What Could Have Been

2014 saw Congress and federal agencies pay more attention to substance abuse and addiction than any other time in recent history.  The growing heroin and opioid epidemic was front and center as both chambers held numerous hearings on the subject this year.  Several members of congress stepped into the fray, from both sides of the aisle and in both chambers.  There were members of congress addressing the issue who had been working on it for years, such as Rep. Tim Ryan and Senator Carl Levin. There were lawmakers, such as Senators Markey and Ayotte, taking up the issue because they were hearing about the spread of heroin in their home states. In the federal agencies, even the Center for Disease Control wants to do more to address the spread of opioid abuse.


Yet for all these efforts, for all the best intentions, no changes will be made in substance abuse treatment and prevention policy if new programs are not created and existing programs are not adequately funded.  Appropriations is king in Washington, and for the moment, the king is on life support.


After the sequester of FY 2013 decimated all federal non-defense discretionary spending – including public health – the Ryan-Murray agreement for the FY 2014 gave a glimmer of hope that the budget and appropriations process could get back on track for FY 2015.  The first few months of the process shaped up fairly well, with the White House budget request making some strong recommendations for new and existing substance abuse treatment programs.  These included a new program for the CDC on prescription drug monitoring (a new $15 million program) and a renewed commitment to the substance abuse treatment workforce at SAMHSA, in large part through their “Now is the Time” initiative.  The Senate Appropriations subcommittee responsible for Health and Human Services funding marked up their appropriations bill on schedule, and was heading for a full committee mark-up just two days later when a political earthquake shook Washington.


Eric Cantor’s loss in the GOP primary for his congressional seat brought almost all legislative action to a standstill.  Lawmakers acted as if petrified when asked to act on an issue that could be interpreted as the slightest bit controversial.  Appropriations for public health may not appear controversial, but when spending for programs that fund the Affordable Care Act are at stake, politicians tend to become gun-shy, especially in a political environment as volatile as this one. So the Senate appropriations committee, which was sailing along smoothly toward producing a bill, ground to a halt.


Grinding to a halt in the senate was still, however, light years ahead of progress in the House of Representatives, where action on the bill needed to fund new public health programs was hovering steadily at zero.  The chairman of the appropriations subcommittee responsible for public health funding, and in turn substance abuse treatment funding, was Rep. Jack Kingston (R-GA).   Mr. Kingston spent most of the winter and spring campaigning for his party’s nomination for a senate seat. In addition, many believe that he was hesitant to work on HHS appropriations, as his opponents would portray him as supporting large government spending bills, especially one so inexorably linked to the ACA.  Mr. Kingston was unsuccessful with his bid, leaving the House appropriations bill in limbo and leaving public health and substance abuse treatment funding with little hope.


“Just a tiny fraction of the federal budget goes toward supporting all of our nation’s public health needs—everything from preventing disease, to keeping our food and drugs safe, to ensuring that Americans have access to primary care doctors. That small pot of money has faced huge cuts in recent years, many triggered simply because Congress couldn’t find a permanent solution to sequestration,” said Emily Holubowich, President of the Coalition for Health Funding. “We need Congress to stop further cuts to public health programs and continue investing in keeping American families and communities strong, safe, and healthy.”


What we are left with is the sickening prospect of another continuing resolution, which continues funding for all federal programs at a maximum of last year’s levels.  Under a CR, no new programs can be created.  This will put the brakes on new programs proposed by both SAMHSA and the CDC that are aimed at reducing opiate abuse through a variety of measures.


The Senate Appropriations subcommittee, in an unusual step, released a report to accompany what would have been their appropriations bill, despite the fact that the bill has not yet passed the committee and is unlikely to, at least before November.  The bill gives us a glimpse at what might have been in terms of progress for the funding of substance abuse treatment.  With all of the attention being paid by Congress and the media to the problem of opioid abuse, the senate bill is promising in the sense that showed a commitment to new and innovative programs.  The committee restored cuts recommended by the White House to the SBIRT program at SAMHSA, and restored $10 million in White House cuts to criminal justice activities. 


The Addiction Technology Transfer Centers also saw a modest increase, which is nothing to dismiss in a fiscal environment this challenging.  “The Committee

rejects the administration’s proposed reduction to the ATTCs, which are a network of regional and national centers that develop and strengthen the addiction treatment workforce,” the committee wrote.  “The Committee notes that the demand for substance use disorder treatment services is anticipated to increase as a result of the Affordable Care Act and the Mental Health Parity and Addictions Equity Act. The Committee expects that the increased funding should be used by the National and Regional ATTCs to enhance the skills of the current addiction workforce and to recruit and mentor new professionals into the addiction workforce.” These words and the senate leadership have the best of intentions, but they are hollow until an appropriations bill for FY 2015 is enacted.


Substance abuse and addiction treatment services are a microscopic portion of the federal budget, but even the smallest boat cannot sail at low tide.  Right now, the tide is very low, and not even the biggest ships can leave the harbor.

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