Before the election, the plan for FY 2017 spending was clear: Congress passed a short-term spending bill in September that would keep the government running until Dec. 9, at which point the omnibus spending bill would be released, setting appropriations for the fiscal year that began Oct. 1. Now, President-elect Donald Trump would prefer that he, and not Obama, have a say in appropriations, and wants Congress to go along with him on that. On Nov. 17, Congress decided just that: instead of an omnibus bill on Dec. 9, they will approve a continuing resolution (CR) that keeps the government running under current appropriations until March of next year.
There had been indications that Congress had been leaning toward a CR, which has happened frequently. This time, it simply adds to the confusion and concern about what protections will be retained for health care, including substance use disorder (SUD) treatment and prevention.
“The work continues,” said Robert Morrison, executive director of the National Association of State Alcohol and Drug Abuse Directors (NASADAD). He takes an “all-of-the-above” approach when it comes to vehicles for the Comprehensive Addiction and Recovery Act (CARA) or any other funding for treatment and prevention.
Of greatest concern to the treatment field in general is a threat to the Affordable Care Act (ACA), which both Trump and Republicans in Congress have vowed to repeal. Ron Pollack, executive director of Families USA, issued a call to action after the election. “We must take Trump at his word, and he has repeatedly said his first act would be to repeal the ACA — even calling Congress into special session, if necessary,” said Pollack. “This will have tragic consequences for tens of millions of people, and we at Families USA are going to be on a total war footing to make sure this never comes about.”
Key aspects of the ACA include Medicaid expansion, which not all states participated in, and subsidies for health insurance policies. This was very important for SUD treatment, because in many states, single men were unable to get Medicaid. Also included in the ACA is a list of 10 essential health benefits, one of which is behavioral health care. The ACA also prohibits insurance companies from denying coverage on the basis of pre-existing conditions.
Trump also wants to put Medicaid into a block grant, which would cap it; as an entitlement, Medicaid is not capped at the federal level.
“Studies show that repealing the ACA will force 20 million people into the ranks of the uninsured. Approximately 130 million people with pre-existing conditions will be in danger as insurance companies are once again allowed to discriminate against the sick,” said Pollack. “We will see a return to annual and lifetime insurance caps that can leave people with severe illnesses or accidents in a ‘no-insurance zone’ where they will either go without care or go bankrupt. And women will pay higher premiums again merely because they are women.”
Restructuring Medicaid would jeopardize health care for more than 70 million low-income people, added Pollack. “We will fight at the grassroots level and in the halls of Congress to make sure Mr. Trump’s proposed ACA repeal and Medicaid restructuring don’t happen. Millions of people should not have their lives placed in jeopardy through reckless action.”
Becky Vaughn, executive vice president and chief operating officer of the Addiction Policy Forum, said that changing the essential benefit or Medicaid expansion would be a big concern for treatment. “And my biggest worry would be moving Medicaid to a block grant, because with that kind of cap, a lot of people wouldn’t get services,” she said.
A block grant is a fixed amount of money given to a state. Federal Medicaid dollars, by contrast, are only limited by the amount a state spends on Medicaid; the more a state spends of its own dollars, the more the federal “match” is.
On the other hand, Trump did say he favors keeping the pre-existing condition prohibition in the ACA — or whatever the new version of “Obamacare” will be. He also favors the provision allowing families to keep their adult children on their policy until the age of 26.
There is evidence that many more young people have gotten SUD treatment as a result of that provision, said Vaughn. Still, the majority of people who have gotten treatment as a result of public money is either through expanded Medicaid or the Substance Abuse Prevention and Treatment block grant in states that didn’t expand Medicaid, she said.
On the bright side, there is the Mental Health Parity and Addiction Equity Act. This parity law has not yet fulfilled its promise of making treatment for SUDs covered on par with treatment for medical and surgical care, but it’s still in place. “That is of some comfort to us, and we are continuing to push for stronger enforcement of it,” she said.
Vaughn has worked through many administration transitions, having been in the field for more than three decades. But this is different, because of the ACA, she said. “Before, we were mostly thinking about how the new administration would affect the block grant,” she said. “There is a lot more at stake this time.”
Even in a more usual transition, there is a lot of education that takes place, as the former administration passes on information to the new one. However, in this case, precedent will be broken, as the new administration will not be abiding by the budget set by the previous one.
Last week, Republicans in Congress put a hard stop to Obama budget priorities, opting for a continuing resolution for the FY 2017 budget instead of the Dec. 9 omnibus that had been planned previously.