expensive changes to Medicaid payments for addiction treatment. There’s no sign yet they’ll iron out those issues before the Senate votes.
That procrastination means a select group of lawmakers will spend September and October — if not longer — hammering out the contentious details. A final vote, lawmakers, congressional aides, and lobbyists told STAT, likely won’t come until the lame duck session this November.
“Every Republican senator has approved moving the bill to the floor,” Sen. Lamar Alexander (R-Tenn.), who has shepherded much of the bill, said this week. “As soon as both parties agree, we can have a roll call vote next week. When we do that, it’ll get virtually unanimous support, and then we’ll work with the House and put the bills together.”
Worse yet, in the eyes of many addiction treatment and prevention advocates, the theatrics and the delay could all prove for naught. The bleak appraisal one advocate familiar with the legislation offered: “A little drama for little substance.”
A copy of the Senate legislation reviewed by STAT outlines a number of proposals advocates are likely to support, including provisions that expand access to the addiction treatment drug buprenorphine and step up screenings for fentanyl being illegally imported by mail.
The bill would also give patients easier access to some addiction treatments via telemedicine; fund new tools to train providers about pain treatment and screening for substance use disorders; and encourage better disposal of unused prescription opioids.
But, as was the case with the House version, it does little to fundamentally alter the way addiction is treated in the U.S., where evidence-based care that includes counseling and medication remains the exception and not the norm.
“Overdose rates continue to rise, and our response is still falling short given the mammoth size of the problem,” said Andrew Kessler, the founder of Slingshot Solutions, a behavioral health consulting group. “We are in the early phases of our response to this epidemic, and I can only hope that this bill is the first of many we can pass.”
Republican leaders in the Senate have nonetheless worked in the past week to resolve objections from as many as seven senators across both parties. One Democratic senator continues to block the bill from a floor vote, a spokesman for Majority Leader Mitch McConnell (R-Ky.) reiterated on Wednesday. Minority Leader Chuck Schumer (D-N.Y.) didn’t comment on which of his colleagues was blocking the legislation, or why.
Assuming the Senate votes in the coming weeks, lawmakers have plenty of boxes left to check off. High on the list: They must decide whether to repeal the so-called IMD exclusion, a regulation that prevents addiction treatment facilities with more than 16 inpatient beds from receiving Medicaid dollars. Advocates say the cap severely limits how many patients can seek help.
The House bill repeals the provision, but only for opioid use disorder and cocaine addiction. Advocates say that language is impractical, as many seeking treatment use multiple substances, and would effectively discriminate based on the drug an individual uses.
The Senate’s version does not include any language to address the issue.
Sen. Rob Portman (R-Ohio) is still hoping the final version will repeal the cap — for all substances. He told reporters this week he had worked out a draft version that fell just short of earning a shaky agreement between leaders in both parties.
“We’ve worked out an agreement that I think most leadership on both sides agree with, but we weren’t able to get the signoff from everybody,” Portman said.
That means he’s stuck with the House version — and still hoping it “can be improved,” he added.
Another unresolved policy issue is the debate over whether medical providers should have much broader access to information about a patient’s history with substance use disorders.
The House bill includes an iteration of “Jessie’s Law,” named for a Michigan woman in recovery from an opioid addiction who overdosed after a post-surgical oxycodone prescription. It would eliminate a restriction that information on past substance use treatment can only be released with patient consent.
The charge to repeal those privacy requirements has not been partisan, with Reps. Markwayne Mullin (R-Okla.) and Earl Blumenauer (D-Ore.) leading the charge in the House.
But opponents of the legislation caution that more prominently displaying a patient’s past substance use in medical records — especially without a patient’s consent — could discourage some patients from seeking addiction treatment, given the discrimination Americans with addiction often face in medical and other settings.
Right now, the Senate bill includes a softer version of the change, which would only encourage the Department of Health and Human Services to develop best practices for displaying information about past substance use, when requested by the patient.
House leaders, including Rep. Greg Walden (R-Ore.), the chair of the Energy and Commerce Committee, have indicated internally that they are unlikely to leave a conference process without securing their version of patient privacy reform, according to sources familiar with the negotiations.
Complicating matters further is a contentious November midterm election in which Democrats are largely expected to seize control of the House.
That could make it even harder to negotiate a deal on a major piece of legislation like an opioids package. Advocates are already wary of a scenario in which Democrats, soon to assume power, and Republicans, soon to leave Washington, cannot reach a final agreement, leaving Congress exactly where it started after two years of talk.
For now, however, the lawmakers who have worked hardest on the Senate package are still pushing to make sure it gets a vote in September.
“Sen. Alexander has worked with everybody — he said 70 senators — to make sure that our viewpoints are taken into consideration,” said Shelley Moore Capito (R-W.Va.). “A lot of that is in the bill.”