With the 2010 midterm elections behind us, there are literally hundreds of questions surrounding Washington. While anyone who says they have all the answers is lying, we can make educated guesses in some cases. Readers of Recovery View are most likely to ask how the current political situation will impact funding for substance abuse treatment and prevention. While these programs are a miniscule fraction of the federal budget, they are inexorably linked to larger federal fiscal policy, just as every other field that relies on federal funding is.
The Republicans, now in the majority in the House of Representatives, in large part ran on a platform of smaller government and spending cuts. While a large percentage of their candidates would not specify exactly what programs should be cut, this still does not bode well for health and behavioral health programs. The appropriations bill that funds the Department of Health and Human Services – and in turn SAMHSA and the NIH – is the largest non-military domestic spending bill to come out of congress each year. It is produced by the Appropriations subcommittee on Labor, HHS, and Education, or Labor/H for short. Being one of the largest spending bills, it naturally has a huge bull’s-eye on it.
There have been discussions and rumors that the House leadership would like to see domestic spending reduced to FY 2008 levels, or at the very least FY 2010 levels. This was the goal of the Sessions-McKaskill amendment, introduced in 2010, and defeated by the Senate. Yet now, with a new political landscape, FY 2008 levels for domestic discretionary spending may be returning. Regardless, it is highly unlikely that the House of Representatives will approve any increases for SAMHSA or NIH. Of course, the Senate remains in Democrat hands. So passing any budget can be difficult, and a government shut down this time next year is a possibility. This could have a severe impact on those who depend on Medicare to cover the cost of their treatment, and countless other social services.
The House Appropriations Committee, responsible for establishing funding levels for every federal program, will be chaired by Hal Rogers of Kentucky. While Mr. Rogers does not have an impressive record of supporting Labor/HHS programs in the past, he is a dedicated founder of the newly established House Caucus on Prescription Drug Abuse. Mr. Rogers has been a strong voice for establishing policies that can cut prescription drug abuse and illegal trafficking. However, most of his work thus far has focused on law enforcement and their involvement in this issue. It remains to be seen if this zeal carries over to funding research and services that are connected to this issue. The subcommittee responsible for appropriations to the Department of Health and Human Services, and in turn agencies such as NIDA and SAMHSA, will be Denny Rehberg of Montana. He has a mixed record on health and substance abuse issues, but only an 11 percent rating from the American Public Health Association. He cast a “no” vote on the House bill to enact the Wellstone/Domenici Parity act. He later voted “yes” on the final version, but the initial “no” vote is making many in the advocacy community very cautious.
Also of concern is the recently released report of the National Commission on Fiscal Responsibility and Reform. Among their recommendations are the elimination of the Office of Safe and Drug Free Schools, as well as a 10-percent across-the-board staffing cut at the federal level, with additional cuts to the Congressional and White House budgets. On the discretionary spending front, they propose rolling back spending to FY 2010 levels starting in FY 2012, and require a 1-percent budget cut every year from FY 2013-2015.
While at first glance the staffing and budget cut seems like sound economic policy, keep in mind how dependent our field is on agencies and offices such as SAMHSA, ONDCP, and NIH. Less people doing more work means that our allies in government will be less efficient, and not in a position to give us the help we need. Like it or not, the funding streams for addiction treatment and prevention are heavily linked to federal funding, which need to be protected at all levels.
Of course, all of this looks forward to FY 2012. In reality, the budget for FY 2011 has still not gone into effect. The government has been operating on what is known as a “continuing resolution” since September 30, 2010, at FY 2010 levels. Despite several attempts to pass the FY 2011 budget in the closing days of the 111th congress, and the lame duck session this past December, it never came to fruition. This was due in large part to Republicans blocking the legislation in the Senate, knowing they would have a better chance to cut spending if they could postpone votes on the FY 2011 budget until the new Congress was sworn in. The current continuing resolution is in effect until February 4, 2011. If a budget, or new CR, is not passed before then, it will result in a government shutdown. That means any and all services reliant on government funds will cease to operate until a budget is passed. This could severely impact substance abuse services.
As far as health care reform is concerned, it is almost a sure thing that the entirety of the bill will not be repealed. With the Democrats in the Senate and the White House, there is no way that such legislation will pass. However, this does not mean that changes will not be forthcoming. What it comes down to is how certain provisions of the Affordable Care Act are being funded. Those parts that require appropriations over the next two years face trouble in the House. Even before the election, Republicans attempted to chip away at certain provisions via the Johnanns amendment, which would have taken billions of dollars out of the Public Health and Prevention fund created by the act. The amendment was defeated, and $40 million allocated to SAMHSA for the integration of substance abuse treatment into primary care was preserved. In California, grassroots efforts by groups such as CAADAC and CFAAP urged a defeat of the amendment, joining with hundreds of other national associations.
According to the National Council of Community Behavioral Health, we will likely see many proposals related to changing the healthcare reform law, and most concerning to the addiction and mental health community will be efforts to scale back, or delay the Medicaid expansion scheduled for 2014. We have already discussed that federal discretionary funding will not be growing, and that additional federal Medicaid assistance is unlikely. The consequences of these actions is to put further pressure on state and county appropriations, further eroding addiction and mental health funding for indigent populations.
Of particular concern to the research community, and those whom support NIDA and NIAAA, is the election of Pat Toomey of Pennsylvania to the Senate. Mr. Toomey has a history of challenging NIH grants that he considers to be controversial, and has attempted to de-fund specific grants in the past. While most of these grants were focused on human sexual behavior, many are connected to the prevention and treatment of HIV. Members of the substance abuse treatment community, as well as many outside it, understand what a critical role substance abuse plays in the transmission of HIV, both via risky behavior with syringes, and unsafe sexual behavior brought on by substance abuse.
Also of concern is the appointment of Rep. Joseph Pitts to chair the subcommittee on health of the influential Energy & Commerce committee. Pitts, by virtue of this position, will have oversight of all HHS departments, including NIH and SAMHSA. Pitts, like Tomey, has a history of challenging the scientific merit of NIH grants that have focused on human sexuality. Not only do challenges to specific NIH grants reflect a lack of knowledge about the scientific process and how specific grants are chosen to be funded, but it is a threat to the culture of NIH, thus impacting the thousands of grants that focus on addiction research. With NIDA and NIAAA in the NIH forefront due to the possibility of a new institute being created, it is very possible that many of their grants can come under scrutiny. Also, if a new institute is created in place of two, Congress may see this as an opportunity to cut research funding in order to appear fiscally responsible. At NIH, Director Francis Collins has already spoken his mind. The reduction in funding proposed by Speaker-to-be John Boehner would be “very devastating” and would demoralize scientists, whose odds of winning a research grant from the agency could drop to about 10 percent, he told the Washington Post.
A notable absence in the 112th congress will be that of Rep. Patrick Kennedy, the undeniable Congressional champion for substance abuse treatment over the last decade. Following closely on the heels of Rep. Jim Ramstad’s retirement after the 111th Congress, the Addiction, Treatment, and Recovery Caucus has lost both its Democrat and Republican chairmen in a span of just two years. This means that Congress is now without a member whose top priority is substance abuse treatment and prevention. Many members of Congress are sympathetic to the issue, but none currently in Congress make it a top priority, save possibly one exception, Rep. Mary Bono-Mack of California, who has worked hard to become a visible leader on the issue. Rep. Tim Ryan of Ohio will be taking over as the Democratic chairman of the ATR caucus, joining Rep. John Sullivan of Oklahoma as the Republican chairman.
Without a doubt, it’s going to be an interesting and challenging two years.