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States face an opioid funding cliff next year

WASHINGTON -- Congress has provided billions of new dollars to fight opioid abuse. But the problem will be far from solved when the one-time appropriations run out next year.

President Donald Trump and Health and Human Services Secretary Alex Azar announced $1.8 billion in grants last week to help states increase access to medication treatment and mental health care for those struggling with addiction. It's part of a new infusion of funding -- passed by Congress one year ago -- aimed at the epidemic that kills tens of thousands of Americans every year.

"By the end of this month, HHS will have awarded a record $9 billion to expand access to prevention, treatment and recovery services to states and local communities during my administration," Trump said. "And they're doing a great job locally when they get the funds ... and great results."

But here's the catch: States use much of the funds to help uninsured people who don't have a way to pay for their treatment. When the dollars run out, treatment could be once against beyond the reach of these patients if they don't find a long-term way to pay for care through insurance.

"It doesn't inspire a lot of commitment to see these grants are just a year and they or may not go away," said Anand Parekh, chief medical adviser for the Bipartisan Policy Center, which released a report in March analyzing the dozens of federal funding streams for opioid addiction and how states are using the money.

It's a particularly pressing problem in states that didn't expand their Medicaid programs, such as North Carolina, where more than 10 percent of its population lacks coverage.

North Carolina has received $75 million in new federal grants, said Susan Kansagara, chronic diseases section chief at the state's Department of Health and Human Services. The grants have allowed the state to supply about 10,000 people with treatment. But there's no guarantee they'll continue getting the treatment once those funds are gone, considering North Carolina has one of the country's highest uninsured rates.

"We have a huge population of uninsured that can receive treatment from these funds, but how are they going to continue to receive treatment?" Kansagara said. "We know [opioid abuse] is a condition that requires many years, if not a lifetime, of treatment and recovery support."

She added: "It's hard to tell, for example, a practice to hire two more physicians if I don't now if funding is going to continue to come in after two years."

It's hard to overstate Medicaid's role in helping mitigate the opioid crisis. The program for the low-income was the expected payer for 37 percent of opioid-related hospital stays and 44 percent of emergency department visits in 2016. About 17 million additional Americans joined the program when many -- but not all -- states expanded it under the Affordable Care Act.

"Without expansion, you're missing a fundamental tool that can address the epidemic," said Jocelyn Guyer, managing director of Manatt Health, a consulting firm.

But even states with this "tool" of Medicaid expansion are struggling to figure out the best way to direct the funding. "The one- to two-year challenges are very much apparent," said Kate Harris, chief deputy commissioner at the Colorado Division of Insurance.

Tackling the opioid crisis, which has reached across the United States and prompted a public health emergency declaration by Trump, is far from simple, involving a patchwork of stakeholders and approaches.

States and localities are suing opioid makers to help pay for treatment. Mallinckrodt Pharmaceuticals, one of the largest manufacturers of generic opioids, announced last week it has agreed on a settlement in which it will pay two Ohio counties $24 million in cash and donate $6 million in drugs, including for addiction treatment medications.

Officials have recently clashed over how to even pursue damages. Ohio Attorney General Dave Yost has sued to halt a landmark trial in October, part of a consolidation of thousands of opioid lawsuits brought by local governments. Yost charges that the Ohio counties involved in the case are trying to seize potential payments from the opioid makers that could be better used by the state.

And then there's the money coming to states from the federal government, both from last year's Support Act and two pieces of legislation President Barack Obama signed in 2016 to address the epidemic. In analyzing those two measures, Parekh and his colleagues identified 57 different federal funding streams across six executive branch departments, a complex web he said makes coordination difficult for states trying to put all the funds to best use.

Doctors, who have borne much blame for leading to the crisis by overprescribing opioid painkillers, are offering states advice of how to best use the dollars. On Tuesday, the American Medical Association released six recommendations on how states should direct the funding.

The recommendations include removing barriers to medication-assisted treatment, ensuring private health plans cover mental health services in accordance with the law, expanding alternative to opioids for managing pain and making naloxone, the overdose-reversing drug, more readily available.

"We have to think about building an infrastructure to address this epidemic," Harris told reporters.

It would be up to Congress to extend the opioid funding beyond next year. The Trump administration hasn't said whether it's asking lawmakers to do so.

"If I could, I would," Elinore McCance-Katz, director of the Substance Abuse and Mental Health Services Administration, recently told the New York Times.

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