The Substance Abuse and Mental Health Services Administration (SAMHSA) has released its budget request for fiscal year 2016, with some good news for opioid treatment programs (OTPs). Some key areas of the proposed SAMHSA budget relate specifically to opioid use disorders.
We talked with Barbara Cimaglio, deputy commissioner of the Vermont Department of Health, the person in charge of substance use disorders (SUDs) for Vermont, about the budget. “They’re really encouraging states that may not have used medication-assisted treatment (MAT) very much to think about doing so,” she said.
Ms. Cimaglio has been at the forefront of single state agencies (SSAs) supporting MAT. The SSAs have control of the Substance Abuse Prevention and Treatment (SAPT) block grant, which funds most publicly funded SUD treatment. The SAPT block grant received level funding at $1.8 billion, also good news at a time of budget cuts.
Under Obamacare everyone is supposed to have either private health insurance or Medicaid. But that isn’t what’s happened. Many states did not expand Medicaid. And even in a state like Vermont, which has a robust private exchange as well as Medicaid expansion, the block grant is needed for treatment, said Ms. Cimaglio. “Unfortunately, there are still a number of people who either have a very high deductible or who have not signed up for health insurance, so we still have to use the block grant for them,” she said.
Ultimately, the block grant can be used for other services not reimbursed by insurance, she added. But that day isn’t here yet. Massachusetts is perhaps the best example of why the block grant has to be used for treatment services, despite health care reform. By far the most covered population in the country even before it embarked on its own health care reform, Massachusetts still has to use the block grant for SUD treatment services, noted Ms. Cimaglio. “We’re seeing in Vermont what happened in Massachusetts, which is that we’re dealing with a population that is just unable to get health insurance,” she said. “They may present for treatment, and then sign up for coverage.” But the services have to be delivered right away─before the insurance kicks in─and the block grant has to cover that.
In addition, there are people who sign up for insurance with the lowest premiums, which means the highest deductibles and copays. The draft block grant application, which is separate from the budget, suggests that the block grant can be used for copays. “We’re looking at what this would mean,” she said. “There are a lot of analyses that need to be done if we’re making significant changes like that.”
The most practical option involves giving providers more flexibility to use the block grant for “connecting services,” such as connecting patients to housing and social services. OTPs already provide the most comprehensive services, said Ms. Cimaglio. The outpatient providers who prescribe buprenorphine are not able to help patients with employment and housing. “We’re trying to look at a more comprehensive approach.”
One problem that can’t be solved by the SAMHSA budget: locations for OTPs. Even in OTP-friendly Vermont, there are still waiting lists for treatment. “They’re only half as long as they used to be,” she said. “But it’s still challenging” to get access to treatment with methadone for everyone who needs it. “The biggest challenges are in our Burlington area.” The problem is one of physical space, where providers don’t have room to expand. “We may need to look for another facility in order to take on more patients,” she said.
Access to Recovery
While the block grant funding stayed level, the SAMHSA budget does once again propose zeroing out Access to Recovery (ATR), the voucher-based program allowing patients to choose recovery support and other services.
The SAMHSA budget proposal calls for removing the remaining $38.2 million in ATR funding. Many states have relied on it. “We have never had an ATR grant; it’s far too complicated to think about,” said Ms. Cimaglio. “But the states that had it are very concerned. It helped them provide a lot of recovery support, and it will be a big loss.”
Recovery support is considered essential to long-term recovery, especially in the early stages.
The proposed budget also includes an additional $12 million for states to use to purchase naloxone, the overdose-reversal medication.
It’s important to have some new resources for naloxone, which in some states is being distributed by OTPs. “We had to find money for naloxone,” Ms. Cimaglio told AT Forum. “The health department is responsible for the naloxone pilot project, which does include law enforcement as well as health care providers.” There is controversy over whether the $12 million from SAMHSA for naloxone will go to health providers or law enforcement; the budget leaves it up to states to decide.
For the budget in brief, go to http://www.hhs.gov/budget/fy2016/fy-2016-budget-in-brief.pdf.
For the Congressional Justification, which has narrative explaining why SAMHSA is making its requests, go to http://www.samhsa.gov/sites/default/files/samhsa-fy2016-congressional-justification_1.pdf.
For the revised draft block grant application, go to http://www.samhsa.gov/sites/default/files/bg_application_fy16-17_12112014_final_draft_clean_rev_r122914d.pdf