4 questions we should be asking the White House

The mixed messages coming from the Department of Health and Human Services (HHS) these days have left me scratching my head. President Trump and HHS Secretary Tom Price have identified three excellent priorities—childhood obesity, mental illness and the opioid epidemic—but their actions seem to be underwhelming if not counterproductive.

Here’s what I want to know:

1. What new funds will be made available to combat the opioid crisis?

In April, Price announced $485 million in grants were being handed out to all 50 states for treatment and prevention efforts. That’s a tidy sum, but let’s acknowledge the funds come from two pieces of legislation that President Obama signed. HHS didn’t have a choice but to hand out the money as prescribed, so this isn’t exactly an achievement of the current administration. Price has promised these grants are not the end of the administration’s commitment, but he hasn’t been forthcoming with specifics just yet.

2. The president recently created a new opioid commission that must deliver a report to the White House by October. How will that new document differ from the much-lauded  “Facing Addiction in America” report that was released by the surgeon general in November 2016 after more than a year of comprehensive research?

New Jersey Governor Chris Christie leads the president’s commission, and former Congressman Patrick Kennedy—who is an influential advocate for addiction treatment—has just been appointed to participate as well. I sent a note to Kennedy’s people to ask them my question about the report, but as of this writing, I had not received a response.

I was also in the room when the CEO of Thresholds, Mark Ishaug, asked Vivek Murthy (he was still in the surgeon general position at the time) how the president’s new report might differ from Murthy’s own comprehensive tome of information and recommendations. Murthy, speaking at the National Council’s annual conference, delicately reiterated the fact that addiction is a bipartisan issue and seemed reluctant to answer directly. It’s possible he was not privy to the information since he was never included on the commission in the first place.

I’m going to go out on a limb and predict the president’s new report will focus not on stigma, prevention, treatment or scientific evidence, but rather it will be a financial statement of how and where federal money is being spent to fight addiction. The executive order establishing the commission seems to point in that direction. Christie, Kennedy and others on the commission will do a fine job regardless, but what remains to be seen is what the White House ultimately does with the information.

Incidentally, Politico reported that Price is skeptical of buprenorphine and methadone—in spite of the evidence—but believes naltrexone is “exciting stuff” and “we ought to be looking at those types of things to actually get folks cured.” I imagine the clinical community bristled at the comment, especially the word "cured."

3. Why make addiction a priority and then propose to cut the budget for the Office of National Drug Control Policy by 95%?

Part of the White House’s 2018 fiscal year preliminary budget proposal aims to cut ONDCP funding by 95%, and an orchestra of industry leaders blasted the administration for it. Politico reported earlier this month that according to an internal office e-mail, funding would drop to $24 million in 2018 from $388 million this year. The Drug-Free Communities Support Program—which would be eliminated under the proposal—is the largest addiction prevention effort in the United States, coordinating grants for 5,000 local programs to serve their communities in the way they believe is best. Yes, the administration is looking to cut bureaucratic redundancy and give states more flexibility, but ONDCP is already in that role.

4. How are the states going to make up for the $880 billion Medicaid cut contained in the American Health Care Act?

The federal government currently funds about 57% of Medicaid costs, but it varies by state. It is also an open-ended funding stream that can be adjusted for extenuating circumstances (like it was for Louisiana after Hurricane Katrina, for example). While I understand that a lot of money is spent on the Medicaid program, limiting the federal contribution will only shift costs to states that can ill afford to take on more. The end result is fewer people receiving care.

Check my arithmetic but $880 billion could pay for nearly 12 million visits to a primary care physician, if you estimate the cost at $75 per visit. That’s a lot of care being cut, and, arguably, that's a lot of income for Medicaid physicians, too.