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Trump said he would end the opioid crisis. When’s he going to start?

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

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President Trump came into office promising to end the opioid crisis that is now killing more than 30,000 Americans a year. Full stop.

But since January, people who work on the issue have been in a near-constant state of panic. Almost every signal from the Trump administration has been one of retrenchment on drug addiction, not embracing the public health mentality favored by advocates.

On multiple fronts, Trump's team has given the recovery community reason to worry:

  • The president is weighing the almost complete elimination of the White House "drug czar" office, per Politico. The office has some baggage from its war on drugs days, but many recovery advocates believe it could be their seat at the White House table with the right leader.
  • Trump has proposed major spending cuts across the public health spectrum: CDC, NIH, HHS, etc. "The White House has stated many times that the opioid epidemic and drug addiction is a high priority," Andrew Kessler, a lobbyist who works on the opioid crisis, told me. "In Washington, however, priorities are illustrated through budgets."
  • The House health care bill that Trump is pushing would cut spending for Medicaid — the single largest payer of addiction services in the country — by more than $800 billion over 10 years. It would also allow states to opt out of the Obamacare rule that health plans cover certain services, including addiction treatment.
  • HHS Secretary Tom Price disparaged medication-assisted treatment, widely considered an essential tool in combating addiction and preventing overdoses, this week. “If we’re just substituting one opioid for another, we’re not moving the dial much,” he said. “Folks need to be cured so they can be productive members of society and realize their dreams.”
  • Attorney General Jeff Sessions is considering reprioritizing mandatory minimum sentences for low-level drug offenses, reversing a change made by the Obama administration that was seen as deescalating the war on drugs.

Taken together, despite Congress's recent support for more treatment funding and public health strategies, advocates fear Trump is moving the drug addiction issue back into the law enforcement arena.

"Republicans in both Congress and the administration are keen on putting more focus on criminal justice and less on public health to combat the opioid scourge," one advocate who closely tracks the action in Washington told me. "One of things that keeps me up at night as a person in recovery is we may be going back to criminalizing addiction."

The most positive sign they could point to is Trump's commission on opioids, led by New Jersey Gov. Chris Christie. But as one advocate put it in an email: "You can have all the listening sessions and commissions you want. It's all about the $$$."

The crisis is going to play a part in the Senate's debate on its health care reform bill. Crucial votes like Sens. Rob Portman (R-OH) and Shelley Moore Capito (R-WV) are worried about what rolling back Obamacare's Medicaid expansion too quickly would mean for those receiving treatment that is covered by the program.

Portman told reporters this week that in Ohio, one of the states hardest hit by opioid addiction, half of the costs for people covered by Medicaid expansion are estimated to pay for mental health and addiction services.

"We’re facing the worst drug crisis in the history of our country," he said. "We’re just trying to be sure, at a time that we’re facing this crisis, that we don’t make this worse.”

He suggested, for example, though the enhanced federal funding for Medicaid expansion could eventually be phased out under the GOP bill, more robust financial assistance for people to buy private insurance could help offset the risks for people in recovery who got covered through the expansion.

“There are ways to do this," Portman said. "Our own strategy, rather than relying on what the House did, is to look at this with fresh eyes and think, 'How can you ensure these people continue to get coverage?'”

You can expect advocates to be watching the specifics of any such proposal closely.

Chart of the Day


The government subsidy for health insurance to rule them all. We spend a lot of time talking about Obamacare's tax subsidies and its Medicaid expansion. But never forget the huge outlay in the federal budget for the unlimited tax break for employer coverage. Read more from Axios here.

Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

Today’s top news:

  • "Senate health care effort wrestles with spending vs. coverage": “Many GOP senators have been clear that they want their health care bill to have more generous tax credits than the House bill and to soften its Medicaid expansion phaseout. But their hands may be tied: According to Senate budget rules, the upper chamber's bill must save at least as much as the House bill. And the changes some of these more moderate senators want cost money.” —Caitlin Owens, Axios
  • "Senate Panel Rejects Bid to Ease Drug Imports From Canada": “A Senate panel on Thursday rejected a Democratic effort to make it easier for Americans to purchase medications from Canada, where prescription drugs are typically sold at significantly cheaper prices than in the United States.” —Jon Reid, Morning Consult
  • "Trump’s pick to run mental health is poised to shake things up. Even some liberals can’t wait": “President Trump’s pick to run federal mental health services has called for a bold reordering of priorities — shifting money away from education and support services and toward a more aggressive treatment of patients with severe psychiatric disorders. The proposal has some psychiatrists — a generally liberal bunch — cheering despite their distrust of the Trump administration.” —Meghana Keshavan, Stat News

Analysis and longer reads:

  • "The Bipartisan ‘Single Payer’ Solution: Medicare Advantage Premium Support For All": “As conservative heavyweight Charles Krauthammer recently asserted, we may be heading 'inexorably' toward a single-payer system. Poll after poll has in fact shown that a majority of Americans support such an approach. Most recently, an Economist/YouGov survey found that 60 percent of Americans support expanding Medicare to cover everyone, with only 23 percent opposed.” —Billy Wynne, Health Affairs

"52 ways to repeal Obamacare": “Senate Republicans want to do their own Obamacare repeal plan — but nearly all 52 Republicans have their own ideas about how it should look. With his razor-thin majority, Majority Leader Mitch McConnell can afford to lose only two GOP votes. That turns each senator into a de facto powerbroker with the ability to shape — or kill — legislation simply by aligning with two other members.” —Jennifer Haberkorn, Politico

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