Providing for Consideration of H.R. Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act; Providing for Consideration of H.R. Individuals in Medicaid Deserve Care That is Appropriate and Responsible in its Execution Act; and Providing for Consideration of H.R. Overdose Prevention and Patient Safety Act

Floor Speech

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Mr. BURGESS. Mr. Speaker, by direction of the Committee on Rules, I call up House Resolution 949 and ask for its immediate consideration.

The Clerk read the resolution, as follows: H. Res. 949

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Mr. BURGESS. Mr. Speaker, for the purpose of debate only, I yield the customary 30 minutes to the gentleman from Massachusetts (Mr. McGovern), pending which I yield myself such time as I may consume. During consideration of this resolution, all time yielded is for the purpose of debate only. General Leave
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Mr. BURGESS. Mr. Speaker, House Resolution 949 provides for the consideration of three important bills aimed at curbing the deadly opioid epidemic plaguing this country and providing Americans with the tools to overcome their addictions: H.R. 6, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, or the SUPPORT Act; H.R. 5797, the Individuals in Medicaid Deserve Care that is Appropriate and Responsible in its Execution Act; and H.R. 6082, the Overdose Prevention and Patient Safety Act.

The three bills included in today's rule all seek to accomplish one goal: assist Americans struggling with opioid addiction in controlling their addictions and moving forward in achieving productive and healthy lives.

The rule provides for 1 hour of debate on H.R. 6, equally divided and controlled by the chair and ranking minority member of the Committee on Energy and Commerce. The rule makes in order eight amendments offered by both Republicans and Democrats. Further, the rule provides the minority with one motion to recommit with or without instructions.

The resolution also provides for a structured rule for H.R. 5797, allowing 1 hour of debate to be divided and controlled between the chair and ranking minority member of the Energy and Commerce Committee. The rule also provides for debate on an amendment by Mrs. Mimi Walters of California, an active member of the Energy and Commerce Committee. Finally, the rule provides the minority with the customary motion to recommit with or without instructions.

The final bill included in today's resolution, H.R. 6082, will also receive 1 hour of debate on the House floor, equally divided and controlled by the chair and ranking member of the Energy and Commerce Committee. As the Committee on Rules received no germane amendments to H.R. 6082, no amendments were made in order in today's rule. The minority does receive the customary motion to recommit with or without instructions.

The statistics that many of us have heard on numerous occasions--at our district townhalls, in opioid roundtables with stakeholders, constituent meetings in our offices, and in our committee hearings--are truly heartbreaking stories, with more than 115 people dying in the United States every day from an opioid overdose. That is five people per hour.

According to national reports, emergency room visits and opioid overdose deaths have more than quadrupled in the last 15 years, and a preliminary analysis indicates those numbers are to rise. The misuse of and addiction to opioids--including prescription pain medications, heroin, and synthetic opioids such as fentanyl--is, indeed, an urgent national crisis that continues to threaten our public health, social fabric, and economic welfare. Both community hospitals and local paramedics are frequently coming across people overdosing on an opioid drug or a drug laced with fentanyl.

The opioid epidemic has affected families not only in my district in north Texas, but in communities large and small from Maine to California. It has also impacted American employers and businesses due to lost productivity and difficulty finding qualified candidates for employment. President Trump is right to call this epidemic the ``crisis next door.''

The efforts of the Energy and Commerce Committee in the Comprehensive Addiction and Recovery Act and the 21st Century Cures Act in the previous Congress were a good start, delivering critical funding and resources to communities hit most hard by the opioid epidemic. But there was much more we still could do.

To start this process, the Energy and Commerce Health Subcommittee, which I chair, held a Member Day last October, where more than 50 bipartisan Members of this body, both on and off the committee, shared their personal stories from their districts and offered their solutions. This was followed by a series of three legislative hearings with markups where nearly 60 bills were considered and advanced to the full Energy and Commerce Committee that acted on these bills shortly thereafter.

The culmination of the work from the Energy and Commerce Committee and other House committees has brought us to consider many of these policies over the course of the last 2 weeks on the House floor. It required an all-hands-on-deck approach, and I believe the American people will see that, by this week's end, we did, indeed, come together in a bipartisan fashion and worked to address this crisis.

Today's rule provides for consideration of three important bills that will expand treatment options, deliver lifesaving services, and make necessary public health reforms, including Medicare and Medicaid, to bolster prevention and recovery efforts.

First, H.R. 5797, the Individuals in Medicaid Deserve Care that is Appropriate and Responsible in its Execution Act, the IMD CARE Act, allows State Medicaid programs to remove the institutions for mental diseases exclusion for beneficiaries aged 21 to 64 with an opioid use disorder for 5 years' time. The bill provides the continuum of care by removing a barrier of care under current law, so Medicaid can cover up to a total of 30 days of care in an institute for mental disease during a 12-month period, and eligible enrollees can get the care that they actually need.

The IMD exclusion is one of the treatment barriers consistently identified by State Medicaid directors, health policy experts, and many provider groups. Currently, this exclusion under Medicaid significantly limits the circumstances under which Federal Medicaid matching funds are available for inpatient services or for outpatient treatments.

Unfortunately, this policy has barred individuals with an opioid use disorder and mental illness from accessing short-term, acute care in psychiatric hospitals, or receiving treatment in residential substance use disorder treatment facilities. A 2017 Medicaid and CHIP Payment and Access Commission report stated that the Medicaid IMD exclusion is one of the few examples in the Medicaid program where Federal financial participation cannot be used for medically necessary and otherwise covered services for a specific Medicaid population receiving treatment in a specific setting.

In the midst of the opioid crisis, States must leverage all available tools to combat this epidemic. Section 1115 demonstration waivers are an important tool, but, so far, less than half of the States have sought or received an appropriate waiver from the Centers for Medicare and Medicaid Services to help patients with substance use disorder.

The IMD CARE Act also allows States the option to use the State plan amendment process, which is generally faster than using waivers. Under this process, once a State plan amendment is submitted, the Centers for Medicare and Medicaid Services has 90 days to decide or the proposed change will automatically go into effect.

H.R. 5797 amends an outdated law that has been in effect since the enactment of the Medicaid program in 1965. Since that time, there have been advances in behavioral health, and there have been advances in addiction treatment services where more, improved treatment options now exist.

It is long overdue to revisit this policy so that State Medicaid programs can better meet patients' needs and physicians can determine the most appropriate setting for care based on an individual's treatment plan.

Next, H.R. 6082, the Overdose Prevention and Patient Safety Act, makes timely reforms to a privacy law that affects patient access to healthcare and creates barriers to treatment. Specifically, the bill updates the Public Health Service Act to permit substance use disorder records to be shared among covered entities and 42 CFR part 2 programs by aligning part 2 with the Health Insurance Portability and Accountability Act of 1996 for the purposes of treatment, payment, and healthcare operations.

As a physician, I believe it is vital that when making clinical decisions, I have all of the appropriate information to make the correct determination in the treatment of a particular patient. Those suffering from substance use disorder should receive the same level of treatment and care as other individuals.

Patients afflicted with substance use disorder deserve to be treated by physicians who are armed with all of the necessary information to provide the best possible care.

I certainly do understand and respect that patient privacy protection is paramount and should be held in the highest regard.

The Overdose Prevention and Patient Safety Act maintains the original intent of the 1970s statute behind 42 CFR part 2 by protecting patients and improving care coordination. In fact, this bill increases protections for those seeking treatment by more severely penalizing those who share patient data to noncovered entities and non-part 2 programs than under the current statute, with certain exceptions.

Lastly, it requires the Secretary of Health and Human Services to, among other things, issue regulations prohibiting discrimination based on disclosed health data and requiring covered entities to provide written notice of privacy practices.

The issue of the stigma associated with substance use disorder has been a constant in many of the discussions members of the Energy and Commerce Committee and the stakeholders have had in both our offices and in our hearings.

This carefully crafted legislation seeks to help break the stigma and help individuals with this complex disease gain access to healthcare and support services critical to getting them on the road to recovery.

We should not continue to silo the substance use disorder treatment information of a select group of patients if we want to ensure that these patients are indeed receiving quality care. This information should be integrated into our medical records and comprehensive care models to prevent situations where physicians, not knowing a patient's substance use disorder, may prescribe medications that have significant drug interactions, or worse, may prescribe a controlled substance that makes their patient's substance use disorder worse.

As it currently stands, 42 CFR part 2 is actively prohibiting physicians from ensuring proper treatment and patient safety and, paradoxically, it is perpetuating that stigma.

Providing high quality healthcare is a team effort, but physicians leading the team must have the necessary information to adequately coordinate care. We must align payment, operations, and treatment to allow coordination of both behavioral and physical health services for individuals with substance use disorder.

There is a reason why the Substance Abuse and Mental Health Services Administration and most of the health stakeholder community are asking for this change. Clearly, there is an issue here that must be addressed. H.R. 6082 achieves the goal and contributes to Congress' effort in trying to stem the current crisis.

Finally, Mr. Speaker, H.R. 6, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, is a package of bills that reform Medicare, Medicaid, and other health provisions to further combat this crisis by advancing many critical initiatives.

As we all know, this opioid epidemic is in our hospitals, but it is also in our living rooms and on our streets. Our partners at Federal agencies must rise to the challenge and deliver vital resources for States and communities most devastated by the crisis. The SUPPORT for Patients and Communities Act will provide our Department of Health and Human Services, including the Centers for Medicare and Medicaid Services and the Food and Drug Administration, with the necessary tools to address this crisis.

Title I of H.R. 6 addresses the ways in which Medicaid can be used to increase access to quality care and management for individuals suffering from substance use disorders. Some of these changes in Medicaid reflect the success of our State Medicaid programs by implementing State successes at the Federal level.

Section 101 under title I will expand protection for at-risk youth by requiring State Medicaid programs to restore Medicaid coverage of a juvenile following their release from incarceration. The next section also allows former foster youth to maintain their Medicaid coverage across State lines until they turn 26 years of age. These are vulnerable populations of individuals that will greatly benefit from increased access to treatment.

Section 105 builds on the current State Medicaid drug utilization review, which saves money and promotes patient safety. This section will require State Medicaid programs to have safety edits in place for opioid refills, monitor concurrent prescribing of opioids and certain other drugs, and monitor antipsychotic prescribing for children.

Care for mothers suffering from substance use disorder and their babies who are born with neonatal abstinence syndrome is a growing problem in the face of this epidemic. Section 106 requires HHS to improve care for these infants with neonatal abstinence syndrome and their mothers. It also requires that the General Accountability Office study the gaps in Medicaid coverage for pregnant and postpartum women with substance use disorders.

Section 107 of the bill provides additional incentives for Medicaid health homes for patients with substance use disorder.

Mr. Speaker, these health homes will allow States to create a comprehensive person-centered system of care coordination for primary care, acute and behavioral healthcare, including mental health and substance use. As our healthcare system moves towards caring for the whole person, it is important that we enable our physicians and our payers to provide that comprehensive care.

The SUPPORT for Patients and Communities Act also enables better pain management for our Nation's Medicare beneficiaries, ranging from increased access to substance use disorder treatment, including through the use of telehealth, to modification of physician payment for certain nonopioid treatments in Ambulatory Surgery Centers.

Title II of the bill contains Medicare provisions that encourage the use of nonopioid analgesics where appropriate and also aims to decrease fraud and abuse regarding prescriptions by requiring e-prescribing for the coverage of Medicare Part D controlled substances.

H.R. 6 strives to provide support for at-risk beneficiaries who might fall victim to substance use disorder. Section 206 of the bill accelerates the development and the use of drug management programs for at-risk beneficiaries. While this program is currently voluntary, by plan year 2021, it will become a mandatory program.

Lastly, the bill expands Medicare coverage to include opioid treatment programs for the purpose of providing medication-assisted treatment. Opioid treatment programs are not currently Medicare providers, which forces Medicare beneficiaries who need medication- assisted treatment to pay out-of-pocket costs for those services. These efforts should provide improved access to treatment for Medicare beneficiaries who have substance use disorders while also incentivizing the use of opioid alternatives, which hopefully will prevent the development of substance use disorders.

Even though an estimated 46,000 Americans died from opioid overdoses from October 2016 to October 2017, there is a lack of innovation and a lack of investment in the development of nonaddictive pain and addiction treatment.

A bill that I introduced, H.R. 5806, the 21st Century Tools for Pain and Addiction Treatments, is included in section 301 on H.R. 6 and requires the Food and Drug Administration to hold at least one public meeting to address the challenges and the barriers of developing nonaddictive medical products intended to treat pain or addiction.

The Food and Drug Administration is also required to issue or update existing guidance documents to help address challenges to developing nonaddictive medical products to treat pain or addiction.

Mr. Speaker, I did work closely with the Food and Drug Administration to get the policy in this section correct and to ensure that it will clarify those pathways for products that, in fact, are so desperately needed by America's patients.

I have remaining concerns about the language in section 303 that will allow nonphysician providers to prescribe buprenorphine. While I understand and greatly appreciate the intent to increase access to medication-assisted treatment, as a physician, I also respect how complicated the treatment of patients suffering from substance use disorder may be.

The Hippocratic Oath, we all know, is to first, do no harm. Patient safety should be our highest priority.

This is a complex patient population, Mr. Speaker. On average, people with substance use disorder die 20 years sooner than other Americans.

Additionally, buprenorphine is a schedule III drug that can be misused and could exacerbate the underlying problem. I am unsure about expanding these authorities to additional nonphysician providers at the risk of making the problem worse. I have worked to strengthen the reporting requirements of this section of H.R. 6 and look forward to reviewing that report on this particular policy.

Taken together, H.R. 6, the SUPPORT for Patients and Communities Act, will improve access to care for individuals suffering from substance use disorder, provide our healthcare system with tools and resources that it needs to care for patients, and to help prevent future misuse of opioids.

Before I close, I would like to share a quote from President Trump. He said: ``Together, we will face this challenge as a national family with conviction, with unity, and with a commitment to love and support our neighbors in times of dire need. Working together, we will defeat this opioid epidemic.''

The number of bills and policies advanced on the House floor in the last 2 weeks illustrates our shared commitment, and I am confident that we will make significant progress in defeating this epidemic.

Mr. Speaker, I urge my colleagues to support today's rule and the three underlying bills that are critical to our Nation's effort to stem the opioid crisis.
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Mr. BURGESS. I yield the gentleman from Pennsylvania an additional 1 minute.

I do want to remind everyone that 18 months ago, in the previous Congress, with the passage of the 21st Century Cures Act and the Comprehensive Addiction Recovery Act, CARA, $1 billion was made available for treating people with substance use disorder. That was then supplemented with the passage of the more recent appropriations bill last month--2 months ago, with $4 billion.

Unprecedented amounts of money have been made available in the last 18 months to combat this crisis.

And then, finally, it is very, very difficult to integrate care if you don't reform the 42 CFR part 2, which is before us today.

Mr. Speaker, the good news is that all forms of medication-assisted treatment are required for 5 years under H.R. 6. So I look forward to the gentleman's support when we get to the vote, and I reserve the balance of my time.

Mr. Speaker, I don't need to remind anyone that the lie of the year for 2012 was: If you like your doctor, you can keep your doctor--words that will ring through this body probably for the rest of time.

I want to read from the Statement of Administration Policy, back to the business at hand, the rule on the three bills that we are considering today. This is the Statement of Administration Policy: ``Addressing the opioid crisis has been a top priority of the President since day one, and the administration welcomes legislation that complements its efforts to end the opioid crisis. The administration strongly supports House passage of bipartisan bills to protect patients enrolled in Medicare and Medicaid, create targeted programs for at-risk populations, expand access to medication-assisted treatment for opioid use disorders, and provide resources for States and communities struggling to deal with the scale of the opioid crisis.''

The statement goes on, and it concludes: ``These initiatives represent bold, evidence-based steps to prevent and treat opioid abuse, and will help save the lives of countless Americans. The administration commends the House on taking up these important bills. . . . The administration supports House passage of H.R. 5797, H.R. 6082, and H.R. 6. . . .''

Mr. Speaker, today's rule provides for the consideration of these three important pieces of legislation aimed at addressing the opioid crisis affecting so many of our fellow Americans.

H.R. 6, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act; H.R. 5797, the Individuals in Medicaid Deserve Care that is Appropriate and Responsible in its Execution Act; and H.R. 6082, the Overdose Prevention and Patient Safety Act, will all play a critical role in treating patients and providing Americans the tools to put the pieces of their lives back together again.

I commend Chairman Walden for his efforts on bringing so many Members of this body into the discussion and taking the many ideas offered by Members, incorporating them into the legislative products. The result of those efforts is a legislative trio that this entire body can be proud of, and this entire body can support.

I, therefore, urge my colleagues to support today's rule and the three underlying pieces of legislation.

The text of the material previously referred to by Mr. McGovern is as follows: An Amendment to H. Res. 949 Offered by Mr. McGovern

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This vote, the vote on whether to order the previous question on a special rule, is not merely a procedural vote. A vote against ordering the previous question is a vote against the Republican majority agenda and a vote to allow the Democratic minority to offer an alternative plan. It is a vote about what the House should be debating.

Mr. Clarence Cannon's Precedents of the House of Representatives (VI, 308-311), describes the vote on the previous question on the rule as ``a motion to direct or control the consideration of the subject before the House being made by the Member in charge.'' To defeat the previous question is to give the opposition a chance to decide the subject before the House. Cannon cites the Speaker's ruling of January 13, 1920, to the effect that ``the refusal of the House to sustain the demand for the previous question passes the control of the resolution to the opposition'' in order to offer an amendment. On March 15, 1909, a member of the majority party offered a rule resolution. The House defeated the previous question and a member of the opposition rose to a parliamentary inquiry, asking who was entitled to recognition. Speaker Joseph G. Cannon (R-Illinois) said: ``The previous question having been refused, the gentleman from New York, Mr. Fitzgerald, who had asked the gentleman to yield to him for an amendment, is entitled to the first recognition.''

The Republican majority may say ``the vote on the previous question is simply a vote on whether to proceed to an immediate vote on adopting the resolution . . . [and] has no substantive legislative or policy implications whatsoever.'' But that is not what they have always said. Listen to the Republican Leadership Manual on the Legislative Process in the United States House of Representatives, (6th edition, page 135). Here's how the Republicans describe the previous question vote in their own manual: ``Although it is generally not possible to amend the rule because the majority Member controlling the time will not yield for the purpose of offering an amendment, the same result may be achieved by voting down the previous question on the rule. . . . When the motion for the previous question is defeated, control of the time passes to the Member who led the opposition to ordering the previous question. That Member, because he then controls the time, may offer an amendment to the rule, or yield for the purpose of amendment.''

In Deschler's Procedure in the U.S. It is one of the only available tools for those who oppose the Republican majority's agenda and allows those with alternative views the opportunity to offer an alternative plan.
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