Individuals in Medicaid Deserve Care That is Appropriate and Responsible in its Execution Act
Floor Speech
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Mr. PALLONE. Mr. Chair, I yield myself such time as I may consume.
Mr. Chair, I stand in opposition to H.R. 5797, the IMD CARE Act.
I think we all agree that we need all the tools available to us to address the opioid crisis. Inpatient treatment centers that focus on the treatment of behavioral health needs of patients with substance use disorder are part of that. Congress must do what we can to ease access to care.
But I believe this legislation, as drafted, is misguided. It is also counterproductive and an ineffective use of scarce Medicaid dollars. But more importantly, it may undermine the ongoing efforts to improve the full continuum of care for people with substance use disorders.
This policy spends more than $1 billion in Medicaid to pay for a policy that is far narrower in both scope and flexibility than what many of our States already have and any State could do through Medicaid substance use disorder waivers.
In addition, as countless data has indicated, there are many gaps in treatment for Medicaid beneficiaries with substance use disorder. Yet this bill does nothing to incentivize States to provide the full continuum of care.
Community-based services are necessary for both people not treated in residential inpatient facilities and also for people who leave residential inpatient treatment and need community-based services to continue their treatment and recovery.
We already face a shortage of community-based care for substance use disorder and should be working with States to increase this capacity. Yet this bill doesn't tie Federal funds for IMD care to improvements in community-based services. Without that connection, States simply will not pursue these needed improvements.
Without incentives to improve access to treatment more broadly, repealing the IMD exclusion to only a narrow population--in this case, opioid use--through legislation may simply encourage greater use of expensive inpatient treatment, including for people for whom it may not be the best option.
We can't push a system where people cycle in and out of institutions. People with substance use disorders need a range of supports to stay well and sober long term, not just a limited stay in an IMD.
Existing guidance from both the Obama and Trump administrations allows States to waive the IMD exclusions if the States also take steps to ensure that people with substance use disorder have access to other care they need, including preventive, treatment and recovery services.
So far, there are 22 States, Mr. Chair, that have waivers approved or pending before the administration. I think these waivers are important to support.
My home State of New Jersey has approval for a waiver right now. Under that waiver, they expanded access to all substance use disorder services in their Medicaid program. We should build on that policy, which emphasizes the full continuum of care, with any bills that repeal the IMD exclusion.
In addition, I have concerns about creating a system in States whereby only some of our Medicaid beneficiaries with substance use disorder have access to the full continuum of care they need.
This bill specifically limits residential treatment to adults with opioid use disorders, with the possible addition of an amendment for cocaine use disorders. But it doesn't help the overwhelming majority of individuals with other substance use disorders, such as alcohol, which is far more commonly abused.
Treatment for substance use disorder, especially in the midst of our opioid crisis, must include a comprehensive approach that addresses the entirety of a patient's medical and psychological conditions. This legislation creates a perverse incentive toward individuals reporting opioid abuse or going out and getting addicted to opioids, for instance, in the hopes of gaining access to the treatment they need.
Expanding access to inpatient residential treatment in a vacuum I think would undermine State efforts to ensure the availability of substance use disorder treatment that meets the needs of all patients in the most appropriate environment.
In the short time this legislation has been publicly available, countless stakeholders have weighed in vehemently on particulars of this bill, echoing my concerns today. In fact, coalitions with more than 300 groups as well as other mental health, substance use, and disability groups have sent letters in opposition. I think we need to work with stakeholders. This issue is too important to get wrong.
For these reasons, Mr. Chair, I oppose H.R. 5797.
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Mr. PALLONE. Mr. Chair, I yield myself such time as I may consume.
Mr. Chair, I want to speak briefly on a point that I think is being lost here.
This bill presumes that expanding access to residential treatment is the answer, and it is not necessarily. Without any requirement that States address gaps in Medicaid community-based services, I think there is a possibility that we risk more harm than good.
The former director of national drug control policy has reminded us that most of these IMD facilities provide detoxification services. But detoxification is only the first stage of addiction treatment. Indeed, it may increase the potential for overdose if patients do not remain or have any support when released, since, with detoxification, their tolerance for opioids is significantly reduced.
The proposal before the House will likely create an overreliance on institutional treatment and may exacerbate the dearth of community-based health services.
People with substance use disorder often find themselves unable to access intensive community-based behavioral health services when they need it. Likewise, many cannot access services in the community when they are discharged following a crisis.
Incentivizing inpatient care may actually increase opioid overdose, the very harm that Congress is seeking to prevent. Experts have raised serious concerns with this bill's institutional focus because recent data suggests that inpatient detoxification is an important predictor of overdose, largely because many who receive inpatient care aren't then connected to community-based treatment programs or put on medication, leaving them extremely vulnerable.
Again, I am concerned that we may be contributing to this crisis with this legislation.
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Mr. PALLONE. Mr. Chair, I yield myself the balance of my time.
Mr. Chair, in closing and in urging opposition to this bill from my colleagues, the reason the IMD exclusion was put in place in the beginning was because of the fear that people who had overdosed, who had opiate problems, would be put into institutions, if you will, and then throw away the key. In other words, they put them in there, maybe they get detoxed, and then they come out. But without any treatment or any followup, community-based treatment, they would just go back to the same thing again; they would overdose again and end up back in the facility.
So the fear was that we would have these large facilities where they go in and, without any kind of continuum of care, the cycle just keeps repeating itself. I just want my colleagues to be mindful of that.
What happened was, during the Obama administration, States had asked for waivers from the IMD exclusion, and the Obama administration decided they would do that if they provided a continuum of care and community-based services so that the problem that led to the IMD exclusion would not repeat itself.
I guess my fear is, today, that this seems like such a simple solution: Okay. We will get rid of the 16-bed exclusion because we need people to go into these institutions.
However, since we are not providing any continuum of care or community care in eliminating this exclusion, it goes back to the same problem, which is we don't want people to just be warehoused to detox, come out again, overdose again, and go back in without any kind of community services.
That is why I am making the argument that the actual waivers that exist now, which I think almost half of the States have, is a much better alternative than just lifting and getting rid of the exclusion. That is why I believe that this bill is misplaced and why I would urge my colleagues to oppose it, because I think it may actually go back to the days where we were just warehousing people and we are not actually giving them the kind of treatment that they need.
Mr. Chair, I would urge my colleagues to vote against the bill, and I yield back the balance of my time.
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Mr. PALLONE. Mr. Chairman, I thank the chairman for yielding.
Mr. Chairman, I support Mr. Rush's amendment, but I remain in strong opposition to the underlying bill. I support my colleague's, Mr. Rush's, work to add cocaine use disorder.
As Mr. Rush noted in our committee, cocaine use claims more African American lives than opioid use and has been a larger problem than opioid use disorder for more than 20 years, yet incarceration, not treatment, is far too often the response.
Unfortunately, adding a single additional drug does not make this legislation whole. Nearly half of all States already reimburse for IMDs for all individuals with substance use disorder. We can and should build on that policy and strengthen the full continuum of care with any IMD policy this body passes.
There is no good reason, policy or otherwise, for us to leave the overwhelming majority of Medicaid beneficiaries out in the cold because they have the misfortunate to be addicted to, for instance, alcohol or meth instead of cocaine or opioids.
So, again, I support the amendment, but I remain in strong opposition to the underlying bill.
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Mr. PALLONE. Mr. Chairman, I thank the gentlewoman for yielding.
Mr. Chairman, I support my colleague's, Representative Kildee's, amendment to this legislation. It is certainly important to require States to report information on individuals with co-occurring disorders and what disorders are suffered, and it is equally important to have information on access to community care for individuals suffering from a behavioral health issue other than a substance use disorder.
Mr. Chairman, I want to stress that this information is important, but the underlying problem with the IMD CARE Act continues. I believe this bill is, at best, an ineffective use of scarce Medicaid dollars. More importantly, it may undermine ongoing efforts to improve the full continuum of care for people with substance use disorders.
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