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Trump’s budget proposal does nothing for the opioid epidemic

Experts say the US needs to spend a lot more money to fight the opioid crisis. Trump isn’t listening.

President Donald Trump walks to the White House after a weekend at Mar-a-Lago in March 2019.
President Donald Trump returns to the White House.
Al Drago/Getty Images

President Donald Trump’s budget proposal shows that his administration isn’t interested in spending much more to combat the opioid epidemic, even as drug overdoses were linked to more than 70,000 deaths — a record high — in 2017.

The budget plan does propose some new funding to fight the opioid crisis, including $245 million over 10 years to let states “extend Medicaid coverage for pregnant women with substance use disorder to one year postpartum.” But it also proposes cuts to some opioid-related programs, particularly at the Department of Justice. At best, the budget maybe adds some tens of millions a year to address the problem.

Tens of millions of dollars may sound like a lot of money, but it’s almost nothing in a budget valued at $4.7 trillion for 2020.

It’s also far short of the tens of billions of additional dollars that experts say is needed to address the opioid crisis. For reference, the White House’s own Council of Economic Advisers in 2017 linked the opioid epidemic to $500 billion in economic losses — so spending tens of billions would be only a fraction of what the White House says the crisis is costing the US.

Trump’s budget plan does implement spending and laws enacted by Congress in recent years to address the opioid crisis, including $3 billion a year approved by Congress early last year.

But Trump himself seemed to acknowledge that this wasn’t enough money. Last year, his budget plan called for an additional $7 billion for 2019. This year’s budget proposal drops that request — with no explanation as to why that money is no longer necessary.

Beyond the lack of money for the opioid epidemic, Trump also proposes steep cuts to domestic programs that could make the current crisis worse. Most notably, he calls for slashing hundreds of billions of dollars from Medicare and Medicaid — both of which, as health insurance programs, can help connect people to addiction treatment. Medicaid in particular pays for a quarter of drug addiction treatment in the US.

The budget proposal does call for $8.6 billion to build parts of a wall at the US-Mexico border, which Trump argues would help combat the flow of illicit drugs into the country and, as a result, mitigate the opioid crisis. But experts say this would be ineffective since most illegal drugs come through legal ports of entry, not through illegal border crossings that a wall would aim to stop.

The White House did not immediately respond to questions about the budget proposal.

The president’s budget blueprint is very unlikely to make it through Congress, especially now that Democrats control the House. But the budget plan offers a look at Trump’s priorities. The opioid epidemic is apparently not one of them, even as the statistics suggest that much more action is necessary.

Trump needs to go bigger

The opioid epidemic is a truly massive crisis. Since the 1990s, more than 700,000 people in the US have died of drug overdoses, mostly driven by the rise in opioid-related deaths. That’s comparable to the number of people who currently live in big cities like Denver and Washington, DC. Some estimates predict that hundreds of thousands more could die in the next decade of opioid overdoses alone.

When experts talk about the current epidemic, they compare it to previous public health crises like HIV/AIDS, which also killed tens of thousands of Americans each year.

“To actually stem the tide of overdose deaths, we need funding and innovation that is on par with our response to HIV/AIDS,” Sarah Wakeman, an addiction medicine doctor and medical director at the Massachusetts General Hospital Substance Use Disorder Initiative, previously told me. That, she explained, will require “a massive infusion of funding and a fundamental restructuring of how we treat addiction in this country.”

The New York Times last year asked 30 experts how they would spend $100 billion over five years to address the opioid epidemic — a number comparable to how much the US spends domestically on HIV/AIDS. That may sound like a lot, but some experts cautioned that even that amount of cash may not be enough.

That’s in large part because a lot of America’s addiction treatment infrastructure is in a very bad spot.

Federal data suggests that only one in 10 people with any substance use disorder and one in five people with an opioid use disorder seek specialty treatment. Even when an addiction treatment clinic is available, fewer than half of facilities offer any of the opioid addiction medications, such as methadone or buprenorphine, as an option, even though the medications are widely considered the gold standard for opioid addiction treatment. In other words, treatment is inaccessible enough that most people who need it don’t get it, and even when treatment is available, it doesn’t meet the best standards of care.

To change this, Congress needs to invest much more, and for the long term. In response to the HIV/AIDS crisis, for example, Congress set up the Ryan White program to provide long-term, sustained resources to deal with HIV/AIDS, particularly in the worst-hit communities. Unlike the limited-time grant money that lawmakers have allocated for the opioid crisis so far, the Ryan White funding is something that people on the ground know they can rely on for years to come.

Some lawmakers have called for similar actions in response to the opioid crisis, like the CARE Act proposed by Rep. Elijah Cummings (D-MD) and Sen. Elizabeth Warren (D-MA). But these proposals have not moved forward in Congress, largely due to Republican concerns about the extra spending.

Instead, Congress has passed limited measures like the Support for Patients and Communities Act, which Trump signed into law last year. As Stanford drug policy expert Keith Humphreys told me when the law passed, it takes some good steps, but it just isn’t enough: “This reflects a fundamental disagreement between the parties over whether the government should appropriate the large sums a massive response would require. Lacking that, Congress did the next best thing — which is to find agreement on as many second-tier issues as they could.”

Experts have long told me there is no silver bullet that will solve the opioid epidemic overnight, but there’s a mix of policies that would help: more treatment (particularly medications like methadone and buprenorphine), more harm reduction (such as better access to naloxone), fewer painkiller prescriptions (while ensuring the drugs are available to those who really need them), and policies that can help address the root cause of addiction (like mental health issues and socioeconomic despair).

A recent study by Stanford researchers found that a mix of these options could save at least tens of thousands of lives in the next decade.

But Trump hasn’t embraced a full approach. He hasn’t called for putting tens of billions of dollars toward treatment infrastructure. His administration declared a public health emergency over the opioid epidemic, but nothing significant came out of it. When he has spoken about the crisis, he’s done so to advocate for ineffective policies such as the wall and expanded use of the death penalty.

That shows in Trump’s budget, in which the opioid epidemic is relegated to practically a non-issue.