Ohio Gov. Kasich Stumps Again In Support Of Medicaid Expansion


Four years after going out on a limb to get Medicaid expansion enacted in Ohio, outgoing Republican Gov. John Kasich is worried about the future of the program. So he is now defending it — through a study and through the stories of people who have benefited from the coverage expansion.

One of those people is Brenda Jean Searcy, a 55-year-old law student who lives with her 93-year-old father in the Columbus suburb of Westerville. She says she had always been healthy but was felled by Lyme disease and then Graves’ disease; the diagnosis of the latter came after she had signed up for Medicaid through the expansion.

“I am very grateful to have Medicaid. It has made my life much better and made me much healthier,” Searcy says at a press conference.
Searcy is one of the 653,000 Ohioans who gained coverage through the Medicaid expansion, four years after Kasich defied his fellow Republican legislators in pushing Medicaid expansion through.

He claimed it would bring $13 billion in federal funding to help low-income people in Ohio get health care — especially those struggling with mental illness and addiction. Kasich is nearing the end of his second term and will leave office in January. He wants the Medicaid expansion to continue, and his Medicaid department commissioned an independent study on the effects of the expansion to support it.

Ohio Medicaid Director Barbara Sears says the analysis shows Medicaid expansion has cut in half the number of uninsured Ohioans. Ninety-six percent of people in the program with opioid addiction got treatment, and 37 percent of smokers were able to quit. One-third reported improved health, including better access to medical care for high blood pressure and diabetes. ER visits went down 17 percent, and there was a 10 percent increase in the number of people seeing primary care doctors. And most recipients said Medicaid expansion made it easier to find work, earn more money and care for their families.

The state’s budget office, part of the executive branch, estimates Medicaid expansion will cost nearly $5.2 billion in 2021, the first year Ohio will pay its full share of the costs as determined by the Affordable Care Act.

Ohio budget director Tim Keen says the state’s projected share would amount to $354.1 million. However, with drug rebates, assessments on managed care plans, a 1 percent tax on premiums and other offsets, the state’s share drops to $163.1 million. “Medicaid expansion is a significantly better deal for the states and for Ohio than the traditional program, and that’s important as one considers our ability to fund this program,” Keen says.

But Republican lawmakers have long had concerns about the program’s cost.

And so does the Republican candidate to replace Kasich, Attorney General Mike DeWine. After stating for months that he feels the Medicaid expansion is financially unsustainable, DeWine says he’ll keep it but makes changes, such as implementing work requirements and wellness programs. DeWine hasn’t made clear how much those changes would save the program – for instance, 96 percent of Medicaid expansion recipients in Ohio would be exempt from work requirements.

Kasich says he has talked to DeWine’s team about supporting the program. “I worry a little bit about somebody kind of nickeling and diming it away somehow — a little bit here, a little bit there — but I think they’ll be for it,”



Forty Years of Winning Friends and Influencing People


An interview with former US Representative Henry Waxman of California.

Of the more than 12,000 Americans who have served in Congress since it convened in 1789, few have had careers as fruitful as Henry Waxman’s. Representing west Los Angeles and its surrounding areas for 40 years, Waxman, 78, left a remarkable imprint on US health policy. His manifold accomplishments were capped by the passage of the Affordable Care Act (ACA) in 2010. A son of south-central Los Angeles, he worked at his father’s grocery store, earned a law degree at the University of California, Los Angeles, and in 1968 won a seat in the State Assembly. He was elected to the US House in 1974 in an era when bipartisanship was ordinary and health care had yet to become an overwhelming economic and political force in American life. Waxman was known in Congress for his persistence at wearing down opposition. Republican Senator Alan Simpson of Wyoming famously called him “tougher than a boiled owl” after negotiating the landmark Clean Air Act amendments of 1990. Waxman led efforts to ban smoking in public places and to require nutrition labels on food products. I talked with him recently about his experiences, the future of health policy, and the changing language of health reform. The transcript has been lightly edited for length and clarity.

Q: In 1974, when Los Angeles voters first sent you to Washington, health policy wasn’t the ticket to political influence. You are a lawyer, not a doctor. What drew you to health care?

A: When I was first elected to the California State Assembly in 1968, I believed that if I specialized in a policy area I would have more impact than if I tried to be an expert on everything. Health policy fit my district in Los Angeles, and I could see that government needed to be involved in a whole range of decisions, from health care services to biomedical research to public health. I was chairman of the Assembly Committee on Health. I was elected to Congress in 1974 in a Democratic wave election. I wanted to get on a health policy committee, which was Energy and Commerce. Democrats picked up so many seats and there were so many committee vacancies that year that it was easy to claim one, and I got on that committee. Within four years there was a vacancy for chair of the health and environment subcommittee, and I stepped up to that. It gave me a lot more impact.

Q: What role do you think health care will play in the upcoming elections?

A: If the Democrats do as well as I expect and hope, it will be more because of what Trump was doing in the health area than anything else. Even though people value health care services and insurance, the idea that the president and the GOP wanted to take away health insurance and reduce benefits for people who needed it — that was something they didn’t expect and were angry about.

Q: Is it feasible to provide health coverage to everyone?

A: I have always felt we needed access to universal health coverage. It wasn’t until we got the ACA under Obama that we were able to narrow the gap of the uninsured — those who couldn’t get insurance through their jobs, who weren’t eligible for Medicare and Medicaid, who had preexisting conditions, or who couldn’t afford the premiums. The ACA helped people have access to an individual health policy by eliminating insurance company discrimination and giving a subsidy to those who couldn’t afford coverage. It wasn’t a perfect bill, but it was important. The idea that Republicans would come along and bring back preexisting conditions as a reason to deny people coverage is what drove enough GOP senators to stop the GOP repeal bill from going forward last year. We’ll see what they do by way of executive orders or through the courts to try to frustrate people’s ability to buy insurance.

The Republican ACA repeal bill last year was a real shock because they also wanted to repeal the Medicaid program and allow states to cut funds for people in nursing homes, people with disabilities, and low-income patients who rely so heavily on that program. And they had proposals to hurt Medicare that House Speaker Paul Ryan had been advancing. The American people do not want to deny others insurance coverage and access to health services.

Q: Bipartisanship has gone out of style. Can it be revived?

A: It doesn’t look very likely now, but I built my legislative career on the idea that there could be bipartisan consensus to move forward on legislation. All the big bills had bipartisan support. The only bill that got through on a strictly partisan basis was the Obamacare legislation, and I regretted that. The Republicans just wanted to denigrate it and scare people into believing the ACA would provide for death panels, hurt people, take away their insurance, and keep them from getting access to care. None of that was true.

Q: A growing number of Democrats want to establish a single-payer health care system for the state. Do you agree with them?

A: A lot of people mistake the phrase “single payer” with universal health coverage. While I share the passion of people who want to cover everybody, single payer is not a panacea. My goal is universal health coverage. The Republican attempt last year to repeal the ACA and send 32 million Americans into the ranks of the uninsured was an albatross around their necks.

But the Democrats could turn this winning issue into a loser if some make a single-payer bill such as Medicare for All into a litmus test. I cosponsored single-payer legislation in Congress with Senator Ted Kennedy, and I always sought to bring the nation closer to universal coverage. I authored laws to bring Medicaid to more children and to establish the Children’s Health Insurance Program, and I led the fight to enact the ACA. These bills were very important. If we passed something like a single-payer bill, which would be extremely hard to do, we would be passing up opportunities to make progress. A lot of people who want a Medicare for All bill don’t realize that those of us on Medicare have to pay for supplemental insurance, because Medicare doesn’t cover everything. Medicare doesn’t generally cover certain services like nursing home care, so to get help you have to impoverish yourself to qualify for Medicaid.

One organization is sending out letters telling voters to support a single-payer bill and you won’t have to pay anything anymore. We can’t afford something like that. Democrats can embrace a boundless vision for a health care future without being trapped by a rigid model of how to get there. We should increase the number of people with comprehensive health insurance and focus on lowering costs. People with Medicare don’t want to give it up. People have health insurance on the job.

I would rather expand on what we have and build it out to cover everybody.

People don’t seem to remember that Democrats could barely muster the votes for the ACA when we had 60 votes in the Senate and a 255–179 majority in the House. Even if we recapture Congress and the presidency, I don’t think we would get a Medicare for All bill passed. It would require such a high tax increase that people would be absolutely shocked.

Q: What would be the national impact of California adopting a universal coverage plan?

A: Californian progress would be a model for the rest of the country, and we would be doing what’s right for the people of California who don’t have access to coverage. I think California is a trendsetter — for good and for bad. Proposition 13 and term limits started in California and spread to other states, and I think they have been a disservice. We’ve also done a lot of good things in California, and the rest of the country follows those things as well.

People who try to marginalize California do so at their own risk. People around the country look at California as a leader. California embraced the ACA, expanded Medicaid, and has been moving forward on making sure our public health care system is reforming itself to represent the needs for population health care and to ensure that uninsured low-income patients get access to decent, good-quality health care.

Q: More states are adopting work requirements in Medicaid. Do you think that will become the standard nationwide?

A: Work requirements are inconsistent with the Medicaid law. We’re talking about making people go to work to get health care when they’re sick. I just don’t think it makes sense. The courts may throw it out, and if not, at some point there will be a reaction against it, and it will be repealed by a future Congress.

Q: Some see parallels between the conduct of tobacco companies and opioid makers. Do you think “Big Pharma” will be held to account like “Big Tobacco?”

A: In the difficult fight against big tobacco, one of the lessons we learned was that even an extremely powerful group like the tobacco industry could be beaten if you keep pushing back. Even though there was overwhelming public support for regulation of tobacco, it took until 2009 before we could enact tobacco regulation by giving the Food and Drug Administration (FDA) authority to act. In the meantime, there were lawsuits by states to recover money they spent under Medicaid programs to cope with the harm from smoking. With opioids, there will be more and more lawsuits against distributors and manufacturers whose actions resulted in deaths of people from opioid addiction. Congress now is grappling with many bills to help people who are addicted, to prevent addiction from spreading further, and to restrict the ability to get the drug product. I’m optimistic we can come to terms with this crisis.

Q: What have you been doing since retiring from Congress?

A: I wanted to stay in the DC area near my son, Michael Waxman, and his family. He had a traditional public relations firm and he asked me to join him. In the health area, we represent Planned Parenthood in California, public hospitals in California, community health centers at the national level, and hospitals that get 340b drug discounts because they serve many low-income patients. We have foundation grants to work on problems of high pharmaceutical prices, and foundation grants to have a program to make sure women know about the whole range of health services available to them for free under the ACA. I enjoy working with my son and pursuing causes I would have pursued as a member of Congress.




Suicide rates rise sharply across the United States, new report shows



Suicide rates rose in all but one state between 1999 and 2016, with increases seen across age, gender, race and ethnicity, according to a report released Thursday by the Centers for Disease Control and Prevention. In more than half of all deaths in 27 states, the people had no known mental health condition when they ended their lives.

In North Dakota, the rate jumped more than 57 percent. In the most recent period studied (2014 to 2016), the rate was highest in Montana, at 29.2 per 100,000 residents, compared with the national average of 13.4 per 100,000.

Only Nevada recorded a decline — of 1 percent — for the overall period, although its rate remained higher than the national average.

Increasingly, suicide is being viewed not only as a mental health problem but a public health one. Nearly 45,000 suicides occurred in the United States in 2016 — more than twice the number of homicides — making it the 10th-leading cause of death. Among people ages 15 to 34, suicide is the second-leading cause of death.

The most common method used across all groups was firearms.

“The data are disturbing,” said Anne Schuchat, the CDC’s principal deputy director. “The widespread nature of the increase, in every state but one, really suggests that this is a national problem hitting most communities.”

It is hitting many places especially hard. In half of the states, suicide among people age 10 and older increased more than 30 percent.Percent change in annual suicide rate* by state, from 1999-2001 to 2014-2016 (Centers for Disease Control and Prevention)

“At what point is it a crisis?” asked Nadine Kaslow, a past president of the American Psychological Association. “Suicide is a public health crisis when you look at the numbers, and they keep going up. It’s up everywhere. And we know that the rates are actually higher than what’s reported. But homicides still get more attention.”

One factor in the rising rate, say mental health professionals as well as economists, sociologists and epidemiologists, is the Great Recession that hit 10 years ago. A 2017 study in the journal Social Science and Medicine showed evidence that a rise in the foreclosure rate during that concussive downturn was associated with an overall, though marginal, increase in suicide rates. The increase was higher for white males than any other race or gender group, however.

“Research for many years and across social and health science fields has demonstrated a strong relationship between economic downturns and an increase in deaths due to suicide,” Sarah Burgard an associate professor of sociology at the University of Michigan, explained in an email on Thursday.

The dramatic rise in opioid addiction also can’t be overlooked, experts say, though untangling accidental from intentional deaths by overdose can be difficult. The CDC has calculated that suicides from opioid overdoses nearly doubled between 1999 and 2014, and data from a 2014 national survey showed that individuals addicted to prescription opioids had a 40 percent to 60 percent higher risk of suicidal ideation. Habitual users of opioids were twice as likely to attempt suicide as people who did not use them.

High suicide numbers in the United States are not a new phenomenon. In 1999, then-Surgeon General David Satcher issued a report on the state of mental health in the country and called suicide “a significant public health problem.” The latest data at that time showed about 30,000 suicides a year.

Kaslow is particularly concerned about what has emerged with suicide among women. The report’s findings came just two days after 55-year-old fashion designer Kate Spade took her own life in New York — action her husband attributed to the severe depression she had been battling.

“Historically, men had higher death rates than women,” Kaslow noted. “That’s equalizing not because men are [committing suicide] less but women are doing it more. That is very, very troublesome.”

National Institute of Mental Health director Joshua A. Gordon explains some of the latest research surrounding suicide rates in the U.S. 

Among the stark numbers in the CDC report was the one signaling a high number of suicides among people with no diagnosed  mental health condition. In the 27 states that use the National Violent Death Reporting System, 54 percent of suicides fell into this category.

But Joshua Gordon, director of the National Institute of Mental Health, said that statistic must be viewed in context.

“When you do a psychological autopsy and go and look carefully at medical records and talk to family members of the victims,” he said, “90 percent will have evidence of a mental health condition.” That indicates a large portion weren’t diagnosed, “which suggests to me that they’re not getting the help they need,” he said.

Cultural attitudes may play a part. Those without a known mental health condition, according to the report, were more likely to be male and belong to a racial or ethnic minority.

“The data supports what we know about that notion,” Gordon said. “Men and Hispanics especially are less likely to seek help.”

The problems most frequently associated with suicide, according to the study, are strained relationships; life stressors, often involving work or finances; substance use problems; physical health conditions; and recent or impending crises. The most important takeaway, mental health professionals say, is that suicide is an issue not only for the mentally ill but for anyone struggling with serious lifestyle problems.

“I think this gets back to what do we need to be teaching people — how to manage breakups, job stresses,” said Christine Moutier, medical director of the American Foundation for Suicide Prevention. “What are we doing as a nation to help people to manage these things? Because anybody can experience those stresses. Anybody.”People without known mental health conditions were more likely to be male and to die by firearm. (CDC)

The rates of suicide for all states and the District of Columbia were calculated using data from the National Vital Statistics System. Information about contributing circumstances for those who died by suicide was obtained via the National Violent Death Reporting System, which is relatively new and in place in only 27 states.

“If you think of [suicide] as other leading causes of death, like AIDS and cancer, with the public health approach, mortality rates decline,” Moutier said. “We know that same approach can work with suicide.”



Medical Research, Drug Treatment And Mental Health Are Winners In New Budget Bill


Sen. Susan Collins, R-Maine (center), is joined on Wednesday by Sen. Lindsey Graham (from left), R-S.C., Sen. Lisa Murkowski, R-Alaska, and Rep. Greg Walden, R-Ore. Collins was pushing for provisions in the budget bill aimed at lowering premiums for people purchasing health insurance in the Affordable Care Act’s marketplaces. That didn’t happen.


The big budget deal reached this week in the House doesn’t include a long-sought-after provision to stabilize the Affordable Care Act marketplaces. But the $1.3 billion plan, set to fund the government through September, has lots of new money for medical research, addiction treatment and mental health care.

Here’s the rundown of what’s included in the 2,232-page spending bill, now in the hands of a Senate vote, based on summaries released by the House and Senate appropriations committees.

  • $78 billion in overall funding for the Department of Health and Human Services, a $10 billion increase
  • $3.6 billion to fight the opioid addiction crisis
    • This more than doubles the money allocated in fiscal 2017 and boosts funding for treatment and prevention, as well as helping to find alternatives for people suffering from pain.
  • $3.2 billion for mental health care
    • This is a 17 percent boost from last year and goes to treatment, prevention and research.
  • $37 billion for the National Institutes of Health
    • This is a $3 billion increase over fiscal 2017 and boosts spending on research into Alzheimer’s disease and a universal flu vaccine, among other things.

Lawmakers could not agree on language designed to stabilize the Affordable Care Act insurance markets and lower insurance premiums that Sens. Lamar Alexander, R-Tenn., and Susan Collins, R-Maine, have been fighting for since last fall. That bill would have reinstated the cost-sharing reduction payments, by which the government reimburses insurance companies that give the lowest-income customers a break on their copayments and deductibles.

Last year President Trump announced that the government would stop making the payments, a decision that drove the unsubsidized premiums on insurance policies higher.

Alexander says his proposal would restore those payments and cut premiums as much as 40 percent.

“Nothing is more important to Americans than health care, and nothing is more frightening than the prospect of not being able to afford health insurance, which is the case for a growing number of Americans,” he said at a news conference Wednesday.

But Democrats refused to support the provision because it also included language that would have barred any insurance policy sold on the ACA marketplaces from covering abortion.




The Wrong Way to Treat Opioid Addiction

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Rather than defining addiction as destructive, compulsive behavior, this ideology focuses on physical dependence. If you need a drug to avoid being physically ill, you are considered addicted. So Prozac would be considered addictive, but not cocaine, because quitting Prozac abruptly can cause flulike symptoms while stopping cocaine doesn’t, even though it elicits extreme craving.

In the 1980s, crack cocaine made clear just how addictive cocaine could be, even without physical withdrawal symptoms. Today, both the National Institute on Drug Abuse and the Diagnostic and Statistical Manual of Mental Disorders reject the idea that addiction is synonymous with dependence. Unfortunately, many clinicians, including doctors, haven’t caught up.

What is addiction, then? The root problem is craving, which drives a compulsion to use drugs despite the harm they cause. That’s what makes crack addictive, while Prozac can be therapeutic.

Because methadone and buprenorphine are opioids themselves, it’s easy to assume that using them is “substituting one addiction for another.” However, the pattern of taking the same dose every day at the same time means that there is no high or intoxication. Patients on maintenance doses are able to nurture a baby, drive, work and be a loving spouse.

In these patients, addiction is replaced by physical dependence. And that’s not a problem for those who have health care coverage: It’s no different from needing antidepressants or insulin. When a drug’s benefits outweigh its risks, continued use is healthy, not addictive.

Sadly, though, there’s another reason for widespread skepticism about addiction medication. It comes from the fact that many patients will continue to misuse opioids. Medication reduces relapse more than abstinence does — but relapse is still common, as in Mr. Thompson’s case. In abstinence treatment, however, relapsers drop out and are invisible; with medication, they often remain in treatment.

And remaining in treatment is important because it cuts overdose risk, even during relapse. Many highly traumatized people also need the continued health care support before they are able to quit street drugs.

When we fail to understand that these medications can be used both to reduce harm and stabilize people in recovery, we risk letting the perfect be the enemy of the good. For some, medication is a way to reduce risk while drug use continues. For others, it’s a path to rapid recovery. Often, people will need to take the first route to survive long enough to reach the second.

For harm reduction to work, maintenance drugs need to be almost as accessible as street drugs. Whenever people take buprenorphine rather than heroin, their risk of dying is lowered, especially since so much heroin these days is tainted with deadly strong fentanyl. For stabilization, people need empathetic counseling that doesn’t view dependence as continuing addiction.

Change will require innovative measures. The government should stop funding and insurers should stop covering any program that does not use all the F.D.A.-approved anticraving medications and does not provide informed consent about their effectiveness. While abstinence can work for some, we need many options. We also need to rethink our regulations for methadone and buprenorphine prescribing.

Then we need to publicly recognize that recovery on medication is every bit as valid as any other treatment. What matters is whether, as Freud put it, you can love and work, not the chemical content of your brain or urine.


Trump Asked Kellyanne Conway To Tackle The Opioid Crisis & Here’s Why Experts Are So Worried


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On Wednesday, Attorney General Jeff Sessions announced that President Donald Trump’s counselor Kellyanne Conway will take on the opioid crisis, overseeing all White House initiatives combating the current overdose epidemic. More than 52,000 people lost their lives to drug overdoses in 2016 alone, according to a CNN report, with at least 33,000 of them were due to opioid drugs, including prescription painkillers. Trump labeled the opioid crisis a public health emergency in October.

Now, the president is calling for an “opioids czar” to lead efforts against the epidemic — and Conway is taking on that role. She will “coordinate and lead the effort from the White House” related to the opioid crisis, Sessions said at a news conference on Wednesday.

One opioid policy expert, Andrew Kolodny of Brandeis University’s Opioid Policy Research Collaborative, told BuzzFeed he thinks this is a good move.

However, he also pointed out that the administration still doesn’t have anyone leading the Office of National Drug Control Policy, nor has it released a comprehensive strategy for addressing this public health crisis. Trump has previously said he’d like to launch an advertising campaign similar to Nancy Reagan’s “Just Say No” campaign, which was widely unsuccessful.

Christie also called the need for an opioids czar “overblown.” He feels that they already know how to handle the issue, and it starts with limiting the prescriptions for painkillers, cutting fentanyl exports from China, and providing naloxone to communities, BuzzFeed reported. Naloxone blocks and reverses the effects of opioid drugs, and gives non-medical people the ability to save lives. While it’s controversial, as some say it enables more drug use, it’s been shown to decrease the number of overdoses. There are also drugs, like methadone and buprenorphine, shown to help recovering addicts stay in treatment longer.

Kelly Pfeifer, director of high-value care at California Health Care Foundation, an Oakland-based philanthropic nonprofit, explains to Bustle:

Unfortunately, there’s a stigma surrounding a lot of these treatments — people view it as trading one drug, for instance heroin, for another, like methadone. But scientific evidence continues to show the benefits of medication-assisted treatment versus complete abstinence. This has led the Hazelden Betty Ford Foundation, a top treatment provider in the United States, to even start providing anti-addition medications as part of its recovery program.

But Conway’s expertise isn’t so much in medicine or addiction as it is in “messaging,” according to Sessions.

He also emphasized a focus on law enforcement to deal with the crisis.

Still, many feel the country needs a lot more than a good ad campaign and stricter laws. “We have spent billions on the failed ‘war on drugs’ and have learned that exclusive focus on law enforcement will not end the epidemic or save lives,” Pfeifer says. “The evidence is with addiction treatment — and that is where funding should go.”

Why Advertising Is a Poor Choice to Tackle the Opioid Crisis


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In declaring the opioid epidemic a public health emergency last week, President Trump promised that the federal government would start “a massive advertising campaign to get people, especially children, not to want to take drugs in the first place.” But past efforts to prevent substance abuse through advertising have often been ineffective or even harmful.

Perhaps the most famous American antidrug advertisement featured a sizzling egg in a frying pan to the sound of ominous music and a stern voice-over warning, “This is your brain on drugs.” A sequel to this ad featured Rachael Leigh Cook smashing an egg and the better part of a kitchen to dramatize the impact of heroin.

Many other ads denouncing drugs and emphasizing their destructive effects — as in the “Just Say No” campaign — appeared regularly on television and in print beginning in the 1980s. Most of them were funded by the White House Office of National Drug Control Policy, which received hundreds of millions of dollars a year from Congress for such campaigns.

Visually dramatic though the ads were, evaluations of them were deeply discouraging. The billions spent from the late 1980s through the mid-2000s at best had no effect on drug use, research shows. At worst, exposure to the campaign might have actually increased the likelihood of adolescent marijuana use. A study of over 20,000 youths 9 to 18 found that those who had been exposed to more antidrug ads expressed weaker intentions to avoid marijuana and more doubts that marijuana was harmful.

Why was the original campaign such a failure? In part it suffered from perverse incentives. Congress provided substantial money for the ads and was intensely interested in them at the height of the so-called war on drugs, creating internal pressure to make the ads appealing to members of Congress. But while ads that lectured or scared people about drugs might have seemed compelling to the modal member of Congress (a 60-year-old white male), they did not necessarily dissuade drug use by adolescents. In some cases, this kind of approach may make drugs more attractive as a sign of rebellion.

Other reasons that campaigns backfire is that they make adolescents aware of a drug that they might not have heard of, sparking curiosity in some to try it. Campaigns against drugs can also create a false sense that drug use is more common than it is, making those who don’t use drugs feel socially abnormal.

After the failure of the government’s initial antidrug media campaign, which was highlighted in the press and congressional hearings, it was significantly redesigned. The new approach, named Above the Influence, moved more toward the message that not using drugs exemplified and maximized youth freedom.

The retooled campaign had stronger results, with one study of over 4,000 adolescents showing that it reduced teenage marijuana use.

In switching tack, antidrug campaigns were taking a page from antismoking campaigns like the “truth.”This campaign, which research has estimated has deterred hundreds of thousands of adolescents from beginning to smoke, turns youthful rebellion to its advantage. Refraining from smoking was not about pleasing a parental authority figure; the “truth” pointed out to adolescents that people their parents’ age ran the tobacco companies and took them for saps (not cool). To be free thus meant to snub their seduction (cool).

Still, the positive results for Above the Influence and the “truth” are not the norm. A recent Cochrane review of rigorous studies collectively examining over 180,000 people reported that the average effect of mass media campaigns on drug use in randomized studies was essentially zero. Why is it so hard for media to change young people’s drug use?

By the time they reach adulthood, Americans are typically exposed to tens of thousands of advertisements promoting substance use, be it beer, cigarettes or more recently cannabis in some locations. Although opioids are not directly advertised to the public, seeking relief through pills certainly is (“Ask your doctor about …”).

Given this environment, it is not surprising that the comparatively small number of ads promoting the opposite message do not make much difference. In fact, it would probably be more consequential as a media strategy to stop the promotion of addictive products, but American courts are almost alone in the developed world in treating commercial speech comparably to the protection given free speech.

Media campaigns against drug use by young people thus can at most make a modest contribution to turning around the opioid epidemic, with some risk of making it worse if the lessons of past failed antidrug campaigns are not heeded. But the safest bet is that the results will be between those two end points: zero. To fight the opioid crisis, public money is probably best spent elsewhere.

Opioid Commission Unveils Blueprint To Fight Crisis, But Passes Funding Buck To Congress

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The group’s 56 recommendations include tightening prescription practices and expanding drug courts, prevention efforts, treatment access and law enforcement tactics.

President Trump’s bipartisan commission on the opioid crisis made dozens of final recommendations on Wednesday to combat a deadly addiction epidemic, ranging from creating more drug courts to vastly expanding access to medications that treat addiction, including in jails.

The commissioners did not specify how much money should be spent to carry out their suggestions, but they pressed Congress to “appropriate sufficient funds” in response to Mr. Trump’s declaration last week of a public health emergency.

The 56 recommendations — which covered opioid prescribing practices, prevention, treatment, law enforcement tactics and funding mechanisms — did not so much advocate a new approach as expanding strategies already being used.

Reaction from treatment advocates was mixed, with many expressing frustration that the commission had not called for a specific level of funding. Chuck Ingoglia, a senior vice president at the National Council for Behavioral Health, which represents treatment providers, said that his group agreed with many of the recommendations, but that the report “starves the country for the real resources it needs to save American lives.”

Although the commission did not put a dollar amount on its recommendations, it had specific ideas for how federal money should be funneled to states. Its top recommendation was to streamline “fragmented” federal funds for addiction prevention and treatment into block grants that would require each state to file only a single application instead of seeking grants from dozens of programs scattered across various agencies.

The commission also appealed to the Trump administration to track more carefully the huge array of interdiction, prevention and treatment programs it is funding and to make sure they are working. “We are operating blindly today,” its report said.

Regina LaBelle, who was chief of staff in the White House Office of National Drug Control Policy under President Barack Obama, said the recommendations recognized “the importance of proper and appropriate treatments” for addiction, particularly medications that help people avoid cravings and symptoms of withdrawal. But, she added, “There needs to be more funding for this.”

The head of the commission, Gov. Chris Christie of New Jersey, a Republican, suggested in a television interview Sunday that Mr. Trump would soon ask Congress to allocate far more money for fighting the nation’s addiction problem. “I would say that you’re going to see this president initially ask for billions of dollars to deal with this,” he said on ABC’s “This Week.”

The White House issued a statement thanking the commission and saying it would review the recommendations.

It is hard to determine how much money is truly needed. When Senate Republicans added $45 billion in addiction treatment funds to an Obamacare repeal bill that ultimately failed, Gov. John Kasich of Ohio, a Republican, said that amount was akin to “spitting in the ocean.”

Richard Frank, a health economics professor at Harvard Medical School who worked in the Obama administration, estimated that it could cost roughly $10 billion a year to provide medication and counseling to everyone with opioid use disorder who is not already in treatment. Treating opioid-dependent newborns, meeting the needs of children in foster care because of their parents’ addiction and treating hepatitis C and other illnesses common among opioid addicts would cost “many billions more,” Mr. Frank said.

Mr. Frank also cautioned that block grants would not work if the administration decided to include federal Medicaid funding for addiction treatment in them. “When one starts to carve out certain services as grants, as opposed to insurance funding, one undermines the insurance,” he said. “It is a method of killing Medicaid with 1,000 nicks.”

Some of the commission’s other recommendations included making it easier for states to share data from prescription drug monitoring programs, which are electronic databases that track opioid prescriptions, and requiring more doctors to check the databases for signs of “doctor shopping” before giving a patient opioids.

The commission encouraged the federal Centers for Medicare and Medicaid Services to review policies that it claimed discouraged hospitals and doctors from prescribing alternatives to opioids, especially after surgery. According to the commission’s report, C.M.S. pays a flat, “bundled” payment to hospitals after patients undergo surgery, which includes treatment for pain. Because they get a flat fee, hospitals are encouraged to use cheap products – and most opioid medications are generic and inexpensive.

“Purchasing and administering a non-opioid medication in the operating room increases the hospital’s expenses without a corresponding increase in reimbursement payment,” the report said.

More broadly, the report said the federal government as well as private insurers should do a better job of covering a range of pain-management and treatment services, such as non-opioid medicationsphysical therapy and counseling. And it recommended that the Department of Health and Human Services and other federal agencies eliminate any reimbursement policies that limit access to addiction medications and other types of treatment, including prior authorization requirements and policies that require patients to try and fail with one kind treatment before getting access to another.

One prevention measure the commission did not embrace is expanding syringe exchange programs, which public health experts say save money and lives by reducing the spread of H.I.V. and hepatitis C with contaminated syringes.

“I was hoping to see that in this report,” Ms. LaBelle said.

The commission’s members – Mr. Christie, Gov. Charlie Baker of Massachusetts, a Republican; Gov. Roy Cooper of North Carolina, a Democrat; Pam Bondi, the Republican attorney general of Florida; Patrick Kennedy, a former Democratic congressman from Rhode Island and Bertha Madras, a Harvard professor – all voted for the final recommendations, which came about a month later than expected.

His voice quaking with emotion, Mr. Kennedy said during the commission’s meeting Wednesday that Congress needed to appropriate sufficient funds for the initiative, suggesting at least $10 billion.

”This town doesn’t react unless it hears from real people“ who will vote in the next election, he said, nodding to guests who had testified about their families’ searing experiences with addiction, stigma, lack of treatment options and the refusal of insurance companies to cover treatment.

Mr. Kennedy also noted that insurance coverage is crucial to fighting addiction; in another commission meeting earlier this year, he took Republicans to task for working to repeal the Affordable Care Act and cut Medicaid.


Editorial: Trump’s response to opioid epidemic is more pep talk than plan


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President Donald Trump promised to come out swinging with Thursday’s emergency declaration on opioid abuse. Swing, he did, but he failed to make contact.

By labeling the crisis a public health emergency, Trump skirted a legal definition that would have prompted emergency federal funding and placed the drug epidemic on a scale similar to major disaster response. He should have pledged a dollar amount equal to the challenge of combating an addiction epidemic that, by his own assessment, contributed to at least 64,000 U.S. overdose deaths last year.

Trump clearly grasps the magnitude of the problem, outlining it in the starkest terms: “Citizens across our country are currently dealing with the worst drug crisis in American history and even, if you really think about it, world history. … Drug overdoses are now the leading cause of unintentional death in the United States by far. More people are dying from drug overdoses today than from gun homicides and motor vehicles combined,” he said.

The driving force behind this epidemic is heroin and opioid abuse among an estimated 12 millions Americans. Trump labeled the United States as “by far the largest consumer of these drugs” in the world. “Opioid overdose deaths have quadrupled since 1999 and now account for the majority of fatal drug overdoses.”

Surely, a problem of this magnitude deserves a gargantuan plan of action. Trump’s speech Thursday contained no plan at all. He said the administration planned to announce a new policy to help relax restrictions that limit the number of beds in treatment facilities. He called for greater resolve.

He said he awaited a report from New Jersey Gov. Chris Christie, the head of a presidential commission on opioid abuse, to address the problem. Trump reiterated the previous administration’s program to alert doctors about the dangers of over-prescribing opioids. He promised lawsuits against “bad actors.”

As if invoking First Lady Nancy Reagan’s “just say no” campaign in the 1980s, Trump said, “One of the things our administration will be doing is a massive advertising campaign to get people, especially children, not to want to take drugs in the first place because they will see the devastation and the ruination it causes to people and people’s lives.”

Trump did outline expenditures for programs already in place to boost law enforcement, border security, addiction treatment and pain management. None of those programs, however, has stemmed the addiction tide.

“We’re going to do it. We’re going to do it,” Trump insisted.

This was Trump’s moment to go big and bold in confronting a crisis that kills more Americans in a single year than all the hurricanes, earthquakes, floods and fires the nation has suffered in the past decade. America needs a plan of action, not a pep talk.

Medicaid’s Role in Financing Behavioral Health Services for Low-Income Individuals


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Behavioral health conditions affect a substantial number of people in the U.S. and are especially common among people with low incomes.1,2,3 Behavioral health conditions include mental illnesses, such as anxiety disorders, major depression, bipolar disorder, schizophrenia, and post-traumatic stress disorder, as well as substance use disorders (SUD), such as opioid addiction. These conditions range in severity, with some being more disabling than others.  People with behavioral health needs may require a range of services, from outpatient counseling or prescription drugs to inpatient treatment.

As a major source of insurance coverage for low-income Americans, and as the only source of funding for some specialized behavioral health services, Medicaid plays a key role in covering and financing behavioral health care. In 2015, Medicaid covered 21% of adults with mental illness, 26% of adults with serious mental illness (SMI), and 17% of adults with SUD.4 In comparison, Medicaid covered 14% of the general adult population.5 In total, approximately 9.1 million adults with Medicaid had a mental illness and over 3 million had an SUD in 2015. Nearly 1.8 million of these adults had both a mental illness and an SUD.6,7

Current Medicaid program financing guarantees federal financial support to states with no pre-set limit. The Better Care Reconciliation Act (BCRA), as proposed by the Senate, restructures federal Medicaid financing by changing it to a per capita cap or block grant, which would likely impact states’ ability to provide coverage for and access to behavioral health services for people who need them. This issue brief provides an overview of Medicaid’s role for people with behavioral health needs, including eligibility, benefits, service delivery, access to care, spending, and the potential implications of the BCRA.