Alicia Ault

May 24, 2017

SAN DIEGO — It was supposed to be an opportunity for an official from the Substance Abuse and Mental Health Services Administration (SAMHSA) to present the agency's challenges and opportunities over the next 4 years to delegates attending the American Psychiatric 'Association (APA) 2017 Annual Meeting.

But after inviting attendees to ask questions, Acting Deputy Assistant Secretary Kana Enomoto, MA, was bombarded with complaints, concerns, and fears from psychiatrists who said they were worried the Trump Administration was gutting mental healthcare.

The anxiety in the room was palpable as, one after another, clinicians asked how they could protect their patients from what they viewed as an unsympathetic Trump Administration.

"A lot of stuff is going on that's very upsetting to us as psychiatrists, which is why we are here," said a female clinician from Los Angeles. "It would be nice to know, as psychiatrists, how we can get involved…and be advocates for our patients," she said.

"This whole system is upside down and we don't seem to understand it," said another woman, who said she was originally from Canada but had lived in the United States for 40 years. Under President Obama, she said, "it felt like we did go in the right direction." Now, she said, "it's terrifying to me to see it going backwards."

Karen Wiener, MD, who works in the Rochester Regional Forensic Unit at the Rochester Psychiatric Center, New York, also wanted to know what psychiatrists could do to help influence the administration when it came to funding the National Institutes of Health and other government agencies.

"It feels like we're stepping backwards in time instead of going forward and it's very, very frightening," said Dr Wiener.

The session came on the day President Trump issued his proposed budget  for 2018. The document outlined $610 billion in cuts to Medicaid over the next decade, a phase-out of the Children's Health Insurance Program, a proposal that will make it harder to qualify for Social Security disability and reduce the program by $72 billion, a repeal of the Affordable Care Act, and an 18% cut to funding for the Department of Health and Human Services (including the National Institutes of Health, which would also see an 18% reduction).

Enomoto told Medscape Medical News that she was not authorized to discuss SAMHSA's budget. Attendees pressed her for details, but she told them that the agency's budget picture is more complicated than what might be contained in the just-released Trump document.

SAMHSA's budget would be cut by $400 million, or 9%, in 2018. But the agency has also received a recent funding boost from two new laws: the 21st Century Cures Act ($1 billion over 2 years) and the Comprehensive Addiction and Recovery Act ($20 million in 2017).

An Opportunity vs a Problem?

Enomoto said she's begun using a Chinese proverb as a mantra: "During times of great wind some build windmills, others build bunkers." With the new administration, "there are opportunities, and we have to look at those opportunities," said Enomoto.

With so much focus on opioid use, "there is a light being shown on our issues," she said. And, the three clinical policy priorities outlined by HHS Secretary Tom Price — opioids, serious mental illness, and childhood obesity — fall within the purview of psychiatry, said Enomoto.  "I absolutely think he's willing to listen" to clinicians' concerns, she said.

Psychiatrists will have a chance to influence funding and program directions by making their views known to the President's Commission on Combating Drug Addiction and the Opioid Crisis and the Interdepartmental Serious Mental Illness (SMI) Coordinating Committee, said Enomoto.

The SMI committee will soon be seeking nominations to fill the 14 slots for members of the public. Secretary Price is seeking to chair the committee himself and has asked the heads of various agencies to step into the seats being held open for rank-and-file officials, said Enomoto.

One member of the audience still was not satisfied. He said the government was in the midst of a huge reorganization and criticized Enomoto for focusing only on opioids.

"These are small potatoes items you're talking about," he said. "What are the budget cuts going to mean, and how is the government going to be reorganized? What should APA members be doing in this environment, what should we be doing to make sure our patients are going to be taken care of?"

Enomoto noted that as a representative of the federal government and the President, she could discuss programs but not tell doctors exactly how to be advocates.

"Some of this is up to you to figure out where and how you can be involved," said Enomoto, who urged psychiatrists to look closely at the proposed cuts and to work with the APA to make their concerns known to members of Congress and state and local representatives.

"I think we have to be on our toes for the next 4 years," Enomoto said.  Her final thought: "How do we make the best out of what is certainly a challenging situation?"

American Psychiatric Association (APA) 2017 Annual Meeting. Presented May 23, 2017.

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