Senate to clear opioids package this week, next steps unclear

The Senate will likely vote Thursday on its package of 70 bills aimed at reining in the opioids epidemic. But it remains unclear how the Senate and House of Representatives can hammer out the significant differences between their bills as November's midterm elections loom near.

The Senate's package left out several major items passed by the House, including two controversial measures that hospitals badly want: loosening the so-called IMD exclusion to channel Medicaid funds to facilities with more than 16 beds for treatment of opioid addiction as well as rolling back the extra privacy laws protecting addiction patients.

The Senate measures run a wide gamut of funding grants, mandatory demonstrations and studies on the effectiveness of certain treatments, prescription monitoring and law enforcement to block distribution of opioids like fentanyl.

The package includes bills to monitor prescriptions for potentially at-risk Medicare Part D beneficiaries, expand the "sunshine laws" mandating disclosures of gifts from drug manufacturers to a wider array of clinicians, and allowing more Medicaid payments to go to facilities that help treat mothers and babies with neonatal abstinence syndrome.

The Senate dropped a bill that would implement the Centers for Disease Control and Prevention's recommended three-day limit on opioid prescriptions after providers pushed back on the proposal. It was replaced by a directive for HHS to study the impact of laws and regulations on opioid prescriptions.

But the contents of the final package ultimately depend on how the House and Senate handle the reconciliation. Either chamber could convene a conference headed up by select lawmakers, or the two chambers could trade their versions back and forth until they have settled on final legislation. A senior GOP aide would not confirm whether a final deal is expected before the midterms.

Congress faces a crammed schedule before November, including final negotiation and passage of 2019 spending bills for the first time in over a decade and confirmation of Supreme Court nominee Brett Kavanaugh.

However, Washington is mindful of public opinion and polling on the opioid epidemic and how the federal government has responded as it prepares for the elections.

A Politico-Harvard T.H. Chan School of Public Health survey from August found that 39% of Americans believe federal spending to curb the epidemic is too low, 26% are satisfied, and 15% think it is too high. The poll also found that the public diverges from the provider community in their trust in medication-assisted treatment—with just one-third of the people surveyed saying it is effective. Americans are also almost evenly split about needle exchanges, with a slight majority opposing them.

Researchers from the Harvard T.H. Chan School of Public Health in late 2017 released a study of polls from 2016 and 2017 that showed only 28% of the public think the opioid epidemic is a national emergency, and that Americans are also split over which level of government should shoulder most of the work to stem addiction. Only half believed there is long-term, effective treatment for opioid addiction.

Democrats and industry lobbyists have criticized the packages from both chambers for the limited funding. The legislation would reauthorize the 21st Century Cures' state targeted response grants, which are due to expire in spring of 2019. Congress included $1 billion for these funds in the March spending omnibus, which appropriated $4.7 billion in total for the opioid epidemic.

But providers on the ground and behavioral health advocates in Washington criticize the focus on grants, arguing that they block long-term planning and investment in a systemic approach to the crisis.

Altarum, a not-for-profit research firm, estimated in February that since 2001 the opioid crisis has cost the U.S. economy $1 trillion since 2001, largely in terms of lost wages and tax revenue. Healthcare costs between 2001 and 2017 reached nearly $216 billion, largely from emergency department visits to stabilize people who had overdosed, according to Altarum. The study noted that a "disproportionately large share of this cost" has fallen to Medicaid.