Trump Budget Ups Funds to Fight Opioids, Cuts HHS

Alicia Ault

February 12, 2018

President Donald J. Trump's 2019 budget proposal adds $30 billion in new federal spending to combat the opioid crisis over the next 5 years, while cutting 21% from the Department of Health and Human Services (HHS) budget.

At the same time, the budget teases the idea of relaxing federal penalties and requirements for meaningful use of electronic health records. It also targets physician training programs.

The budget "supports our four priorities here at HHS: addressing the opioid crisis, bringing down the high price of prescription drugs, increasing the affordability and accessibility of health insurance, and improving Medicare in ways that push our health system toward paying for value rather than volume," said HHS Secretary Alex Azar in a statement.

The proposed 2019 budget requests $68.4 billion for HHS, which is a $17.9 billion — or 21% — decrease from the 2017 enacted level, according to budget documents.

The new budget did not originally take into account the spending agreement just signed into law by Trump on February 9. White House Office of Management and Budget Director Mick Mulvaney told Congress today that the administration has now taken that bill into account, and that it supports removal of spending caps for defense but not for nondefense spending.

Opioid Funding Prioritized

Although many federal agencies overseeing the fight against the opioid crisis will experience overall cuts, they will also get new funds earmarked for prevention, treatment, and interdiction.

The White House Office of National Drug Control Policy, which had been rumored to be on the chopping block, would instead get $17 million, keeping it level with its 2017 funding.

The $30 billion in opioid funding would be spread out over 14 executive branch departments, the federal judiciary, and the District of Columbia, according to the budget.

HHS would get $1 billion in 2019, to be allocated to the following areas:

  • $50 million for a media campaign;

  • $625 million for state responses;

  • $50 million to improve first responder access to overdose-reversal drugs;

  • $100 million for surveillance and opioid abuse prevention activities, including improving prescription drug monitoring programs (PDMPs);

  • $20 million for drug courts;

  • $10 million for treatment for pregnant and postpartum women

  • $10 million for FDA efforts to develop tools to stem the misuse and abuse of opioids; $65 million to support multisector, county-level teams in high-risk rural communities to improve access to care, and expand treatment and recovery services;

  • $45 million for supplemental grants for opioid abuse prevention, treatment, and recovery services in American Indian and Alaska Native communities;

  • and $25 million to evaluate the impact of medication assisted treatment on reducing overdose deaths.

The budget would allot $100 million to the National Institutes of Health (NIH) for work with the pharmaceutical industry to develop addiction prevention strategies, treatments for addiction and overdose reversal, and nonaddictive therapies for pain. The Substance Abuse and Mental Health Services Administration (SAMHSA) would get $123 million for opioid abuse prevention, treatment, recovery support, and overdose reversal, and the US Centers for Disease Control and Prevention (CDC) would receive $126 million to support prevention and surveillance.

The budget is proposing to help Medicaid expand coverage of evidence-based

Medication Assisted Treatment (MAT) programs, and to test bundled payments for community-based MAT for Medicare, along with coverage of methadone treatment, which previously has been prohibited by Medicare.

Medicare Part D drug plans will be required to participate in federal programs to prevent prescription drug abuse. Also, if a prescriber is barred from Medicare because of abusive prescribing, the Drug Enforcement Administration would be allowed to revoke a provider's certificate.

Finally, the administration is proposing to strengthen opioid addiction prevention in schools, by allotting $43 million to a Department of Education program that would help school districts implement multitiered, evidence-based strategies to prevent opioid misuse and address associated behavioral and academic challenges through interventions such as trauma counseling, violence prevention, and targeted academic support. This funding would also support technical assistance centers that develop and provide opioid abuse prevention and treatment resources that would be publicly available to all schools and institutions of higher education.

Trump also said his administration would prevent illegal drugs from coming into the United States through Mexico — in part through a proposed $18 billion wall.

CDC, NIH, ACA Take Hits

The NIH budget — which was targeted by the Trump administration for cuts in its 2018 budget request — gets a very slight reprieve in 2019, with a request that restores it to 2018 appropriations — about $34 billion. Still, most institutes within NIH would take a cut, including the National Cancer Institute. However, the National Institute on Neurological Disorders and Stroke, the National Institute on Mental Health, and the National Institute on Drug Abuse would all get increases.

The CDC is due for a big cut of about $1 billion — most of it coming from an $800 million reduction in the Affordable Care Act's (ACA) Prevention and Public Health Fund. The CDC, which received almost $8 billion in 2018 outlays, would see its funding reduced to $7.5 billion.

The US Food and Drug Administration (FDA) would get slightly less than the $3.3 billion it received in 2017, while SAMHSA would get a small increase — to about $3.6 billion, up from $3.4 billion it was allocated in 2017.

A key element of the new HHS budget is to repeal and replace the ACA. Trump said that the proposed budget would create $675 billion in savings across HHS and the Department of the Treasury. "The President is committed to rescuing States, consumers, and taxpayers from the failures of Obamacare," according to the budget proposal.

The Trump administration wants to see the ACA replacement proposed by Senators Lindsay Graham (R-SC) and Bill Cassidy, MD (R-LA) enacted as quickly as possible. That bill ran into a dead end in the Senate in September last year.

Similar to Graham-Cassidy, the proposed budget would allow states to eliminate the essential benefits requirement for policies. It also would reverse the ACA's Medicaid expansion, and instead turn the program into block grants to states, institute per capita spending caps, and prioritize grant money to states that establish work requirements for Medicaid recipients.

Among the administration's key goals, the budget proposes reducing drug prices "by addressing perverse payment incentives and exposing drug companies to more aggressive competition, all while continuing to promote innovation and extend American dominance in the pharmaceutical field," according to the budget. It would do that by tinkering with the 340B program that pays for drugs administered in the hospital; allowing five states to test negotiating prices directly with drug makers; and creating an out-of-pocket drug spending cap for Medicare beneficiaries.

Reprieve From Meaningful Use?

Included in the new budget is a proposal that hospitals and physicians would have "freedom to use electronic health records as they deem best," according to a summary of the budget document released by the White House today. Not surprisingly, the budget proposal would cut the Office of the National Coordinator of Health IT's budget by a third to $38 million.

The budget for the fiscal year beginning in October would also eliminate

"reporting burden and low-value metrics in performance-based payment for physicians," and improve physician incentives to participate in Medicare's advanced payment models. And it proposes to overhaul medical malpractice laws.

The budget also takes aim at physician training programs, stating that they are inefficient, and that more needs to be done to address physician shortages, especially in underserved areas. Toward that end, the president proposes to consolidate graduate medical education (GME) spending in Medicare, Medicaid, and the Children's Hospital GME Payment Program into a new mandatory GME capped grant program. Funding would be targeted to address medically underserved communities and health professional shortages. Some $451 million will be cut from other health professions and training programs, "which lack evidence that they significantly improve the Nation's health workforce," according to the budget.

Public Health Service Targeted

The budget proposes to "modernize" the US Public Health Service Commissioned Corps, which consists of about 6500 uniformed public health professionals — including the Surgeon General and many in the leadership of the CDC. The move was already signaled by the administration when it failed to deliver on a congressional order to transition to a special pay system by January 28.

At that time, the corps was told that its members should expect a cut in pay for the foreseeable future, according to the Washington Post.

According to the Trump budget, the corps is receiving higher pay than civilian counterparts doing the same jobs, and that its "mission, assignments and functions have not evolved in step with the public health needs of the Nation." It said it would look at possibly phasing out the corps, or slimming it down.

The budget also proposes to streamline administrative functions at the NIH, but it does not offer specifics.

The Trump budget includes a number of other health-related proposals, including:

  • New investments to connect individuals with serious mental illness to treatment, including Assertive Community Treatment; increased funding to improve mental health services for those in the criminal justice system; and, maintenance of funding for the Community Mental Health Services Block Grant.

  • Expansion of Medicare's site-neutral payment policy.

  • Allowing Medicare beneficiaries who are in high-deductible health plans to make tax-deductible contributions to health savings accounts.

  • Creating a $40 million, five-state demonstration project administered by the CDC to jointly eliminate multiple infectious diseases, focusing on areas seeing a rise in infectious diseases related to opioid abuse.

  • Reauthorization of the Ryan White HIV/AIDS Program.

  • Modifying hospital payments for uncompensated care.

The full text of the budget proposal is available on the White House website.

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