Biden’s State of the Union: Bold Promises on Public Health

On March 1st, President Biden delivered his first State of the Union Address to both chambers of Congress and the American people at large. Amid a slew of foreign and domestic policy proclamations, particular attention should be afforded to the statements and commitments made about addressing the COVID-19 pandemic and public health, more broadly. Championing the landmark legislation that was the American Rescue Plan, the President laid out how the legislation’s programming reduced food pantry lines, increased employment, and how expansion of the Affordable Care Act’s subsidies resulted in lower insurance premiums for many Americans. In addressing the COVID-19 pandemic, Biden also recognized a sobering outcome that will shake the nation: within the next few weeks, the United States’ official COVID death toll will surpass one million people. Though the President misstated the moment in that those empty seats at dinner tables will be more than a million; on average each COVID death has impacted 9 other people, including orphaning children across the country. Biden then shifted the address, citing the Centers for Disease Control and Prevention’s recent announcement of adjust masking guidelines and metrics of risk, trying to signal a much-needed political win in the fight against COVID. However, immediately following these statements, the President also focused on providing the country with another round of free at-home COVID-19 tests and implementing a tactic already well-known in the HIV space: test-to-treat, with added bonus of the program following the COVID vaccine model and having no out-of-pocket expense for patients.

The program ideals outlined in the days that followed found some confusion, need for clarity, and even some professional association bickering. Public health professionals who have long advocated for more robust responses to the pandemic took to news outlets to vent their frustrations and the American Medical Association drew derision on social media for their statement discouraging pharmacists prescription and provision of COVID antivirals. Pharmacists have long been a target for HIV advocates, especially in terms of increasing pre-exposure prophylaxis (PrEP) access and decreasing test to treat initiation delays. Wouldn’t it be nice if this COVID program provided a model outside of vaccination in which pharmacists could also serve a more robust role in facilitating seamless treatment and prevention? The meaningful hiccups the administration and advocates should keep a close eye on in this regard is the labor shortage of pharmacists, closing of more rural locations for chain pharmacies, and any developments around anti-competitive practices of pharmacy benefit managers (PBMs) associated with pharmacies. Consequences of these will extend beyond immediate COVID programming and ideal HIV programming.

The President also made statements referring to medication costs and price controls and needing to make sure more Americans could afford their care. However, details were lacking and if any recent effort is indicative, singularly focusing on manufacturer list prices won’t address patient costs or get much anywhere. Buyer beware, some proposals in the apparently sunk Build Back better legislation would also cut provider compensation in public payer programs, a dire consequence as the nation struggles with health care staffing shortages. Those shortages should be noted in detail because the American Rescue Plan provided funding meant to supplement the financial demands of staffing a pandemic and there’s good reason to suspect administrators, rather than providers, enjoyed the fruits of that labor. Further, most Americans experience their out-of-pocket costs of care due to the benefit design of their insurer (and PBM), not the manufacturer list price. Indeed, the Biden Administration appears to eb as insurer friendly as the Obama admin. To impact the costs facing patients more meaningfully at the pharmacy counter and other burdens in accessing medication, the Biden administration should focus more on developing patient protections via the regulatory process, limiting the aggressive utilization management (or deny-first coverage) policies, increasing formulary restrictions, and discriminatory plan design. Some of the tools for doing so already exist, but the federal government has yet to curb the tactics of payers in avoiding their responsibilities under the ACA’s medical-loss-ratio rules or ensure payers are not inappropriately applying cost-sharing for qualifying preventative medications and services.

The President also became the first to mention “harm reduction” in a State of the Union Address. Urging Congress to pass the Mainstreaming Addiction Treatment Act (MAT Act), President Biden is seeking to fulfill his commitments to address the opioid epidemic and move toward modernizing domestic drug policy. In a sign of acknowledgment of the scope and size of substance use epidemic in the country, Biden endorsed recovery programs and recognized the more than 23 million people struggling with addiction in the country. Immediately following the MAT Act mention, the President moved on to address of a lesser defined but equally important need in encouraging commitment to a robust set of policy ideals aimed at meeting the mental health needs of the country.

All these good things can easily be outweighed by what wasn’t mentioned. President Biden did not mention any interest in extending another round of stimulus payments, despite the program resulting in one of the largest reductions in poverty in US history. And while there was focus on rebuilding the nation’s health care staffing, no mention was afforded to rebuilding the nation’s public health infrastructure. Meanwhile, we’ve known for quite some time poverty as a notable association with HIV and decreasing poverty also decreases HIV risks and prevalence, data remains in the decline with regard to HIV and STI screenings, Hepatitis C rates are still on the rise, and inconsistencies in PrEP usage during the height of initial COVID waves likely foretells a more diverse at-risk community. Even the government’s own HIV.gov webpage dedicated to the State of the Union fails to mention any HIV or HCV specific programming efforts associated with the address.

While there’s much to celebrate about the President’s COVID goals, advocates should be cautious about projecting those goals onto other public health efforts. Afterall, COVID proved we could provide more up to date reporting than the 2 year delays we typically see in HIV and HCV surveillance, but we haven’t. COVID-related telemedicine expansion was welcomed by patients across the nation but Congress is poised to claw back those gains. For many of us, while the state of the union is improving coming out of the Omicron wave of the COVID-19 pandemic, much work remains. Including reminding this administration that it is empowered to protect patients, access to and affordability of care, an obligation to invest in public health programs beyond COVID and has committed to advancing efforts to End the HIV Epidemic.

Congress Eyes Equipping Providers to Combat the Opioid Crisis; The MAT Act

A year ago this month, Representative Paul Tonko introduced H.R. 1348 to the House of Representatives and Senator Maggie Hassan (NH) introduced its companion bill, S. 445, to the Senate. Both of these bills hold the short title “Mainstreaming Addiction Treatment Act of 2021”. The House version boasts 239 cosponsors with the Senate version enjoying 3 cosponsors. Both are supported on a bipartisan basis. The most recent action on the MAT Act is Senate “HELP” (Health, education, Labor, and Pensions) Committee hearing on February 1st, 2022, wherein the committee discussed and heard testimony on issues of mental health amid the COVID-19 pandemic.

End Substance Use Disorder, an issue education campaign endorsing the MAT Act, describes the more than a century old policy of outlawing medication assisted treatment as “outdated” and a moralization of a medical condition. Founded by Erin Shanning after her younger brother, Ethan, experienced a fatal overdose, the organization seeks to educate legislative stakeholders and urge action to adopt a more modern and medicalized approach to substance use disorder. The MAT Act removes the prohibition on providers on prescribing certain medications for the treatment of opioid use disorder maintained in the Controlled Substances Act and entirely removes the necessity for the DEA waiver of this prohibition, known as the “X” waiver. According to ESUD is joined by 418 organizations have either directly supported the MAT Act or have voiced support for eliminating the X waiver, including criminal justice and law enforcement entities. For immediate transparency, Community Access National Network is one of those 418 organizations.

This relatively straight-forward bill would help to expand access to care – especially in rural communities, move public policy into better alignment with research-proven best practices, combat racialized public health disparities, better support families, reduce overdose deaths, and more. Directly, the most immediate and significant impact of the MAT Act is an expansion of providers eligible to prescribe medication assisted treatment, specifically including certain community health practitioners. The only apparent opposition to the MAT Act is a group representing the interests of commercial addiction treatment centers.

With overdose deaths having skyrocketed by at least 20% in 2020, relative to 2019, emphasizing the need to press forward with the MAT Act is the least the Biden administration can do to begin to meet its promises around drug reform and health care access. Mental health and substance use service providers still need more support from the federal government in order to meet the need of the moment. Equipping providers with tools like medication assisted treatment, improving (read: increasing) Medicaid reimbursement rates for the treatment of substance use disorder, working to destigmatize the issue of substance use disorder, and more explicitly issuing Department of Justice guidance to family courts, social service organizations, and employers on protections afforded under the Americans with Disabilities Act for people recovering from substance use disorder are the least in a long list of actions this administration can take today.

If you would like to urge your elected representatives to remove barriers to care for clinically-proven, best practices in harm reduction, follow this link and to add your organization’s name to ESUD’s letter of support for the MAT Act, click here.