Background

The opioid epidemic has emerged as a major public health issue in the United States. Beginning with a surge in opioid prescription in the 1990s and followed by waves of addiction to synthetic opioids such as fentanyl, the crisis has grown and morphed since its inception. Since 1999, there have been more than 600,000 opioid-related deaths in the U.S. and Canada. Over the years, U.S. lawmakers have responded to the opioid epidemic with several policies including the Comprehensive Addiction and Recovery Act (CARA) and the 21st Century Cures Act, which both laid a promising groundwork for prevention and treatment but had limited outreach and funding. In 2018, Congressed passed the SUPPORT Act with the goal to tackle the crisis in a new way.

What is the SUPPORT Act of 2018?

The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act of 2018 was signed into law by former President Trump on October 24th, 2018. The bill aimed to address the opioid epidemic through prevention, treatment, and recovery, with emphasis on law enforcement and provisions to Medicare & Medicaid. Its core provisions are as follows:

• Prevention: The Act includes a set of policies that aim to reduce the incidence of cases related to opioid use and addiction. The bill expands public health education, implements opioid stewardship in hospitals and clinical settings, and promotes the use of alternative pain management theories.
• Treatment and Recovery: The Act expands access to medication-assisted treatment (MAT), building on top of the work of the TREAT Act and the Addiction Treatment Access Improvement Act. Expansion of MAT will allow administrators of MAT — doctors, nurse practitioners, physician assistants — to combine medications with therapy to address the biopsychosocial aspects of opioid addiction. 
• Emphasis on Law Enforcement: The Act emphasizes the importance of law enforcement in limiting the distribution of synthetic opioids. The Act also connects law enforcement to healthcare systems in hopes of monitoring the trafficking of opioids. 
• Provisions to Medicare & Medicaid: The Act expands Medicare and Medicaid to cover a wider range of treatments related to substance use disorders including MAT, therapy, and counseling.

Arguments in Favor of the SUPPORT Act

Supporters of the Act emphasize its role in expanding Medicare and Medicaid coverage. They highlight the expansion of coverage including new medications, outpatient services, and health home programs under both Medicare and Medicaid. Proponents believe that the growth of access to treatment allows patients in both residential facilities and outpatient programs to have greater access to treatment. In the past, Medicare has been criticized for its limitations on coverage for substance abuse treatment, so proponents believe that the SUPPORT Act was a crucial intervention to reimburse older patients for medicated treatments, behavioral therapies, and counseling.

Proponents of the SUPPORT Act also applaud the Act for expanding and developing the healthcare workforce; they hold that it eliminated some systemic barriers to care like long waitlists that previous bills did not address. According to the Department of Labour, the SUPPORT Act piloted several grant programs to “deliver training and employment opportunities to encourage more individuals to enter professions that could address the crisis”. Proponents believe one pilot grant program through the Employment and Training Administration  allowed more people from under-resourced communities join the healthcare workforce and tackle the epidemic in their own communities. Proponents highlight that in addition to providing grants to expand the opioid response workforce, the bill also established funds to respond to economic harm in towns whose workforces are impacted by opioid addiction. 

Finally, proponents applaud the SUPPORT Act for increasing the authority of healthcare workers and hospital systems in administering substance abuse treatments. Proponents believe medication-assisted treatment, or MAT, is especially important in the fight against the opioid epidemic as it combines the use of medications like buprenorphine and counseling, addressing the physical and mental aspects of opioid addiction simultaneously. The Act gained support from several healthcare advocacy groups for giving registered nurses, nurse practitioners, and physician assistants the ability to prescribe buprenorphine once they obtain certification. They argue that this provision increased access to MAT nationwide. Proponents also praise the Act for its funding of health education programs that educated patients on the dangers of opioid misuse, preventing health consequences early-on. 

Arguments Against the SUPPORT Act

Opponents of the bill cite concerns over sustained funding and support from the federal government. The American Hospital Organization raises the issue that Medicaid and Medicare rarely cover the full cost of hospital expenses, leaving a $75.8 billion annual gap that falls on hospitals and other patients to close. With the Act’s expansion of Medicaid and Medicare coverage for substance use treatments like MAT, they argue that hospitals became even more overburdened with costs. The SUPPORT Act provided $6 million for health centers and $2 million for rural health centers for buprenorphine treatment, which critics argued was not enough to sustain the number of patients that need to be served. Similarly, critics contend that the Act did not account for the long-term sustainability of its workforce expansion goals, since the end date for most of its grants was set to January 2023. 

Critics also emphasize how the SUPPORT Act failed to fully address the housing crisis, one of the socioeconomic factors underlying the opioid epidemic. Mimi Walters, former United States Representative, flags a provision of the SUPPORT Act that provided grants for temporary housing but only extended this funding to 50% of states. She warns that inconsistent funding like this only worsens the ongoing challenge of ensuring that people with substance use disorders secure housing. 

Opponents of the bill worry about the impact the SUPPORT Act has on sober homes and residential substance use treatment facilities, locations that help people in recovery transition back into their communities and avoid homelessness. The Eliminating Kickbacks in Recovery Act, a part of the SUPPORT Act, made it punishable by either a $200,000 fine or 10 years in prison for sober homes to receive monetary kickbacks. This worried critics who believe that the lack of access to housing and the overcriminalization of residents who utilize sober homes could create a cycle in which people in recovery struggle to find housing and start using substances again.

ConclusionThe SUPPORT Act of 2018 embodies the struggles the federal government faces in responding to a healthcare epidemic as large and multi-sector as the opioid crisis. Proponents cite the role the SUPPORT Act played in expanding Medicare and Medicaid, developing the workforce, and increasing the abilities of various healthcare workers to provide treatment. Conversely, critics of the SUPPORT Act highlight the bill’s failure to provide enough funding to sustainably support its goals. Congress failed to reauthorize the Act in 2023, signaling a desire for a new approach to the opioid epidemic. Future measures to combat the crisis must learn from the SUPPORT Act’s successes and drawbacks in order to deliver long-term solutions.