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‘Missed Opportunity.’ Warren’s Opioid Plan Has a Major Blind Spot, Experts Say

May 22, 2019, 2:25 PM UTC

Massachusetts Senator and 2020 presidential candidate Elizabeth Warren proposed a $100 billion plan to address the opioid epidemic earlier this month, earning praise for recognizing the scale of response the crisis requires. Drug policy experts, however, say that while her proposal is a step in the right direction, it overlooks the opportunity to fix a broken healthcare system and address substance use more effectively.

“Because it is so focused on opioids, there are blind spots for where you need to expand access to low cost health coverage, and expand access to housing, and address the underlying issues which fuel problematic substance use and overdoses in the first place,” Northeastern law and health sciences professor Leo Beletsky, an expert on the U.S. opioid crisis, told Fortune.

This “missed opportunity,” like other opioid-related legislation, adds more funding to a substance use treatment system that is “fundamentally flawed and broken,” said Beletsky.

Warren’s CARE Act—cosponsored by a number of other 2020 Democratic candidates, including Sens. Kamala Harris, Bernie Sanders, and Cory Booker—proposes $100 billion in federal funding over the next 10 years to address early intervention, harm reduction, and long-term support services for those struggling with addiction.

Of this $100 billion, funded through her proposed ultra-millionaire tax, $4 billion would go to states, territories, and tribal governments; $2.7 billion to the counties and cities hit hardest by the opioid epidemic; $1.7 to public health surveillance, research, and health professional training; $1.1 billion to public and nonprofits on the front lines; and $500 million to expand access to naloxone, a drug used to reverse opioid overdoses.

In 2017, drug overdose deaths in the nation reached an all-time high of nearly 72,000, a 6.6% increase from 2016. Warren’s bill comes just months after a new report named dying of an opioid overdose the leading cause of preventable death in the United States.

In a Medium post announcing her plan, Warren said that along with addiction treatment, “the CARE Act would ensure access to mental health services and help provide critical wraparound services like housing support and medical transportation for those who need them.”

While many agree on where Warren wants to put the money—Beletsky in particular applauded her dedication to harm reduction, a sometimes controversial area—some argue the funds are already in the system.

“She is a champion of healthcare and I think that she’s got a lot of things right,” Michael Cartwright, CEO and co-founder of American Addiction Centers, told Fortune.

“I don’t know that you need any new money,” he added, noting he doesn’t believe Warren’s ultra-millionaire tax is necessary. “The reason I say that is the health plans alone could fund this $100 billion over the next ten years if they just simply followed the Parity Act.”

The Mental Health Parity and Addiction Equity Act, passed in 2008, states that if health insurance companies provide mental health or substance use disorder benefits, the financial requirements and treatment limitations that apply to them must not be more restrictive than the medical or surgical benefits provided.

Despite being more than a decade old, the Parity Act is rarely enforced. According to a coalition of nonprofits who analyzed several major health plans in 2015 and 2016, documents frequently lack necessary details about coverage. Moreover, many patients are not aware of their rights under the Parity Act.

“Critical details about coverage and access to treatment are often missing from plan documents. It would be challenging—if not impossible—for an average consumer to know whether a plan violates the Parity Act,” Paul Samuels, director and president of the Legal Action Center and spokesperson for the Addiction Solutions Campaign (the group that conducted this study), said in a statement.

“Yet, the current system relies on consumers to report problems to insurance regulators,” Samuels continued. “When regulators don’t receive complaints, they assume the plans are in compliance. Our analysis reveals that most parity violations cannot be identified through consumer complaints nor can they be identified via form review.”

The issue has not gone unnoticed: Warren has long advocated for the Behavioral Health Coverage Transparency Act, which, if passed, would strengthen enforcement partially through random audits of insurance plans and a consumer web portal to file complaints.

Since such legislation has not yet been passed, however, the Parity Act continues to be rarely enforced, allowing insurance companies to get away with placing barriers both in policy and practice, preventing some patients from seeking treatment for substance use disorder.

“The Parity enforcement is abysmal and it’s definitely hurting people,” said Beletsky, adding that this act “arguably is more important” than the episodic funding of Warren’s plan and past legislation addressing the opioid epidemic.

“The bottom line is that the more barriers you create for people to get coverage, the better” for the insurance companies, said Beletsky. “And the stigma around addiction is such that this has been an issue that has received too little attention. As long as something is stigmatized and hidden, it makes it easier for insurers to get away with not covering it properly.”

Like Warren’s CARE Act, past legislation—including the 21st Century Cures Act of 2016 and the SUPPORT for Patients and Communities Act of 2018—have attempted to address the opioid epidemic in other ways. The SUPPORT Act, passed under the Trump administration, allocated roughly $6 billion in new funding to address the opioid epidemic through addiction prevention, medication assisted treatment, and support services.

Much of this funding, however, went into the pockets of pharmaceutical companies. The SUPPORT Act required state Medicaid plans to provide coverage for medication assisted treatment, or the use of drugs like methadone and buprenorphine to aid the recovery of those addicted to opioids.

According to Beletsky, the risk of a patient overdosing goes down by 80% when they’re treated with one of these medications. Abstinence-based rehabilitation programs, on the other hand, actually increase the risk of overdose: the program causes the patient’s tolerance to drop, meaning if they relapse and take a dose similar to what they took prior to treatment, it may be too much.

Thus medications like methadone and buprenorphine are a “critical tool,” said Beletsky, but it does “introduce this element of cognitive dissidence” for those who view the pharmaceutical companies manufacturing them as the villain.

Warren’s plan, for example, advocates for the expansion of naloxone. This drug saves lives, but by virtue of being produced by pharmaceutical companies, promoting its expansion puts more money in the pocket of big pharma. (Unlike other bills, however, Warren’s plan addresses the “criminal negligence” of major drug companies, promising to hold them accountable with actual criminal penalties.)

Cartwright argues the money dedicated to these medications would be better spent on learning more about the cause and treatment of addiction.

“I totally believe in using pharmaceuticals when necessary,” he told Fortune, but he’s bothered by the fact past legislation left us “pouring billions of dollars into old, antiquated medications versus billions of dollars into Harvard and MIT to find the answers for the cure.”

Warren’s CARE Act provides $700 million annually to the National Institutes of Health from 2020 to 2029 for the purpose of researching exactly this. The funds are designated for “research on addiction and pain, including research to develop overdose reversal drug products, non-opioid drug products and non-pharmacological treatments for addressing pain and substance use disorder.”

Meanwhile, the medications being used—while beneficial—are outrageously priced. Vivitrol, another medication used for opioid addiction treatment, costs over $1,000 per monthly shot. Naloxone, the drug used to reverse overdoses, reportedly costs about $1 to manufacture, but with insurance it costs around $40 per dose. Warren’s bill requires any federal contract with a naloxone manufacturer to include negotiations for a discounted price.

“We’ve got to ask ourselves, ‘Why are we paying so much—more than every other country on the planet—for pharmaceuticals?’ That’s a serious problem.” said Cartwright. Along with forcing drug prices down, he said “we ought to take a hard look at the money that’s already in the system and ask, ‘Is it being used efficiently?'”

Cartwright argues more should be spent on prevention and telemedicine, the latter of which could have a major impact on rural areas with few resources. Prevention is effective, he says, but according to the Center on Addiction, just two cents of every state and federal dollar spent on addiction and substance use goes towards prevention and treatment.

A truly effective solution to the opioid epidemic, however, will require a restructuring of the way problematic substance use is treated.

“There’s a consensus [among experts] that we really need to be working to integrate substance use treatment into mainstream medicine and reduce the barriers between substance use treatment, mental health, and primary care or other kinds of healthcare,” said Beletsky.

While policymakers are addressing the opioid epidemic, it’s important not to cut out those suffering from related conditions, he added. Warren’s policy is modeled off of the Ryan White CARE Act, which in 1990 allocated significant funding to address the AIDS epidemic that killed more than 100,000 people. The program is celebrated for its positive impact on HIV/AIDS treatment, but it also created this idea of “HIV exceptionalism” where those with HIV were privy to benefits that those at risk of HIV were not.

“You don’t want to create a system where if you’re using opioids, you have access to certain services and if you’re using meth, you don’t,” said Beletsky.

While Warren’s bill addresses the opioid epidemic specifically in some parts, its overarching aim is to provide complete support for all types of substance use disorder. The bill’s text says the grants are to address “substance use,” not specifically opioids.

To prevent a similar crisis in the future, however, any solution to the opioid epidemic should address root causes of problematic substance use. Warren’s plan begins to move in the right direction, but overall “there’s a lot more that needs to be done in terms of recalibrating existing systems,” said Beletsky. “It isn’t just about the healthcare system and it isn’t just about public health prevention. It’s also about the fact that we sink a lot of resources and really emphasize criminal justice approaches and we really need to move away from that.”

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