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Opioid Crisis Legislative Update

Late last week, Senator Lamar Alexander (R-TN) and Senator Patty Murray (D-WA) released a discussion draft of the bipartisan Opioid Crisis Response Act of 2018. The legislation follows a series of six hearings held by the Senate Health, Education, Labor, and Pensions (HELP) Committee since October 2017, and is intended to improve the ability of the Departments of Education, Labor, and Health and Human Services (HHS) to address the opioid epidemic and its effects. Senator Alexander explained, “The opioid crisis is currently our most serious public health epidemic and despite efforts in every state, it’s getting worse. Our response needs to be urgent, bipartisan and effective.”

The House Energy and Commerce Committee has also scheduled a second hearing as they work to compile an opioid legislation package this spring. The hearing is entitled, “Combating the Opioid Crisis: Improving the Ability of Medicare and Medicaid to Provide Care For Patients.” We will live Tweet both the HELP and Energy Commerce Committee Hearings.

In rural America, we have seen the devastating effects of the opioid epidemic since the beginning of this crisis. While only 20 percent of Americans live in rural areas, a disproportionate number of rural communities are struggling with prescription opioids and heroin abuse. According to the Centers for Disease Control and Prevention, rural Americans are more vulnerable to prescription painkiller abuse and overdoses, and the rate of opioid-related overdose deaths in nonmetro counties is 45 percent higher than in metro counties. While there are sections of the Opioid Crisis Response Act that do not address the needs of rural Americans, there are some essential provisions that may assist those rural communities that have been most impacted by this crisis.

Proportional Distribution of Funding
In the 21st Century Cures legislation, passed in 2016, the House and Senate authorized $1 billion in funding for the next 2 years to combat the opioid epidemic. Currently, this funding is being allocated to the states based on the mortality rate and the size of each state. Lawmakers responsible for the legislation intended that money be distributed using a per-capita formula to account for the needs of smaller states impacted more heavily by the crisis. West Virginia has the highest overdose death rate in the country, but only received $5.8 million out of the $500 million allocated for this year. Second-ranked New Hampshire was given $3.1 million, and Kentucky, the third highest received about $11 million. Texas and California, though larger states with bigger populations, had proportionately some of the lowest overdose death rates in the country. Nevertheless, Texas received $27.3 million and California received $44.7 million.

We need proportional distribution of funding to ensure that the states hardest hit by the opioid epidemic have an opportunity to recover. The current formula does not sufficiently consider the scope of the crisis and favors larger states because of the all too significant role that population plays in the equation. We were pleased to see that the Opioid Crisis Response Act corrects this by concentrating federal funds on states and tribes that have been most impacted by the opioid crisis. The bill would appropriately update the funding formula authorized by the 21st Century Cures Act to account more for the number of overdose deaths in each state.

Treatment Opportunities: Telemedicine and MAT
Medication Assisted Treatment (MAT) has been shown to have great success rates. When prescribed and monitored properly, MAT has been shown to reduce illicit drug use and reduce the rate of accidental overdose. However, while as many as 2.5 million people are suffering from substance use disorder, less than 40% have access to MAT. Training to administer buprenorphine is the easiest to complete, but of the 2.2% of U.S. physicians who have received a waiver to prescribe buprenorphine, 90.4% practice in non-urban counties. 82.5% of rural counties do not have a single physician who has obtained a waiver. This legislation would make permanent the ability of nurse practitioners and physician assistants to prescribe MAT and codifies the ability for physicians to prescribe MAT for a larger number (275) patients. Still, we need to work to ensure that there are more NP’s, PA’s, and physicians who have the training and ability to administer MAT in rural areas.
Telemedicine provides the opportunity for care in otherwise underserved communities. Seventy-seven percent of rural communities are Health Professional Shortage Areas (HPSAs), and in 55 percent of all American counties, most of which are rural, there are no psychologists, psychiatrists or social workers. The Opioid Crisis Response Act works to improve the regulations under the Drug Enforcement Association to expand access to telemedicine. The legislation would allow community mental health and addiction treatment centers to register with the DEA to treat patients using telemedicine. As a result, qualified centers could work with the DEA to treat more patients, specifically in rural areas with few or no qualified providers.
Workforce and Provider Shortages
Additionally, to address the above-mentioned workforce and provider shortages in rural areas, the legislation would allow health providers participating in the National Health Services Corps (NHSC) through the Health Resources and Services Administration (HRSA) to provide services in schools in areas with that have been hit hardest by the opioid crisis and with mental health professional shortages. This also allows licensed substance use disorder (SUD) treatment counselors to receive loan repayment for practicing in underserved areas.
The bill also includes grants to address the economic and workforce impact of the opioid crisis. The goal of these grants would be to support state workforce boards to target workforce shortages in the substance use and behavioral health treatment workforce. They would also facilitate the streamlining of job training and treatment services. While we appreciate the intention of these two provisions, we do ask that they be more specifically focused on rural areas impacted by the crisis.
Medicaid and Medicare Coverage
As we work to find cures for the opioid epidemic, we need to consider coverage of treatment under Medicaid and Medicare, especially for rural populations which are on average older, sicker, and poorer than their urban counterparts. The Energy and Commerce Committee is considering more than two dozen bills which would expand access and coverage to opioid treatment programs, including for telemedicine and other alternative SUD treatments.
We would like to see the Energy and Commerce Committee include the Caring Recovery for Infants and Babies (CRIB) Act in their consideration of Medicaid and Medicare treatment for opioids. NRHA supports this legislation which would establish residential pediatric care centers under Medicaid to provide treatment for babies born with neonatal abstinence syndrome (NAS).
Finding Solutions for Rural America
While the opioid crisis has now impacted communities across the country, we cannot forget the devastating toll it has taken on rural communities already still struggling to recover from the Great Recession. Substance abuse has torn through vulnerable rural communities with few health care resources and limited economic opportunity creating landscapes of despair. As we work to address the opioid crisis in our nation, we cannot afford to leave rural America behind. We must work together to develop a holistic approach that identifies treatment solutions that are practical for even the most remote areas and which address the causes of increased rates of substance abuse.

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