Advocates have been pushing hard over the past couple of years for the reform and expansion of mental illness and substance use disorder (i.e., behavioral health) treatment in the U.S. The 21st Century Cures Act — which has cleared Congress and is awaiting the President’s signature — includes a number of important provisions that reflect those efforts, including sections intended to strengthen, promote, and expand access to information, care, and coverage with respect to behavioral health care across communities and for individuals, families, and the nation’s health care workforce. The Act also includes $1 billion in block grant funding to target the “epidemic of death” associated with the opioid abuse crisis.
Mental Health and Substance Abuse Disorder Provisions
In one of the most noteworthy behavioral health provisions, the Act strengthens leadership within the Substance Abuse and Mental Health Services Administration (SAMHSA) by creating a new Assistant Secretary position. The new role will oversee mental health and substance abuse research, funding, and evidence-based health care practices, and will drive and coordinate federal policy in this area. To do so, the Assistant Secretary will consult with stakeholders to improve community-based and other mental health services, including care for adults and children with serious mental illness, as well as collaborate with other federal departments, including the Departments of Defense, Veterans Affairs, Housing and Urban Development, and Labor, to improve care for veterans and service members and support programs to address chronic homelessness. The Assistant Secretary is also tasked with working with stakeholders to improve the recruitment and retention of mental health and substance use disorder professionals.
The Act also addresses Medicaid coverage of mental health services through various pathways. One section, for instance, provides that effective January 1, 2019, children receiving Medicaid-covered inpatient psychiatric hospital services will also be eligible for the full range of early and periodic screening, diagnostic, and treatment services. Another section clarifies that Medicaid is permitted to pay providers for the delivery of both mental health and primary-care services to the same patient on the same day, which had been an ongoing point of confusion for many providers. The Act also directs the Secretary to report on certain data related to Medicaid managed care regulations and separately report on states that have participated in the Medicaid Emergency Psychiatric Demonstration Project established by the Affordable Care Act.
With regard to promoting and expanding access to substance use disorder care, the Act targets helping individuals and families, as well as affected children and adolescents. Specifically, the Act promotes integration of primary and behavioral health care, strengthens community crisis response systems, and supports mental health and substance use disorder services on college campuses. The Act also increases access to pediatric mental health care and early intervention services by authorizing and reauthorizing important programs for children, including those at risk of or already suffering from mental health or substance use disorders.
Additionally, the Act seeks to improve enforcement of rules for insurers to cover behavioral health care on parity with physical health. It requires the Department of Health and Human Services (HHS) to seek public comment within six months of the Act’s enactment so as to produce an action plan for improved federal and state coordination related to the enforcement of mental health parity and addiction equity requirements. The Act also requires the Administrator of the Centers for Medicare & Medicaid Services to issue an annual report for five years that summarizes the results of all closed federal investigations completed during the preceding year with findings of any serious violation regarding compliance with existing behavioral health parity requirements. Furthermore, the Act requires HHS to issue new guidance documents to assist health plan compliance with existing mental health parity requirements, including disclosure requirements and non-quantitative treatment limitations.
The Act addresses numerous other significant behavioral health issues, including: (i) requiring HHS/Office of Civil Rights to clarify when providers can use patient information protected by HIPAA for treatment purposes and share such information with patients’ family members and caregivers; (ii) boosting financial support to train mental health professionals; and (iii) important justice system reforms, including creating a Drug and Mental Health Court pilot program similar to problem-solving court programs many state and local governments already operate.
Opioid Abuse Treatment Block Grants
Overdose deaths associated with prescription and illicit opioids increased to 33,091 in 2015, according to Centers for Disease Control and Prevention (CDC) data. The increase in the number of deaths was driven, in large part, by a sharp increase in deaths related to heroin and synthetic opioid use. Heroin overdose deaths accounted for 12,990 of the deaths in 2015 – a 23 percent increase over deaths due to heroin overdoses in 2014.
Overdose deaths involving synthetic opioids, other than methadone, accounted for 9,580 of the deaths – a 73 percent increase over 2014. The synthetic opioid fentanyl involved in these deaths appears to have been illicitly manufactured. Taken together, 19,885 deaths in America in 2015 involved primarily illicit opioids: heroin, synthetic opioids other than methadone, or a mixture of the two. At the same time, overdose deaths involving prescription opioids rose only slightly.
In Section 1003 of the Cures Act, Congress attempts to address what Dr. Thomas Frieden, the Director of the CDC, describes as the worsening “epidemic of deaths” by appropriating $1 billion for use by the state governments to deal with the “opioid abuse crisis.” The appropriation covers a two-year period ($500 million for fiscal years 2017 and 2018, respectively). These funds will be made available in the form of block grants by the HHS Secretary. In awarding such grants, the Secretary is to give preference to states with an incidence of opioid use disorders that is substantially higher relative to other states.
The block grants awarded to state governments are to be used for carrying out activities that supplement programs already undertaken by state agencies responsible for administering the substance abuse prevention and treatment block grants under subpart II of part B of title XIX of the Public Health Service Act (42 U.S.C. 300x–21 et seq.). The Act identifies some of the activities for which the grant money may be used. These activities include: i) improving state prescription drug monitoring programs; ii) implementing prevention activities and evaluating such activities to identify effective strategies to prevent opioid abuse; iii) training health care practitioners where such training would include best practices for prescribing opioids, pain management, recognizing potential cases of substance abuse, referral of patients to treatment programs, and overdose prevention; and iv) supporting access to health care services, including those services provided by federally certified opioid treatment programs or other appropriate health care providers to treat substance use disorders. In addition to the foregoing, the money may be used for other public health-related activities “as the state determines appropriate” to address opioid abuse within the state.