Sen. Elizabeth Warren (D-MA) on Wednesday rolled out what advocates and experts say is the most ambitious federal proposal to tackle the opioid epidemic — the latest of many policy proposals from Warren’s presidential campaign.

The proposal, an updated version of the CARE Act that Warren and Rep. Elijah Cummings (D-MD) previously introduced in Congress, would allocate $100 billion over 10 years to fight the opioid crisis, which is now the nation’s deadliest drug overdose epidemic in US history. That matches the level of spending experts have long said is necessary to make a serious dent in the crisis and reverse it.

The bill “is the only one that really grasps the nettle of how big the problem is,” Keith Humphreys, a drug policy expert at Stanford University, previously told me, on the CARE Act. “Whatever else people might say about it, this is the first thing that really recognizes that [the opioid crisis] is a massive public health problem, like AIDS, and is not going to be solved by a tweak here, a tweak there.”

Warren is known for her many policy proposals on the presidential campaign trail and her work against big banks and credit card companies, but in the Senate she’s also built a formidable record on the opioid crisis. She’s called for more research into alternative painkillers, including medical marijuana. She’s tried to hold President Donald Trump’s administration accountable for its weak response to the crisis, pushing a government watchdog agency to investigate the administration.

In 2017, there were a record 70,000 drug overdose deaths, about two-thirds of which were linked to opioids — a toll so high that the Centers for Disease Control and Prevention linked it to a rare drop in US life expectancy that year. And Warren’s home state of Massachusetts has suffered disproportionately: Its drug overdose death rate was 31.8 per 100,000 people in 2017, far above the national average of 21.7.

“Our communities are on the front lines of the epidemic, and they’re working hard to fight back,” Warren told me in an interview earlier this year about the original CARE Act. “But they can’t do it alone. They can’t keep nibbling around the edges.”

Warren rolled out her revised plan before visits this week to West Virginia and Ohio, two of the states hit hardest by the opioid epidemic.

There’s wide agreement among activists and experts that the federal government needs to do more on the opioid crisis. Congress has changed some regulations and rules to open up access to treatment, and it’s allocated some funds here and there, in the single-digit billions, to the crisis. But advocates and experts argue something far more comprehensive — tens of billions of dollars over the next few years — is needed. Republicans, however, have resisted such calls, voicing skepticism of running up government spending (outside tax cuts for the wealthy).

Presidential candidates have started to answer the call for action. Besides Warren, Sen. Amy Klobuchar (D-MN), one of Warren’s opponents in the Democratic primaries, last week unveiled a plan to spend $100 billion on addiction and mental health services over 10 years, although some details of Klobuchar’s proposal remain unclear.

Warren compares her bill with Cummings to legislation that Congress passed in response to the HIV/AIDS epidemic. In 1990, after the federal government took only small-scale actions as the AIDS death toll rose during much of the 1980s, Congress passed the Ryan White CARE Act, which dedicated billions of dollars over the years to boost access to treatment and medications. A few years later — following the law, other programs, and treatment breakthroughs — the crisis hit a turning point: After a decade and a half of rising death, the toll started to decrease in the mid-’90s.

Warren said she and Cummings see the two epidemics as having something in common: “The federal response was constantly too little, too late.” So they reached out to advocates and experts about what would finally turn the opioid epidemic around. Even the name of their bill, the CARE Act, echoes the Ryan White CARE Act that passed nearly two decades ago.

What the CARE Act does

The CARE Act would authorize $100 billion to address drug addiction in the US over 10 years, with the goal of dramatically boosting addiction treatment and other policy initiatives that can reduce overdose deaths.

It would be paid for through a previously proposed wealth tax on the super rich. Warren explained in a Medium post: “If you have more than $50 million, we’re going to ask you to pay a tax of 2 cents per dollar on every dollar after your fifty-millionth and first. It raises $2.75 trillion over the next ten years — enough to pay for my plans to cancel student loan debt and provide universal free college, fully fund universal childcare, and end the opioid epidemic. And guess what — we’d still have nearly a trillion dollars left over.”

The money is divided into several pots. Some would go to states, territories, and tribal governments, while others would go to local governments and nonprofit programs. Some would be based on overdose levels; others would go out through competitive grants. Parts of the money would go to funding innovative treatment models, and some would be dedicated to expanding access to the opioid overdose antidote naloxone. Other funding would be dedicated to research, surveillance, and training for health care staff.

There are some guardrails. For example, the bill would direct the secretary of health and human services to develop standards for the treatment that gets funding. And there are rules, with waivers available, that would push treatment facilities to provide the full range of medications for opioid addiction treatment. The idea is to make sure the gold standard of treatment gets preference, which, in the case of opioids, means medications like buprenorphine and methadone.

There’s some flexibility too. The money, for instance, can go to ideas that aren’t related to opioids. (But given that most overdoses today are linked to opioids, most of the funds would likely go to opioid-related programs, at least at first.) It’s also not limited to addiction treatment; funding could go to, say, needle exchanges or other harm reduction services — as long as there’s evidence that a program would reduce overdose deaths and it doesn’t violate the law.

This generally follows the model set up by the Ryan White program, which has sent funding to all sorts of organizations and governments to scale up the response to HIV/AIDS at every level. It’s widely credited by experts for helping reverse the HIV/AIDS epidemic in the 1990s, particularly by unlocking treatment options for the uninsured and underinsured.

“As the AIDS crisis got worse and worse back in the 1980s and into the ’90s, Congress kept offering little bits of treatment. And the crisis deepened,” Warren previously told me. “It wasn’t until a little boy named Ryan White declared that he had AIDS that Congress was moved to act. They put real money into research and treatment. And it brought down the new instances of HIV/AIDS, and developed a treatment that has kept people alive for years now.”

So far, though, Warren and Cummings’s bill has not moved far in Congress. In the House, the original version got 81 cosponsors — not close to a majority. In the Senate, it got zero cosponsors.

Warren acknowledged that the bill faces tough odds in the current Congress, which she blamed on the stigma around addiction. In talking to congressional staffers over the past few years, I’ve also repeatedly heard that Republicans are very resistant to spending much more money on the opioid crisis, and at least some GOP support would be needed to pass a bill.

Meanwhile, Congress has offered bits of funding here and there. In 2016, it approved $500 million a year with the Cures Act. Last year, it agreed to an additional $3.3 billion a year to fight the opioid crisis. And it’s passed other measures that authorize smaller grant programs, lift restrictions on certain kinds of addiction treatment, and make other legal and regulatory tweaks to open access to treatment.

Experts are reluctant to ascribe a specific dollar figure to the opioid crisis, but they argue that what Congress has done so far falls way short of what’s needed. They point out that even the $10 billion a year that Warren and Cummings proposed isn’t much compared to the $78.5 billion in economic burden in 2013 that one study connected to prescription opioid addiction and overdoses or the $500 billion in economic losses in 2015 that Trump’s White House Council of Economic Advisers linked to the opioid crisis.

“We talk about this huge investment of $100 billion, and that being pie in the sky, but just the budget increase for defense spending last year was $70 billion. Overall, it was like $800 billion,” Leo Beletsky, a professor of law and health sciences at Northeastern University, told me. “People are dropping dead by the thousands [in the opioid epidemic], and we are teetering around the edges. So it’s very frustrating.”

The CARE Act gets the scale of the problem right

The opioid epidemic is by far the deadliest drug overdose crisis in US history. Since the crisis began in the late 1990s, more than 700,000 people have died from drug overdoses — or about as many people as now live in big American cities like Denver or Washington, DC.

A key driver of the crisis is poor access to addiction treatment. Federal data suggests one in 10 people with any substance use disorder and one in five people with an opioid use disorder get specialty treatment. Even when an addiction treatment clinic is available, fewer than half of facilities offer any of the opioid addiction medications, such as methadone or buprenorphine, as an option, even though the medications are widely considered the gold standard. In other words, treatment is inaccessible enough that most people who need it don’t get it, and even when treatment is available, it doesn’t meet the best standards of care.

Fixing this problem, experts say, will require a massive infusion of funding — one that helps build addiction treatment infrastructure from the ground up across the country. Crucially, though, the money has to be sustained. So far, Congress has allocated money tied to grants that can expire after a year. “You can’t invest in long-term personnel if you think the money is going to be pulled in a year,” Regina LaBelle, who currently consults with local and state governments on the opioid crisis, told me.

The CARE Act still uses grants, but by authorizing the money for 10 years, it provides a bigger guarantee to treatment providers on the ground.

The CARE Act “recognizes the scope of the overdose crisis and the need for a significant increase in funding to take effective treatment and interventions to scale,” Sarah Wakeman, an addiction medicine doctor and medical director at the Massachusetts General Hospital Substance Use Disorder Initiative, told me.

The funding also has to be flexible in other areas. As experts have long said, there is no silver bullet that will solve the opioid epidemic overnight, but there’s a mix of policies that would help: more treatment (particularly medications like methadone and buprenorphine), more harm reduction (such as better access to naloxone), fewer painkiller prescriptions (while ensuring the drugs are available to those who really need them), and policies that can help address the root cause of addiction (like mental health issues and socioeconomic despair). A full response allows funding for all these options — which the CARE Act does.

By contrast, no other proposal from federal lawmakers has come close to the scope of the CARE Act. The Trump administration, with a lot of fanfare in October 2017, declared a public health emergency over the opioid crisis — but a report from the Government Accountability Office found the declaration allowed for very little, like bypassing paperwork requirements for a survey. Meanwhile, Trump has focused on building a wall at the US-Mexico border to stop the flow of illicit opioids like heroin and fentanyl into the US, but experts say this would be ineffective since most illegal drugs come through legal ports of entry, not through illegal border crossings that a wall would aim to stop.

And the Trump administration has worked to repeal the Affordable Care Act (also known as Obamacare) — which would rip health insurance that can pay for treatment from hundreds of thousands of people with opioid addiction, according to an analysis by researchers at Harvard Medical School and New York University.

It’s all far from what Trump promised on the 2016 campaign trail, where he claimed that he would “spend the money” to address the opioid crisis.

Warren has repeatedly highlighted the Trump administration’s failures in the Senate and on the presidential campaign trail. “The Trump administration has treated this crisis like a photo op,” she told me. “They talk a good game and produce nothing.”

Congress could do even more if it wanted to. But the CARE Act would be a huge step forward.

While the CARE Act gets the scope of the problem right, some have voiced concerns with the proposal and how it could be implemented.

For one, there’s always a concern that the funding will focus too much on addressing only opioid addiction and overdoses. Experts argue that may make sense now, but it’s possible in the future that our addiction response infrastructure will need to go toward some other kind of drug.

“Over 10 years, it’s entirely possible that we’ll have new drug epidemics,” Humphreys, of Stanford, told me. “Historically, every opioid epidemic has been followed by a stimulant epidemic. And I think that could very easily happen, so that, seven years from now, people are dropping dead from methamphetamine and cocaine more than they are opioids.”

The CARE Act’s money can go to drug-related programs that aren’t specific to opioids. But with so much attention justifiably on opioids right now, this is always a worry for people on the ground.

Reliance on grant programs is also a concern. With just about any other medical condition, the primary response to a problem is the traditional health care system, not federal grants. (Imagine having to rely on a grant program funded annually by Congress, instead of your health insurance, to treat a heart attack.) But in America, addiction has long been separated from traditional medicine — largely since it’s historically not been covered, adequately or at all, by health insurance.

The CARE Act provides “an appropriate amount of money, and perhaps we need even more,” Beletsky, of Northeastern University, said. “But we need to make sure we’re not creating a system that’s contingent on this kind of funding.”

Other policy changes could help build a better treatment system. Public health insurance programs, like Medicare and Medicaid, could boost reimbursement rates for addiction treatment — which is what Virginia, for example, has done with its Medicaid program to enable more people to get treatment. The government could also better enforce existing laws and rules that effectively require private insurers to cover addiction treatment; these laws and rules have existed for years, but, as the White House’s opioid commission found, they remain poorly enforced across the country.

The CARE Act could complement these kinds of approaches. The initial infusion of funds from the bill could help scale up addiction treatment facilities across the US — to make sure people have a clinic to go to. Then insurance payments could help sustain the clinics in the long run, just like they sustain medical facilities for other health problems today. Indeed, the new version of the CARE Act also includes some new requirements and money for Medicaid coverage of addiction treatment.

“You could have as large of a government investment,” Humphreys said, “but it would go further” if there were systems to make sure programs could stay up and running long after the initial boost in funds.

But the CARE Act alone can’t address all of the problems that mire how America treats addiction today. That will require not just more changes by Congress but also a cultural shift in how Americans view addiction — to perceive it as the public health problem that experts say it is.

Still, the bill would be a tremendous start. By creating a mechanism to scale up treatment and other systems, and hopefully start integrating those programs into the rest of health care, the CARE Act would be far above anything Congress has done until now to address the opioid crisis — similar to what the Ryan White program did for HIV/AIDS in the 1990s.

“Resources make a difference,” Warren told me. “Not strong words. Not photo ops. But real money. Without real resources, the opioid crisis will continue to grow.”

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