Throughout 2017, TCA continued to solidify its role as a respected and knowledgeable resource on treatment and SUD policy on Capitol Hill; continued developing important relationships within the new Trump Administration; and continued to build on strong foundations in federal agencies and among other national organizations. TCA recognizes as part of its mission the importance of educating policymakers and other stakeholders on the need to expand access to evidence-based comprehensive addiction and co-occurring treatment that is based on the full continuum of care.
TCA continued to keep the spotlight on the need for access to treatment, including by advocating for action on the IMD Exclusion and for sufficient funding of the Substance Abuse Prevention and Treatment (SAPT) Block Grant. Over the past year, TCA has developed effective public policy initiatives, engaged the executive branch on a direct level, and followed through with an aggressive agenda of public policy activities to promote the mission of TCA and its members on behalf of their clients and others in need of treatment.
Protecting and Advancing Policy Interests
- Transition to Trump Administration– After the fall 2017 elections, TCA prepared and submitted a comprehensive informational package about TCA and our priorities to the Trump transition team and to TCA members positioned to share it with influencers on SUD treatment and opioid policy.
- TCA tracked all relevant nominations, appointments, and personnel changes and updated members in real time. WSW reported to TCA on the nomination hearings in the Senate Finance and HELP Committees for Rep. Tom Price to be Secretary of Health and Human Services; on the confirmation hearing for Senate Homeland Security Secretary-nominee Gen. John Kelly, who discussed the importance of treatment and rehabilitation as part of demand reduction; and on the nomination and confirmation of Sen. Jeff Sessions as Attorney General. TCA also reported out on the selection process, nomination, and confirmation of Elinore F. McCance-Katz for the new position of HHS assistant secretary for mental health and substance use.
- In a related vein, TCA tracked news, gathered information, and shared intel on potential nominees for Director of the Office of National Drug Control Policy (ONDCP), a position that remains unfilled more than one year into the Trump Administration.
- After the resignation of HHS Sec. Price, TCA monitored and reported on the nomination and confirmation of the new HHS Secretary, Alex Azar. Similarly, after Homeland Security Secretary Kelly departed to become White House Chief of Staff, TCA reported out on the nomination and confirmation of Kirsten Nielsen to become HS Secretary, to the extent that opioids were an issue during the confirmation process.
- TCA assisted in arranging introductions and establishing relationships with the new leadership at these departments and agencies. For example, with the assistance of Odyssey House Louisiana, TCA met with HHS Secretary Price to discuss the IMD Exclusion and TCA’s recommended policies to guide the federal response to the opioid epidemic.
President’s Commission on Combating Drug Addiction and the Opioid Crisis
- After taking office, President Trump established via Executive Order the President’s Commission on Combating Drug Addiction and the Opioid Crisis, chaired by New Jersey Governor Chris Christie. The Commission held five formal meetings via webcast during its mandated tenure. The Commission’s mandate was to review the effectiveness of current programs related to addiction and barriers to treatment. Vanessa Vitolo, who has worked closely with Integrity House of New Jersey, participated in the event at the White House where the Commission was established.
- TCA monitored and reported out on each of these meetings and also engaged the Commission directly as it gathered evidence and solicited policy proposals.
- TCA drafted and submitted comments to the Commission focused on the need to expand access to evidence-based SUD treatment by ending the Medicaid Institutions for Mental Diseases (IMD) Exclusion. Crucial to this effort was additional advocacy by Bob Budsock at Integrity House directly to Governor Christie and his staff based on their work on addiction in New Jersey.
- Ultimately, the Commission’s Interim Report used strong language advocating for the elimination of the IMD Exclusion and discussed it as follows as its first recommendation in the report:
- Provide Relief from the Medicaid Institutions of Mental Diseases (IMD) Exclusion
- Rapidly increase treatment capacity through HHS waivers to states.
- Notes that legislation is required to repeal the IMD Exclusion, that HHS should be able to provide rapid waivers with the emergency declaration “and arguably without it.”
- States that “this is the single fastest way to increase treatment availability across the nation.”
- TCA also submitted comments to the Commission after the Interim Report was finalized supporting the recommendation to provide relief from the IMD Exclusion. TCA’s comments highlighted the drawbacks of the current 1115 waiver process and noted existing legislative proposals to include the Road to Recovery Act introduced by Rep. Brian Fitzpatrick (R-PA), which would repeal the IMD Exclusion as it applies to residential, nonhospital inpatient SUD treatment, and the Medicaid CARE Act (S. 1169/H.R. 2687) introduced by Senator Dick Durbin (D-IL) in the Senate and by Rep. Bill Foster (D-IL) in the House of Representatives, that would provide relief from the IMD Exclusion by changing the current exclusion into a cap on Medicaid reimbursement for up to 40 beds at a residential, nonhospital treatment facility, to ensure that there is no unintended incentive to reduce beds and treatment capacity to comply with the IMD Exclusion. TCA also voiced support for the Commission’s recommendation to enforce the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).
- Pursuant to the Commission’s Interim Report, in October, President Trump declared the opioid epidemic a national public health emergency and directed the executive branch to “use every appropriate emergency authority” to fight the crisis. The event represented a milestone becausePresident Trump spoke personally of the IMD Exclusion – as far as we are aware, the first time that a President had publicly discussed changing/ending the law. President Trump’s remarks on the IMD Exclusion were as follows:
“As part of the emergency response we will announce a new policy to overcome a restrictive 1970 rule that prevents states from providing care at certain treatment facilities with more than 16 beds for those suffering from drug addiction. A number of states have reached out to us asking for relief and you should expect to see approvals that will unlock treatment for people in need and those approvals will come very, very fast not like in the past.”
IMD Exclusion Advocacy on Capitol Hill
- TCA continued to advance stand-alone legislation for repeal of the Medicaid IMD Exclusion as it relates to SUD treatment, working closely with Members of the House and Senate to advance a long-term, meaningful solution to this barrier to treatment.
- New SUD-treatment specific legislation was introduced this year. TCA endorsed H.R. 2938, the Road to Recovery Act, introduced by Rep. Brian Fitzpatrick (R-PA), which would repeal the IMD Exclusion as it applies to residential, nonhospital inpatient SUD treatment. H.R. 2938 currently has 37 bipartisan cosponsors, 17 Republicans and 20 Democrats. TCA member DASPOP worked closely with Rep. Fitzpatrick and the Pennsylvania Congressional Delegation to develop the legislative language and introduce the bill. TCA worked closely with Rep. Fitzpatrick’s staff so that TCA President Kathy Icenhower’s remarks in support of the bill were included in the comprehensive media rollout of the legislation.
- TCA also continued to engage extensively with Senator Dick Durbin (D-IL) and his staff regarding his bill S. 1169, the Medicaid CARE Act, and its House companion bill, H.R. 2687 sponsored by Rep. Bill Foster (D-IL). S. 1169/H.R. 2687 would expand access to SUD treatment by modifying the existing Medicaid IMD Exclusion to allow payments for certain residential treatment facilities to treat individuals with substance use disorders and to provide extended duration of residential treatment to pregnant women. In a change to the bill sought by TCA and agreed to by Senator Durbin, the most recent version of the Medicaid CARE Act was modified to change the 40-bed limit from an exclusion to a cap, allowing any program affected by the IMD Exclusion to bill Medicaid for reimbursement of care for up to 40 beds. TCA also educated and mobilized its members to secure cosponsors of S. 1169 and H.R. 2687. S. 1169 currently has 18 bipartisan cosponsors, 6 Republicans, 11 Democrats, and 1 Independent (King). H.R. 2687 has 46 bipartisan cosponsors, 6 Republicans and 43 Democrats.
ACA Repeal Efforts and SUD Treatment
- The Republican majority in Congress devoted over eight months of 2017 trying the repeal major provisions of the ACA through the budget reconciliation process. Because of the importance of the ACA in ensuring access to SUD treatment, TCA actively and vigilantly tracked all developments throughout the process through its conclusion to ensure that TCA members and leadership were informed and ahead of the curve on all policy developments. TCA secured and shared legislative texts, section-by-section summaries, and analysis at each stage, and reported out at every turn on the votes taken in Committee and on the floor of the House and Senate.
- The lengthy process involved several iterations. The initial House bill was known as the American Health Care Act (AHCA). Of particular interest to TCA were the provisions related to Medicaid, the debate related to Essential Health Benefits (EHBs) and SUD treatment, and the future of coverage for the Medicaid Expansion population. Democrats on the Energy and Commerce Committee focused especially on the negative implications for SUD treatment amid the opioid epidemic as it was developed and advanced through that panel.
- As AHCA was prepared for debate on the floor in late March 2017, some GOP moderates and conservatives objected or voiced reservations, in particular out of concern for how the legislation might reduce access to SUD treatment amid the opioid epidemic. As these deliberations played out, some Members, namely Rep. Tom MacArthur (D-NJ), sought and received $15 billion in increased funding to “transition” access to SUD treatment, mental health, and maternity care as EHB protections were rolled back. Dramatically, the bill was pulled from the floor before a vote in March. However, AHCA was resurrected after additional negotiations, and eventually passed the House in early May by a vote of 217-215.
- Subsequently, the Senate moved forward with its own proposals to repeal the ACA, known as Better Care Reconciliation Act (BCRA). This legislation also was modified several times during its development in order to attract support among moderate Republicans, including those intensely interested in the bill’s impact on SUD treatment. At one point, Senate Leadership offered an additional $45 billion in a fund for the response to the opioid epidemic “to provide grants to States to support substance use disorder treatment and recovery support services for individuals who have or may have mental or substance use disorders” and for research on addiction and pain related to the substance abuse crisis. Later, however, the $45 billion fund was removed from the legislation that was considered on the floor of the Senate.
- Like the House bill, BCRA would repeal of Medicaid for the expansion population, while block grants/per capita caps would be applied to Medicaid. The legislation also contained an exception to the IMD Exclusion, which applied only to“qualified inpatient psychiatric hospital services.” In June, TCA members from Utah held a meeting with Senator Hatch’s office to discuss the provision and its application to community-based treatment; but ultimately, the provision would not provide relief for community based treatment, just psychiatric hospitals.
- In a dramatic “down to the wire” vote, the Senate failed to pass a version of the ACA repeal bill in a large part due to the extensive changes to Medicaid included in the package.
- In March 2017, the Trump Administration released an FY 2018 “skinny budget” containing drastic cuts at HHS and the proposed elimination of ONDCP. TCA had monitored and reported out to membership on leaked documents and draft proposals to eliminate ONDCP throughout the early part of 2017 and worked as part of coalitions to push back forcefully against these proposals. Ultimately, Congress rejected the skinny budget’s proposed cuts and agreed to fund the SAPT Block Grant at $1.855 billion, level funding from FY16.
- When a traditional full FY18 budget was released in May 2017, the drastic cuts to HHS remained. TCA evaluated all aspects of the FY18 proposal related to treatment and the opioid crisis and provided a comprehensive review of the blueprint for the Substance Abuse and Mental Health Administration (SAMHSA) as well as other agencies at the Department of Health and Human Services. This included information on funding levels for key programs such as the Substance Abuse Prevention and Treatment (SAPT) Block Grant, interventions to prevent prescription drug overdose deaths, and the Department of Justice’s treatment services furnished through the Bureau of Prisons. Notably, the FY18 budget proposal requested $1.855 billion for the SAPT Block Grant, an increase of $55 million compared to FY17. The budget proposal also requested $500 million for the second year of the $1 billion authorized for the state emergency response to the opioid epidemic pursuant to the 21stCentury Cures Act.
- Throughout the year, as the House and Senate developed the FY18 appropriations bills, TCA advocated to Members and staff about the importance of increased funding for the SAPT Block Grant and its continued importance and relevance as a safety net for people who lack insurance coverage or access to treatment. As the FY18 appropriations bills have been developed and advanced, the House Labor, HHS, Education Appropriations legislation includes $1.855 billion for the SAPT Block Grant, equal to FY17. The Senate version of the legislation, approved in Committee in September but not acted on by the full Senate, includes $1.9 billion for the Block Grant. Both bills, however, include the second year of $500 million in funding authorized under the 21stCentury Cures Act for the state emergency response to the opioid epidemic.
- Currently, the House and Senate are negotiating on an increase in spending caps to provide relief from the Budget Control Act of 2010. Resolution of the FY18 spending bills remains pending pursuant to an agreement on the budget caps.
CARA Oversight and Implementation
- In 2017, Congressional interest in responding to the opioid epidemic continued as relevant panels examined implementation of CARA and conducted oversight of the bill and changes in the epidemic. Extensive debates on treatment for SUD in committees and on the floor of the House and Senate continued.
- TCA monitored and reported on a series of hearings on opioids and heroin in the House Energy and Commerce Committee, with direct jurisdiction over health policy related to treatment, as well as additional hearings in the House Judiciary Committee, the House Oversight and Government Reform Committee, and the Senate Health, Education, Labor and Pensions Committee. Of particular note, the Energy and Commerce Committee conducted a Member testimony day, where over 50 Members of the House of Representative testified about the epidemic, its impact on their constituents, and proposals for responding to the unfolding public health emergency.
- TCA engaged Members on these panels and their staffs, proactively contacting them in advance of the hearings with suggested questions that would shine a spotlight on the importance and effectiveness of community-based residential treatment and the need to reform or repeal the IMD Exclusion as it relates to inpatient, nonhospital residential SUD treatment.
- One of the developing issues that TCA is monitoring and advocating on is related to the issue of patient brokering and bad practices by fake treatment providers. TCA heard from advocates focused on this issue at its fall board meeting, including TCA member Gale Saler of NorthStar Academy, and agreed to work closely with the emerging coalition on ways to combat such fraudulent activities through best practices. In December, the House Energy and Commerce Oversight and Investigations Subcommittee formally investigated the issue at a hearing entitled, “Examining Concerns of Patient Brokering and Addiction Treatment Fraud,” which TCA monitored and reported out on.
Building and Strengthening Key Relationships
- In May 2017, TCA held its Legislative Day on the Hill as part of its Spring Board Meeting. TCA members conducted approximately 70 meetings with the Members or staff for Congressional offices in the House and Senate. TCA members sought to boost support for legislation to reform or repeal the IMD Exclusion, build funding for the SAPT Block Grant in FY18, and increase Member participation in the Addiction, Treatment and Recovery Caucus.
- TCA continued to build meaningful relationships with various relevant congressional entities. TCA worked closely to establish and grow a new relationship with the Bipartisan Heroin Task Force, which is increasingly active on matters related to the opioid epidemic, including the Road to Recovery Act, which it has placed on its legislative agenda.
- Working closely with the Task Force, in May 2017, TCA hosted a briefing sponsored by the Task Force and the ATR Caucus, entitled “Breaking Barriers, Saving Lives: Addressing the Medicaid IMD Exclusion.” Speakers included Congressman Daniel M. Donovan (R-NY), former District Attorney for Richmond County, New York; Sarah Arbes, Principal Deputy Assistant Secretary for Legislative Affairs, HHS, TCA’s own members Seep Varma and Bob Budsock, as well as Integrity House former patient and current advocate Vanessa Vitolo.
- For the fall Executive Committee meeting, TCA invited Representative Fitzpatrick (R-PA) to discuss his Road to Recovery Act legislation and explored further ways of supporting his efforts to eliminate the IMD Exclusion. TCA also organized a second Day on the Hill opportunity for TCA members with a focus on outreach to Members of Congress and Senators well positioned to work on issues related to treatment – including those outside of TCA member districts – with an emphasis on those serving on the House Energy and Commerce and Ways and Means Committees, and the Senate HELP and Finance Committees. TCA members met with 13 congressional offices on this Day on the Hill. The fall meeting also included a reception honoring Senator Dick Durbin (D-IL) with the newly-established Charlie Devlin Award for Excellence for his exemplary efforts throughout his career in behavioral health.
- Separate from the former Hill days, TCA leadership and member programs conducted dozens of additional rounds of Hill visits throughout the year with support from TCA’s Executive Director and WSW, including visits to Washington by SHIELDS for Families, Center Point, Odyssey House Louisiana, and Odyssey House of Utah.
- TCA attended small-scale events throughout the year hosted by WSW, providing an opportunity for interaction with federal elected officials in a setting outside of Capitol Hill.
TCA continued to secure a sustainable organization through development activities, increased member communication and improved financial management:
- TCA held 3 successful board meetings in 2017 that featured timely, expert speakers in the field of substance use disorder treatment, research and prevention.
- The Winter Board meeting allowed our members to review and revise our strategic plan, set goals and objectives for 2017, review our financial infrastructure, as well as schedule public policy activities (i.e. briefings, hill days) for the year ahead. TCA members visited the Westcare facility in Puerto Rico “Caribe, Calle Herber Houver. While at the facility TCA members got a tour and the opportunity to ask questions of the staff and clients. Following the tour TCA members sat through a presentation by Gulf South Strategies called “Law and Sausages” and BrightPoint Search called “Talents You Need, Relationships You want”.
- The spring board meeting featured a presentation by Dr. Mitchell Rosenthal of Rosenthal Addiction Center (NY) called “The future for Long Term Treatment”. Members also attended the TCA briefing on Capitol Hill. The briefing was sponsored by the Heroin Task Force and titled “Breaking Barriers, Saving Lives”. Following the briefing, TCA members participated in the “TCA Capitol Hill Day” where they were able to meet with their legislators.
- Our fall board meeting featured a discussion with Representative Brian Fitzpatrick (R-PA) about his legislation to address the IMD Exclusion. Robert Kent, General Counsel for the NY OASAS, and Norwig Debeye-Saxinger, President of the New York Therapeutic Communities, provided a presentation called “The Medicaid Waiver Approach to Incorporating Residential Treatment Venues into the ACA’s SUD Treatment Continuum: The New York Experience”. Dawn Nelson from the Government Accountability Office did a presentation on” Medicaid: States Fund Services for Adults in Institutions for Mental Disease Using a Variety of Strategies.
- On September 27, 2 017 TCA members gathered in the nation’s Capital to celebrate decades of federal advocacy in support of people overcoming addiction as well as to honor Senator Dick Durbin (D-IL) with the first ever Charlie Devlin Award for Excellence for his exemplary work and leadership in the substance use disorder field.
The leaders of TCA programs from across the country were joined by several Members of Congress to honor decades of federal outreach by the organization, which seeks to support and improve policies and funding that provide access to community-based treatment for Substance Use Disorders (SUD). Among the Members of Congress who attended the reception were U.S. Senator Dick Durbin (IL-PA), U.S. Representative Alcee Hastings (D-FL), U.S. Representative Wm. Lacy Clay (D-MO), U.S. Representative Robin Kelly (D-IL), and U.S. Representative Dwight Evans (D-PA).
- TCA continued to host the monthly “Public Policy” conference call which takes place on the 3rdTuesday of each month at 4:00 pm (EST) and is open to all members. The call is led by Rob Zucker of Winning Strategies Washington. This monthly call allows members to get real time updates on Capitol Hill activities and legislation as well as ask questions.
- TCA now has a weekly newsletter which is sent out each Friday. The newsletter provides our members with ongoing “Public Policy Updates” that notes activities in Congress, monitors legislation of importance, provides information on federal government activities and updates; provides information on webinars and trainings offered in the SUD field as well as highlights TCA member activities.
- TCA launched our newly designed website which reflects the direction in which TCA continues to grow and enhance the services under our mission. The website now allows members to pay and register for board meetings, membership dues, and access to all policy papers. TCA also maintained and updated its Facebook page.
- TCA continues to partner with federal agencies such as SAMHSA, ACF, NIDA, ONDCP, DOL, DOJ and HUD, to name a few. TCA participated in numerous “Stakeholder” meetings and focus groups with our federal partners and the Administration to discuss and promote the continuum of care, funding and research.
- TCA Executive Director, Pat Clay, participated in a number of Coalitions and working groups to include, The Coalition for Whole Health, Addiction Leadership Group, Re-entry Working Group, Coalition to Stop Opioid Addiction, Mental Health Liaison Group, Facing Addiction, Addiction Policy Forum, CARA Working Group, National Alliance for Model State Drug Laws, Friends of NIDA and the Justice Roundtable.
- TCA completed its FY 2016 audit with a clean report which documented TCA’s efforts to improve its systems and practices.
- TCA continued to offer its members an insurance purchasing program through Sterling and Sterling and Heffernan Insurance which allows TCA to receive royalty income as well as provide our members with a variety of insurance program options.
- TCA continued to work with HPSI and receive royalty income through this partnership.
- TCA Executive Director, Pat Clay, attended the Rx Drug Abuse & Heroin Summit in April. The Summit is the largest national collaboration of professionals from local, state, and federal agencies, treatment providers, and allied communities impacted by prescription drug abuse and heroin use and is the event for professionals working to address this public health emergency.
- On November 27, 2017 Pat Clay attended the Government and Oversight Reform Committee Full Committee Hearing on the Opioid Commission Report called“Combating the Opioid Crisis,”The reason for the hearing was to provide Congressional Members the opportunity to evaluate recommendations finalized by the President’s Commission on Combating Drug Addiction and the Opioid Crisis and also discuss Baltimore’s efforts to address the opioid epidemic in their community to better guide federal determinations. The hearing was held at Johns Hopkins Hospital in Baltimore, MD and featured 2 panels. Governor Chris Christie (NJ-R) was on the first panel and was asked a variety of questions by committee members regarding the implementation and funding of the recommendations made in the report. Governor Christie stated that he felt confident that the Trump Administration would implement the recommendations made in the report and felt that states could find the money to fund it. The second panel consisted of Dr. Leana Wen, Health Commissioner of the Baltimore City Health Department, Richard Braum Acting Director of ONDCP and Doctor Caleb Alexander of Johns Hopkins Bloomberg School of Public Health, Center for Drug Safety and Effectiveness. Each of the panelists provided an update as to how their agency is handling the opioid crisis that this country is experiencing.