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Federal legislation and appropriations impacting the SUD field

Federal legislation and appropriations impacting the SUD field. Addiction Professionals of North Carolina ( APNC ) 2019 Policy Summit Raleigh, NC May 8, 2019. Robert Morrison, Executive Director/Director of Legislative Affairs. Topics to Cover. Intro to NASADAD

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Federal legislation and appropriations impacting the SUD field

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  1. Federal legislation and appropriations impacting the SUD field Addiction Professionals of North Carolina (APNC) 2019 Policy Summit Raleigh, NC May 8, 2019 Robert Morrison, Executive Director/Director of Legislative Affairs

  2. Topics to Cover • Intro to NASADAD • Recent legislative milestones • Comprehensive Addiction and Recovery Act of 2016 • 21st Century Cures Act of 2016 • Family First Prevention Services Act of 2018 • SUPPORT for Patients and Communities Act of 2018 • Federal budget and appropriations • Final appropriations for FY 2019 • Budget and appropriations for FY 2020 • What to expect next

  3. Overview of • Mission: To promote effective and efficient State substance use disorder prevention, treatment, and recovery systems. • Office in Washington, D.C. with Policy Department and Research Department. • Research Department houses component groups: prevention, treatment, women’s services, and SOTAs • Governed by Board of Directors • Cassandra Price (GA), President • Mark Stringer (MO), Public Policy Chair

  4. Role of State Alcohol & Drug Agencies • Placement in State government – varies by State May be in Departments of Health, Human Services, Social Services, etc. • Develop annual State plans to provide prevention, treatment, and recovery services • Ensure service effectiveness, quality, improvement and coordination • Collaborate with other State agencies Child welfare; criminal justice; drug courts; medical system; transportation; job training/placement, etc. • Represent key link to substance use disorder provider community • Convene stakeholder meetings • Manage the Federal Substance Abuse Prevention and Treatment (SAPT) Block Grant • Manage STR Grant and SOR Grant

  5. Substance Abuse Prevention and Treatment (SAPT) Block Grant • $1.8 billion formula grant administered by SAMHSA • Supports treatment for 1.5 million Americans per year • 20% set-aside for primary prevention • Flexible program that allows each State to direct resources for prevention, treatment and recovery to meet their own needs • Infrastructure for efficient and effective management and allocation of funds

  6. Without any significant funding increases over the past decade, the SAPT Block Grant has lost 24% of its purchasing power -24% or $444 million

  7. Recap: CARA, CURES, and FFPSA Series of legislative milestones impacting SUD field

  8. CARA of 2016 • CARA signed into law on July 22, 2016. • Provisions related to prevention and education, treatment, recovery, law enforcement, and services for women, families, and veterans, among others. • Provisions that NASADAD tracked closely: • Improving Treatment for Pregnant and Postpartum Women • Opioid Use Disorder Treatment Modernization (Buprenorphine Prescribing) CARA did not include funding for treatment of opioid use disorders.

  9. 21st Century Cures Act • 21st Century Cures Act • Originally focused on expanding innovations in medical research • Became vehicle for other legislation: • Funding for opioids • MH reform; SAMHSA reauthorization • STOP Act

  10. Grants to States to address the opioid crisis CURES authorized account for State Targeted Response (STR) to the Opioid Crisis Grants: • $500 million in FY 2017 (year 1) • $500 million in FY 2018 (year 2) • Additionally, in FY 2018, appropriators allocate, above and beyond year 2 of STR, "$1 billion in new funding for grants to States to address the opioid crisis"--the State Opioid Response (SOR) grants. • $1 billion in FY 2018 • $1.5 billion in FY 2019 • Administration and House Appropriations L-HHS Subcommittee recommend $1.5 billion (level funding) for SOR in FY 2020

  11. Child Welfare Provisions in 2018 Budget Deal Family First Prevention Services Act was included in the Bipartisan Budget Act that passed in March of 2018 • Addresses issues related to child welfare and substance use. • Was included as part of 21st Century Cures Act of 2017, but removed prior to passage. • Alters the allowable uses of Title IV-E [foster care] funding so it can be used to pay for services before children need to be removed from their home. • Allows foster care maintenance payments to be made for children who live with a parent while the parent is in residential treatment for SUD. • Amends the Regional Partnership Grant (RPG) program…

  12. Regional Partnership Grants • RPG program is managed by the Administration for Children and Families (ACF) within HHS. • Originally created to support regional partnerships that improve the well-being, permanency, and outcomes of children who are in, or at risk of, out-of-home placement as a result of a parent’s or caregiver’s methamphetamine use. • SSA historically listed as an optional partner in the regional partnerships with State child welfare agencies. • Grants address a variety barriers to optimal family outcomes (e.g. parental engagement/retention in treatment, professional training, coordinating timeframes for outcomes across agencies, etc.) How did the Budget Act change RPG? • Language updated to reflect current opioid/heroin crisis. • Requires the SSA to be a mandatory partner for the RPG, in addition to State CW agency.

  13. Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (“SUPPORT”) for Patients and Communities Act signed into law in October 2018

  14. SUPPORT Act covers a range of issues… • State Targeted Response to the Opioid Crisis (STR) reauthorization • Comprehensive Opioids Recovery Centers (CORCs) • Recovery coaches in ERs • Student loan repayment for SUD treatment professionals • Recovery housing • PPW reauthorization • Patient limit for buprenorphine prescribing • DATA waiver • IMD exclusion • PDMPs • ONDCP reauthorization • Medicare and MAT • Regional Centers of Excellence in SUD Education • Loan Repayment Program within HRSA

  15. Grants to States to address the opioid crisis (Sec. 7181) • 21st Century Cures Act of 2016 authorized grants to States to address the opioid crisis • Title: State Targeted Response to the Opioid Crisis grant administered by SAMHSA • Eligible applicants: State alcohol & drug agencies • SUPPORT Act reauthorized this grant program • $500 million for each of FY 2019-2021 • 5% set-aside for tribes • Up to 15% set-aside for States and Tribes with highest age-adjusted mortality rate

  16. Loan Repayment for Substance Use Disorder Treatment Providers (Sec. 7071) • Authorizes the Secretary of HHS, acting through HRSA Administrator, to carry out a loan repayment program for eligible professionals providing SUD treatment services. • Services must be delivered in SUD treatment facilities that are in “mental health” shortage areas or counties where the drug overdose death rate is higher than the national average. • Eligible professionals: master’s level social workers, psychologists, counselors, marriage and family therapists, psychiatric mental health practitioners, occupational therapists, psychology doctoral interns, and behavioral health paraprofessionals and physicians, physician assistants, and nurses. • Maximum total amount of repayment by the program is $250,000 per individual.

  17. HRSA’s NHSC SUD Workforce Loan Repayment Program

  18. HRSA NHSC Workforce Loan Repayment Program:Further information For a 2-page Fact Sheet on the program: https://nhsc.hrsa.gov/sites/default/files/NHSC/loan-repayment/nhsc-sud-workforce-lrp-fact-sheet.pdf For general information and an opportunity to sign up for email alerts when the new application cycle opens: https://nhsc.hrsa.gov/loan-repayment/nhsc-sud-workforce-loan-repayment-program.html For the application period that opened December 2018 and closed February 2019: https://nhsc.hrsa.gov/sites/default/files/NHSC/loan-repayment/sud-lrp-application-guidance.pdf

  19. IMD Exclusion (Sections 5051, 5052) • Overview: Allows State Medicaid programs to apply, under a State Plan Amendment, to receive federal reimbursement for up to 30 days of care for patients in an IMD “…but only to the extent that such services are furnished for not more than a period of 30 days (whether or not consecutive) during such 12-month period.” • Time period for program: October 1, 2019 to September 30, 2023 • Eligible individual (definition): • is enrolled for medical assistance under the State plan or a waiver of such plan; • at least 21 and under 65 years of age; and • has at least 1 substance use disorder

  20. IMD Exclusion • Eligible Institutions for Mental Diseases (definition): • “follows reliable, evidence-based practices” • “offers at least 2 forms of medication-assisted treatment for substance use disorders on-site, including, in the case of medication-assisted treatment for opioid use disorder, at least one antagonist and at least one partial agonist” • Process: • “Not less than 8 months after the date of enactment…Secretary shall establish a process…” • E.g. “Dear State Medicaid Director” letter?

  21. Program to Support Emergency Room Discharge and Care Coordination for Drug Overdose Patients (Sec. 7081) • Builds upon the “Anchor ED” recovery coaching model from Rhode Island. • Authorizes the Sec. of HHS to identify of facilitate the development of best practices for: • emergency treatment of known or suspected drug overdose; • the use of recovery coaches, as appropriate, to encourage individuals who experience a non-fatal overdose to seek treatment for substance use disorder and to support coordination and continuation of care; • coordination and continuation of care and treatment, including, as appropriate, through referrals, of individuals after a drug overdose; and • the provision or prescribing of overdose reversal medication, as appropriate. • $10 million for each of FY 2019-2023 Eligible applicants include: a State alcohol and drug agency; an Indian Tribe or tribal organization; or an entity that offers treatment or other services for individuals in response to a drug overdose, such as an emergency department, in consultation with a State substance abuse agency.

  22. Residential Treatment for Pregnant and Postpartum Women (PPW) (Sec. 7062) • SUPPORT Act reauthorizes PPW program within SAMHSA/CSAT • $29 million for FY 2019- FY 2023 • Family-based services for women in residential settings • Pilot program in non-residential settings for State alcohol and drug agencies of up to 25 percent of the residential PPW program referenced above (originally created in CARA) • Initial 3 pilots in MA, VA and NY • Important messaging: Pilot is a supplement and not replacement – the PPW residential program is vital • Target populations: Low-income women, age 18 and over, who are pregnant, postpartum (the period after childbirth up to 12 months), and their minor children, age 17 and under, who have limited access to quality health services

  23. Bupe Cap (Sections 3201 and 3202) • Adds to the category of “qualifying practitioner” clinical nurse specialists, certified nurse anesthetists, and certified nurse midwifes. • Allows qualifying practitioners to treat up to 100 patients (instead of 30) in the first year of holding a DATA waiver if: • at least one year after the practitioner submitted the initial notification, the practitioner submits a second notification to the HHS Secretary of the need and intent of the practitioner to treat up to 100 patients; • the practitioner holds additional credentialing (board certification in addiction medicine or addiction psychiatry); or • the practitioner provides MAT in a qualified practice setting. • Allows qualifying practitioners to treat up to 275 patients if they meet certain requirements, such as having maintained the 100-patient limit waiver for at least 1 year. • Cap was already raised to 275 patients by regulation in 2016

  24. Federal Budget and Appropriations Process

  25. President’s Proposed Budget • Typically in February, the President submits to Congress a detailed budget request for the coming fiscal year, which begins on October 1. • Budget outlines the Administration’s overarching priorities for federal programs • Budget must recommend funding levels for annually appropriated programs (aka discretionary programs). • These discretionary programs fall under the jurisdiction of the House and Senate Appropriations Committees. • President does not need to make recommendations for mandatory funding (e.g. mandatory/entitlement programs and taxes)

  26. Budget and Appropriations Process • Congress holds hearings in February and March to ask Administration officials about their budget requests and, then Congress develops its own budget plan, called a “budget resolution.” • Budget resolution sets overall spending targets for other congressional committees (e.g. Appropriations Committee) that can propose legislation that directly provides spending. • Outlines how much Congress is supposed to spend in each spending category, and how much total revenue the government will collect.

  27. 12 Appropriations Subcommittees with jurisdiction over particular agencies 1. Agriculture, Rural Development, Food and Drug Administration, and Related Agencies; 2. Commerce, Justice, Science, and Related Agencies; 3. Defense; 4. Energy and Water Development, and Related Agencies; 5. Financial Services and General Government; 6. Homeland Security; 7. Interior, Environment, and Related Agencies; 8. Labor, Health and Human Services, Education, and Related Agencies (“Labor-H”); 9. Legislative Branch; 10. Military Construction, Veterans Affairs, and Related Agencies; 11. State, Foreign Operations, and Related Programs; and 12. Transportation, Housing and Urban Development, and Related Agencies.

  28. Labor-HHS Subcommittees have jurisdiction over… …and more.

  29. Final Steps • After passing the subcommittee level, Labor-HHS bill is considered by the full Appropriations Committee. • All 12 appropriations bills are supposed to be passed in “regular order”—full passage through both House and Senate and signed by the President by the start of the federal fiscal year on October 1st. • In recent years, failure to provide appropriations by that date have resulted in continuing resolutions (CRs)—stopgap funding bills that keep the government funded at the previous fiscal year’s funding levels. • FY 2019 spending bill passed before the fiscal year began on Oct. 1, 2018

  30. FY 2019 funding In September 2018, Congress passed final FY 2019 (10/1/18-9/30/19) Labor, Health & Human Services (HHS), Education, and Related Agencies (L-HHS) appropriations bill

  31. Substance Abuse Prevention and Treatment (SAPT) Block Grant • House Appropriations Subcommittee and Full Committee recommended an increase of $500 million for the SAPT Block Grant during the FY 2019 appropriations process. • This proposal was not in the final agreement.

  32. Additional Opioids Allocation • Senate Appropriations Committee Report to Accompany FY 2019 funding: “The Committee recognizes the work moving forward under the SOR program and the State Targeted Response to the Opioid Abuse Crisis grant program. The Committee directs SAMHSA to ensure these resources are aligned with the State plan developed by each State’s alcohol and drug agency as defined by the agency that manages the SAPT Block Grant. This will ensure continuity of funding and coordination of efforts within each State system.” • STR; SOR – critical message: Congress and the Administration support significant resources to States to address the opioid crisis.

  33. SAMHSA’s Center for Substance Abuse Treatment (CSAT) *First Responder Training program, Rural Focus, and Grants to Prevent Prescription Drug/Opioid Overdose Related Deaths were previously funded within CSAP (FY 2017-FY 2018)

  34. CSAT Funding (continued)

  35. SAMHSA’s Center for Substance Abuse Prevention (CSAP)

  36. Department of Justice (DOJ) – Select Programs

  37. Office of National Drug Control Policy (ONDCP)

  38. FY 2020 Budget and appropriations

  39. Delayed FY 2020 budget • Administration typically releases budget in early February. • Due to the 35-day partial government, many employees of the Office of Management and Budget (OMB) were furloughed and unable to finalize the proposed budget on time. • FY 2020 budget was released in mid-March.

  40. SAMHSA Programs • $1.858 billion for the Substance Abuse Prevention and Treatment (SAPT) Block Grant (level compared to FY 2019) • $1.5 billion for the State Opioid Response (SOR) Grant (level) • $430 million for the Center for Substance Abuse Treatment (CSAT), a $30 million cut • $144 million for Programs of Regional and National Significance (PRNS) within the Center for Substance Abuse Prevention (CSAP), a $61 million cut

  41. SAMHSA’s Center for Substance Abuse Treatment (CSAT)

  42. SAMHSA’s Center for Substance Abuse Prevention (CSAP)

  43. Office of National Drug Control Policy (ONDCP) *President’s FY 2020 proposed total for ONDCP includes $16,400,000 for operations, and $12,101,000 for other federal drug control programs.

  44. Department of Justice (DOJ) – Select Programs *HIDTA program has historically been funded under ONDCP (FY 16 – FY 19) **Administration proposes moving the COPS program to OJP

  45. “Dear Colleague” letter on SAPT BG • Congressmen Paul Tonko (D-NY) and Brian Fitzpatrick (R-PA) led sign-on letter to colleagues in the U.S. House of Representatives. • Letter urged appropriators to recommend a $500 million increase to the SAPT Block Grant in FY 2020. • Total of 57 members of Congress signed on

  46. What’s next?

  47. Interest from Freshmen offices • 100 newly-elected freshmen in House and Senate • High interest in addressing opioids specifically, and addiction more broadly • In House, Rep. David Trone (D-MD) is leading Freshmen Addiction Working Group • ~60 freshmen Members of Congress • “What can we do to address SUDs?” • Background on CARA, CURES, SUPPORT • Education about publicly-funded system • Importance of full continuum: prevention, treatment, and recovery • Congress has accomplished a lot legislatively, and now States are in implementation mode (especially with STR/SOR)

  48. Focus on all substances of concern • Recognition of the importance of focusing on SUDs more broadly—including and beyond opioid use disorders • Prior to facing potential fiscal cliff for opioid-specific programs, gradually transition federal funds from drug specific to the SAPT Block Grant

  49. Importance of Primary Prevention • Education on existing programs (SAPT BG, SPF-PFS, DFC) that support primary SUD prevention • Interest from Congressional offices in strengthening school-based programs for SUD prevention • Concept of grant program to State alcohol and drug agencies to create evidence-based SUD prevention programs in elementary and secondary schools; and • Promote school-based prevention programming across the State through coordination with relevant stakeholders, including the State educational agency.

  50. CARE Act • The Comprehensive Addiction Resources Emergency (CARE) Act • Sponsored by Rep. Elijah Cummings (D-MD) in the House, and Senator Elizabeth Warren (D-MA) in the Senate • Re-introduced this week – most likely May 9th • Proposes Ryan White HIV/AIDS program model for substance use disorders: • $100 billion over next 10 years • Grants to States, local entities, and tribes

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