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Stephanie Pellitt

, National Council for Behavioral Health

Trump Releases Budget Proposal, Seeks Medicaid Cuts and Opioid Funding

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On Monday, President Trump unveiled his Fiscal Year (FY) 2019 budget request — detailing his Administration’s legislative and regulatory priorities for next year. The document revives last year’s failed attempts to block grant Medicaid, boosts spending to combat opioid addiction, and outlines other major health care priorities. As with most presidential budgets, this proposal stands little chance of being enacted into law as written. Instead, the President’s budget proposal will act more as a messaging tool to Congress, which just passed a major budget deal boosting defense and non-defense discretionary spending limits last week.

It is important to note that it is the role of Congress, not the President, to design and pass the federal budget. Last week, Congress passed a bill establishing topline spending numbers for various federal policy priorities for the remainder of the current fiscal year (FY 2018) and FY 2019. Now Congress has until March 23rd to appropriate those funds to specific agencies and programs for FY 2018. At the same time, the President has released his budget plan for FY 2019, which starts Oct. 1, 2018, yet it remains to be seen if any of the President’s recommendations (detailed below) will be taken up by Congressional appropriators as they move through the budget process.

Among the highlights of the President’s budget request for the Health and Human Services Department (HHS) for FY 2019:

Medicaid and ACA Repeal: The White House’s budget proposal endorses the Graham-Cassidy health care bill, which would end the Affordable Care Act’s (ACA) Medicaid expansion and convert federal Medicaid funding into block grants to the states. Both measures would result in tremendous cuts to the Medicaid program, however, there appears to be little political willpower to pass these proposals now after multiple ACA “repeal and replace” attempts failed last year. The National Council strongly opposes any attempt to cut or cap Medicaid as these provisions would seriously harm individuals with mental illness and addiction who rely upon Medicaid coverage for life-saving care.

Beyond that, the budget also proposes making it easier for states to charge patients higher co-pays for emergency room visits and bolster requirements that Medicaid recipients show immigration status before enrolling. Many of these changes have already been endorsed and encouraged by the Centers for Medicare and Medicaid (CMS) as part of state Medicaid waivers.

Opioid and Mental Health Funding: The budget proposal includes $10 billion in discretionary funding for HHS to fight the opioid crisis and outlines a number of policy changes in Medicare and Medicaid aimed at curbing drug abuse — part of a larger investment across government agencies to prevent and treat drug abuse. The proposal recommends some of these funds support an expansion of Certified Community Behavioral Health Clinics (CCBHCs) to care for people with serious mental illness and addiction. The budget also includes proposes allowing Medicare to provide comprehensive coverage for substance abuse treatment and requiring Medicaid to cover all three FDA-approved medication-assisted treatment (MAT) options including methadone, buprenorphine and extended-release naltrexone.

Importantly, mental health and addiction advocates should understand that the $10 billion fund is likely not entirely new funding. Although details of the President’s budget are still emerging, some of the $10 billion appears to be offset by proposed cuts to other health care agencies, including a $668 million cut to the Substance Abuse and Mental Health Services Administration (SAMHSA) in FY 2019.

Late last week, the House and Senate passed a budget agreement to lift the budget caps and authorize an additional $6 billion to help address the opioid epidemic over FY 2018 and FY 2019. Over the next two fiscal years, the $6 billion will be allotted for various efforts to address opioid diversion and opioid addiction prevention and treatment. Funding will be distributed via state grants, taking into account each state’s opioid mortality rates. It is also not yet clear how this additional spending authority impacts the President’s FY 2019 budget proposal.

Further, the budget calls for all-but-eliminating the White House Office of National Drug Control Policy (ONDCP) and shifting its key grant programs to different agencies. The proposal requests $17 million for the drug office, down from $368.6 million last year. Most of that drop would come from moving the High Intensity Drug Trafficking Areas grant to the Justice Department, and the Drug Free Communities Act to HHS.

Prescription Drugs: With respect to enforcement, the budget proposes to establish HHS reciprocity with the Drug Enforcement Administration (DEA) to terminate provider prescribing authority for doctors who improperly prescribe addictive painkillers. The budget calls for cracking down on high opioid prescribers and utilizers in Medicaid and would also require plans to participate in a program to prevent prescription drug abuse in Medicare Part D.

NIH and Research Funding: The National Institutes of Health (NIH) would get $35.5 billion, or a $1.4 billion increase over fiscal 2018 funding levels. This includes $750 million from a broader $10 billion investment throughout HHS to fight the opioid crisis and address serious mental illness.

Additional details on the President’s HHS budget request are outlined in the Department’s budget-in-brief document.