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2018 Federal Budget Deep Dive: How Opioid Funding is Fueling Major Spending Increases in the HHS Budget & Shaping Grant Programming

By Christopher LaPage

It turns out that concerns over major spending cuts proposed by the Trump Administration were overblown. The anticipated demise of many popular grant programs did not come to pass. In fact, the Consolidated Appropriations Act of 2018 includes modest to significant increases across the board, increasing defense allocations by $26 billion and non-defense domestic appropriations by $33 billion. In total, Congress passed a budget that essentially rolls back the draconian cuts that were instituted in 2013 - known as sequestration - surpassing the administration’s request by $143 billion.

HHS Budget
The U.S. Department of Health & Human Services (HHS), the largest federal grantmaker, realized a $10 billion increase in funding over 2017 levels. A closer analysis indicates the surge in funding is being fueled by investments in tackling the opioid epidemic that is ravaging the country. This trend becomes crystal clear when you examine the individual budgets of agencies underneath the HHS umbrella.

Health Resources & Services Administration’s (HRSA) Bureau of Health Workforce (BHW)
HRSA’s BHW was allocated just over $1 billion in the 2018 budget, which represents an increase of 26% over 2017 funding levels. BHW’s initiatives and grant programs promote the education, recruitment and retention of health care providers in rural and underserved areas across the United States. Almost two-thirds of the new funding can be attributed to initiatives that target the opioid epidemic, either directly or indirectly. More than $115 million of the $222 million increase in BHW’s budget will fund education and training programs for mental and behavioral health professionals and paraprofessionals, such as social workers and substance abuse counselors. An additional $30 million of the BHW budget is designated for potential loan repayments for behavioral health professionals under the National Health Service Corps through the Rural Communities Opioid Response Program.

HRSA’s Office of Rural Health Policy (ORHP)
If you are looking for evidence that investments related to the opioid epidemic are driving budgetary increases across HHS, look no further than HRSA’s ORHP. ORHP realized an 86% rise in funding compared to last year, which amounts to and increase of approximately $134 million. Three-fourths of the funding increase for ORHP is being driven by a $100 million investment in the Rural Communities Opioid Response Program (RCORP). This is in addition to the aforementioned $30 million allocated to BHW for health professional training activities under the program. RCORP funding will likely be distributed via grants to rural health providers over the next five years as funding is authorized through 2022. The goals of the grant program will be to improve access to and recruitment of new substance use disorder providers, build sustainable treatment resources, increase use of telehealth, establish cross-sector community partnerships, and implement new models of care, including integrated behavioral health. A 2018 solicitation is imminent, and it is anticipated that ORHP will offer one-year planning grants up to $200,000 and make up to 75 awards. Future solicitations will offer more money and focus on implementation activities. ORHP Funding will be targeted at 220 rural counties that have been determined to be at risk by the Centers for Disease Control and Prevention (CDC). A list of the at risk designated counties can be found at https://www.hrsa.gov/sites/default/files/hrsa/about/news/cdc-at-risk-communities.pdf.

Centers for Disease Control & Prevention (CDC)

The CDC received one of the largest programmatic increases in the HHS budget as funding for the Evidence Based Opioid Drug Overdose Prevention Program (EBODOP) increased by 325%, making more than $475 million available through September 30, 2019. Most of this funding will be distributed to states in the form of grants and cooperative agreements to improve the capture and availability of surveillance data, advance interventions that monitor prescribing and dispensing practices, and promote better timeliness and quality of morbidity and mortality data around opioid use. The funding is expected to expand the use of prescription drug monitoring programs (PDMPs) as the CDC strives to improve public health surveillance and clinical decision making in the field through a web of interconnected PDMPs. As such, EBODDOP is likely to include investments to integrate data from PDMPs with electronic health records. For those in states and communities struggling with the opioid epidemic, the following are specific examples of funding programs that may be funded with the EBODOP allocation:
Prevention for States: https://www.cdc.gov/drugoverdose/states/state_prevention.html
Enhanced State Opioid Overdose Surveillance: https://www.cdc.gov/drugoverdose/foa/state-opioid-mm.html
Data Driven Prevention Initiative: https://www.cdc.gov/drugoverdose/foa/ddpi.html

National Institutes of Health (NIH)

The NIH realized an overall budgetary increase of $3 billion, which represents a 9% rise over their 2017 funding levels. About 17% of the funding increase is dedicated to support opioids research, primarily through clinical trials for new medications and other treatment interventions. The $500 million in funding is evenly split between the National Institute for Neurological Disorders and Stroke and the National Institute on Drug Abuse. Funding must be distributed by the end of federal fiscal year 2019. NIH grant funding that specifically targets opioid research can be found at https://www.drugabuse.gov/funding-app/rfa?search=opioids&r=1.

Substance Abuse & Mental Health Services Administration (SAMHSA)
The most dramatic impact of prioritizing opioids in the federal budget can be seen in the $3.2 billion allocation to SAMHSA specifically for substance abuse treatment services. While these dollars will be used to treat a variety of substance abuse issues, the entirety of the agency’s 49% increase in funding will be dedicated to opioid abuse through a $1 billion allocation to the State Opioid Response Grants Program (SORGP). The SORGP was first funded in late 2016 through the 21st Century Cures Act, providing $1 billion over two years to the states to improve prescription drug monitoring programs, make treatment programs more accessible, train healthcare professionals in best practices of addiction treatment and research the most effective approaches to prevent dependency. This influx of funding for the program will make its way to each single state agency for substance abuse (SSA), the same entity that manages the Mental Health and Substance Abuse Treatment and Prevention Block Grants in each state. These funds will likely result in pass-through grants and other funding for local governmental agencies and non-profit providers. The timing is not clear on these new funds. Each state received their FY2018 share of the $500 million that was allocated through the CURES Act just earlier this year. SAMHSA must submit a plan to Congress on how they intend to distribute the funds and the formula that they will use to determine state allocations. In order to provide continuity in funding levels, SAMHSA may recommend utilizing the funds to provide $500 million in 2019 and the rest in 2020, but that decision is not final. Local and private-sector agencies that serve opioid patients should maintain contact with their respective SSA to ensure they are part of any planning efforts around the funds. An updated list of SSA contacts is available at: https://www.samhsa.gov/sites/default/files/sites/default/files/ssa_directory_4-9-2018.pdf.

SAMHSA also experienced modest to significant increases in funding for substance abuse prevention efforts and mental health services, respectively. SAMHSA’s budget for substance abuse prevention rose 11% over 2017 levels, primarily driven by $36 million being made available to fund opioids training to first responders, including paramedics and law enforcement personnel. The agency’s budget for mental health services also rose by more than $300 million, representing an increase of 27% compared to 2017 funding levels. While these services are not specific to opioids, substance abuse disorders typically co-occur with serious mental illness or other mental health issues. Often times correcting opioid abuse and other behavioral health issues requires complimentary and comprehensive mental health counseling and treatment.

In Conclusion

All too often, federal funding is slow to react to public health crises – Lagging far behind the hardships experienced on the ground floor of communities across the country. One such example of this can be seen in preventative care. The federal government is fond of sending a message that every dollar spent on health prevention generates savings by avoiding costly treatments down the road. Yet, year after year,
health prevention funding never seems to make the high priority list when it comes down to the federal budget process.

In the case of opioids, federal agencies and politicians alike have been pounding the drum on opioids for several years. Outside of the CURES Act of 2016, however, there was very little to show in terms of federal funding. That has all changed with the Consolidated Appropriations Act of 2018, which shows a clear and concerted effort to tackle the opioid epidemic. In fact, the commitment to deal with opioids is the driving force behind major increases in funding for HHS. This emphasis on opioids is not just realized only through the new money discussed here, but also within existing grant programming that has been around for decades. For example, the U.S. Department of Agriculture’s (USDA) Distance Learning & Telemedicine (DLT) Grant Program was released this year and for the first time in its history has a preference built in for telemedicine projects that target opioid treatment (for a summary of DLT, see our Grant Snapshot on page 12!). It’s expected that additional Federal grantmaking agencies will continue to reformulate existing programs to prioritize opioids-related projects. The good news is that all signs point to the fact that 2018 will not be an anomaly. The prioritization of opioids is likely to continue as it has broad support across both Democrat and Republican politicians.