[Congressional Record Volume 164, Number 103 (Wednesday, June 20, 2018)]
[House]
[Pages H5335-H5344]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




     INDIVIDUALS IN MEDICAID DESERVE CARE THAT IS APPROPRIATE AND 
                    RESPONSIBLE IN ITS EXECUTION ACT


                             General Leave

  Mrs. MIMI WALTERS of California. Mr. Speaker, I ask unanimous consent 
that all Members may have 5 legislative days to revise and extend their 
remarks and to include extraneous material on the bill, H.R. 5797.
  The SPEAKER pro tempore (Mr. Shimkus). Is there objection to the 
request of the gentlewoman from California?
  There was no objection.
  The SPEAKER pro tempore. Pursuant to House Resolution 949 and rule 
XVIII, the Chair declares the House in the Committee of the Whole House 
on the state of the Union for the consideration of the bill, H.R. 5797.
  The Chair appoints the gentleman from Illinois (Mr. Bost) to preside 
over the Committee of the Whole.

                              {time}  1345


                     In the Committee of the Whole

  Accordingly, the House resolved itself into the Committee of the 
Whole House on the state of the Union for the consideration of the bill 
(H.R. 5797) to amend title XIX of the Social Security Act to allow 
States to provide under Medicaid services for certain individuals with 
opioid use disorders in institutions for mental diseases, with Mr. Bost 
in the chair.
  The Clerk read the title of the bill.
  The CHAIR. Pursuant to the rule, the bill is considered read the 
first time.
  The gentlewoman from California (Mrs. Mimi Walters) and the gentleman 
from New Jersey (Mr. Pallone) each will control 30 minutes.
  The Chair recognizes the gentlewoman from California.
  Mrs. MIMI WALTERS of California. Mr. Chairman, I yield myself such 
time as I may consume.
  Mr. Chairman, the opioid epidemic is ravaging this Nation. Families 
have been torn apart; lives have been destroyed; and communities are 
endangered.
  This crisis does not discriminate. Americans from all walks of life 
in all 50 States are being held hostage by the scourge of opioids.
  Tragically, the opioid epidemic claims the lives of 115 Americans on 
average each day. In my home of Orange County, California, 361 people 
died from opioid overdoses in 2015. That accounts for a 50 percent 
increase in overdose deaths since 2006.
  According to the OC Health Care Agency's 2017 ``Opioid Overdose and 
Death in Orange County'' report, the rate of opioid-related emergency 
room visits increased by more than 140 percent since 2005. Between 2011 
and 2015, Orange County emergency rooms treated nearly 7,500 opioid 
overdose and abuse cases.
  We can put an end to these tragic statistics by providing full access 
to various treatment options to those seeking help with their 
addictions. While many of these patients may benefit from outpatient 
help, others need highly specialized inpatient treatment to ensure they 
are receiving the most clinically appropriate care.
  The IMD CARE Act will increase access to care for certain Medicaid 
beneficiaries with opioid use disorder who need the most intensive care 
possible: inpatient care.
  Current law prohibits the Federal Government from providing Federal 
Medicaid matching funds to States to provide mental disease care to 
Medicaid-eligible patients aged 21 to 64 in facilities defined as 
institutes of mental diseases, commonly known as IMDs. This IMD 
exclusion means that Federal dollars may not be provided for the care 
of Medicaid-eligible patients in this age group for substance use 
disorder treatments at hospitals, nursing facilities, or other 
institutions with more than 16 beds.
  It is time to repeal the IMD exclusion and remove this outdated 
barrier to inpatient treatment. The IMD CARE Act would allow States to 
repeal for 5 years the IMD exclusion for adult Medicaid beneficiaries 
who have an opioid use disorder, which includes heroin and fentanyl.
  These beneficiaries would receive treatment in an IMD for up to 30 
days over a 12-month period, during which time the beneficiary would be 
regularly assessed to ensure their treatment and health needs require 
inpatient care. The bill would also require the IMD to develop an 
outpatient plan for the individual's ongoing treatment upon discharge.
  Throughout the Energy and Commerce Committee's work on the opioid 
crisis, the IMD exclusion is consistently identified as a significant 
barrier to care for Medicaid patients. Not every patient needs 
treatment in an IMD, but those who do are often among the most 
vulnerable. What once was a well-intended exclusion on Federal Medicaid 
spending has since prevented individuals from seeking treatment.
  In the light of the opioid epidemic, I believe my legislation strikes 
the right balance. I know some have suggested States continue to seek 
CMS waivers to allow Medicaid to pay for IMD care. Waivers can be a 
good option for some States, but not all States want a waiver. In fact, 
less than half of the States have applied for a waiver. Additionally, a 
waiver can take a substantial amount of time to develop, review, and 
approve.
  We are losing too many friends and family members to force States to 
navigate a lengthy and uncertain waiver process. The IMD CARE Act 
allows

[[Page H5336]]

States to act now to ensure patients who are suffering from addiction 
get the care they need.
  The National Governors Association and the American Hospital 
Association have endorsed this legislation. Other organizations, such 
as the National Association of State Medicaid Directors and the 
National Association of State Mental Health Directors, have supported 
the idea of Congress addressing the IMD.
  While the repeal of the IMD exclusion would increase mandatory 
outlays and add costs to the Medicaid system, the IMD CARE Act is fully 
paid for by curbing unnecessary Federal and State Medicaid outlays.
  I want to thank Chairman Walden and my colleagues on the House Energy 
and Commerce Committee for their support of this bill, which will 
provide much needed care to Americans suffering from opioid use 
disorder. Through the IMD CARE Act, Congress has a unique opportunity 
to remove a barrier to care and bring specialized treatment to Medicaid 
patients who desperately need it.

  Mr. Chairman, I urge all Members to support this important bill 
today, and I reserve the balance of my time.
  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. I urge my 
colleagues to vote ``no,'' and I reserve the balance of my time.
  Mrs. MIMI WALTERS of California. Mr. Chairman, I yield 3 minutes to 
the gentleman from Texas (Mr. Burgess).
  Mr. BURGESS. Mr. Chair, I want to thank Mrs. Walters for introducing 
this legislation.
  Throughout this committee's and subcommittee's work on opioids, the 
IMD exclusion has been consistently identified by many stakeholders in 
conversations not only in my office but with the subcommittee as a 
barrier to care for Medicaid patients who need inpatient treatment.
  In the face of an epidemic that is taking the lives of 115 Americans 
on average every day, I believe this policy strikes the right balance. 
The IMD CARE Act targets limited resources to remove a barrier to care 
by allowing States to repeal the IMD exclusion for 5 years for Medicaid 
beneficiaries between the ages of 21 and 64 who have an opioid use 
disorder. This approach will provide States the flexibility to increase 
access to institutional care for those who truly need it.

  While getting a waiver from CMS for the IMD exclusion is a good 
option for many States, less than half the States have applied for a 
waiver. We are losing too many of our friends and neighbors each day to 
this crisis to ask States to go through what can be a lengthy and 
uncertain process to secure a waiver.
  The IMD CARE Act allows States to act now to ensure their patients 
who are suffering now from a terrible disease can get the care that 
they need and get it now.
  I ask my fellow Members to join me in support of Mrs. Walters' bill.
  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

[[Page H5337]]

the dearth of community-based health services.

                              {time}  1400

  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.
  Mr. Chair, I reserve the balance of my time.
  Mrs. MIMI WALTERS of California. Mr. Chair, I yield 5 minutes to the 
gentleman from Oregon (Mr. Walden), chairman of the Committee on Energy 
and Commerce.
  Mr. WALDEN. Mr. Chair, I want to thank my colleague Mimi Walters and 
those who have worked so closely with her on this really, really 
important legislation. That is why I am here to support it, H.R. 5797, 
the IMD CARE Act.
  This is really commonsense legislation, and it will make a meaningful 
change to the way Medicaid covers opioid use disorder for its 
beneficiaries. In other words, low-income people in America who get 
their medical assistance through Medicaid are going to get another 
option and more help to deal with their addiction.
  We are discussing this bill because a severely outdated policy limits 
Medicaid's coverage in an institution for mental disease--that is what 
an IMD is, institution for mental disease--for just 30 days. It is old. 
It is antiquated. It doesn't work with today's treatment regimens.
  This exclusion has been in place for decades--decades--certainly long 
before the opioid crisis ever hit our country, and it is now a barrier 
to critical care for low-income people on Medicaid when this vulnerable 
population needs help with their addiction the most.
  Representative Walters' thoughtful bill will allow State Medicaid 
programs, from 2019 through 2023, to remove this antiquated Federal 
barrier to treatment for those on Medicaid, age 21 to 64, with an 
opioid use disorder, through a State plan amendment. In doing so, 
Medicaid would pay for up to 30 total days of a beneficiary's care in 
an IMD during a 12-month period, year.
  So this is limited in scope. It is in partnership with the States. It 
is low-income people getting more help from Medicaid to pay for this 
extraordinarily important treatment.
  This bill also collects much-needed data on the process. After taking 
up this option, States will have to report on the number of individuals 
with opioid use disorder under this plan, their length of stay, and the 
type of treatment received upon discharge. This will help inform better 
programs down the line.
  As a Congress, we have been focused on combating the opioid crisis 
for quite some time. This is not our first legislative attempt to help 
people not only avoid this addiction, but overcome it. It will not be 
our last. We will legislate; we will evaluate; we will legislate; we 
will evaluate, as Republicans and Democrats have been doing for some 
time.
  It is an important step, this bill, that can help get people a vital 
treatment to which they now don't have access. The American Hospital 
Association, the National Governors Association, Republicans and 
Democrats, hospitals and Governors across the country, have said: 
Please do this. This is a need that is unmet. Please help us change 
this antiquated Federal law.
  Many stakeholder groups, including the National Association of State 
Medicaid Directors, the people who run the Medicaid programs in States; 
the National Association of State Mental Health Program Directors, the 
people who know what is needed most to overcome these situations; and 
many others have talked to us in the committee. They have talked to me 
personally. They are pleading with Congress to get rid of this barrier 
to care, this outdated law, and to help people get treatment, 
especially the low-income among us.
  We have an opportunity to deliver, to help. We have an opportunity to 
save lives. It is our responsibility, and we need to pass this 
legislation.
  Mr. Chair, I commend the gentlewoman from California for bringing 
this issue to the committee and shepherding it through. It is so 
important to pass this legislation. Let's help these people get the 
care they need and want.
  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.
  Mrs. MIMI WALTERS of California. Mr. Chair, I yield myself the 
balance of my time.
  Mr. Chair, the opioid crisis requires us to act now. The IMD 
exclusion is consistently identified as a significant barrier to care 
by State Medicaid directors and numerous other stakeholder groups. We 
need to pass this bill in order to increase access to acute, short-term 
inpatient treatment. I urge my colleagues to support this bill and help 
individuals suffering with opioid addiction.
  Mr. Chair, I yield back the balance of my time.
  Ms. MAXINE WATERS of California. Mr. Chair, I rise to oppose H.R. 
5797, also known as the ``IMD CARE Act.''
  H.R. 5797 allows states to use Medicaid funds to treat adult patients 
ages 21-64 with opioid abuse disorders in Institutions for Mental 
Disease (IMDs) with more than 16 beds. While expanding access to 
treatment for substance abuse disorders is an admirable goal, H.R. 5797 
is not the way to accomplish this goal.
  One obvious limitation of H.R. 5797 is that it only applies to opioid 
and heroin use disorders. It does nothing to expand access to treatment 
for other types of substance abuse disorders, including alcoholism and 
the abuse of other illegal drugs like methamphetamine, crack, and other 
forms of cocaine.
  A second problem with this bill is that it only expands access to 
treatment in inpatient IMD

[[Page H5338]]

facilities. It does not provide Medicaid funding for substance abuse 
treatment services in an outpatient setting, nor does it require states 
to make such services available. Not all substance abuse patients need 
to be treated in an institution, and those that do will also need 
outpatient recovery services after they are released from an IMD.
  Currently, states can already use Medicaid funds to treat patients in 
IMD facilities by means of a waiver from the Centers for Medicare and 
Medicaid Services (CMS). In order to qualify for a waiver, states must 
take steps to ensure that patients are able to obtain substance abuse 
treatment and services in the community, as well as in institutions. 
Eleven states already have a waiver for this purpose, and eleven other 
states have waiver applications pending. Expanding access to inpatient 
treatment in states that do not provide outpatient services risks 
forcing patients into treatment that is ineffective and inappropriate 
for their situation.
  Another option that is already available for states that want to 
expand access to substance abuse treatment services is to expand 
Medicaid under the Affordable Care Act. Medicaid expansion would ensure 
that all low-income people, including those with substance abuse 
disorders, are able to obtain treatment for their medical conditions.
  I submitted an amendment that would have required states to expand 
Medicaid pursuant to the Affordable Care Act as a condition for using 
Medicaid funds to treat people with opioid abuse disorders in IMD 
facilities. This amendment would have provided an additional incentive 
for states to expand Medicaid, which in turn would have expanded access 
to a broad range of treatment and services for patients with substance 
abuse disorders.
  Expanding access to Medicaid will benefit patients with substance 
abuse disorders, regardless of the type of addiction from which they 
suffer and regardless of whether they would be best served by inpatient 
treatment, outpatient treatment, or a combination of the two.
  It is especially ironic that this bill is being considered on the 
House floor the day after House Republicans unveiled their fiscal year 
2019 budget proposal, which would cut $1.5 trillion from Medicaid. If 
the majority party cares about Americans suffering from an opioid abuse 
disorder, they would not rob them of the health care services thiey 
already have.
  I urge my colleagues to oppose H.R. 5797 and support a comprehensive 
solution to substance abuse disorders that will meet the needs of all 
people suffering from these tragic medical conditions.
  The Acting CHAIR (Mr. Mitchell). All time for general debate has 
expired.
  Pursuant to the rule, the bill shall be considered for amendment 
under the 5-minute rule.
  The amendment in the nature of a substitute recommended by the 
Committee on Energy and Commerce, printed in the bill, modified by the 
amendment printed in part C of House Report 115-766, shall be 
considered as adopted. The bill, as amended, shall be considered as an 
original bill for purpose of further amendment under the 5-minute rule, 
and shall be considered read.
  The text of the bill, as amended, is as follows:

                               H.R. 5797

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Individuals in Medicaid 
     Deserve Care that is Appropriate and Responsible in its 
     Execution Act'' or the ``IMD CARE Act''.

     SEC. 2. MEDICAID STATE PLAN OPTION TO PROVIDE SERVICES FOR 
                   CERTAIN INDIVIDUALS WITH OPIOID USE DISORDERS 
                   IN INSTITUTIONS FOR MENTAL DISEASES.

       Section 1915 of the Social Security Act (42 U.S.C. 1396n) 
     is amended by adding at the end the following new subsection:
       ``(l) State Plan Option To Provide Services for Certain 
     Individuals in Institutions for Mental Diseases.--
       ``(1) In general.--With respect to calendar quarters 
     beginning during the period beginning January 1, 2019, and 
     ending December 31, 2023, a State may elect, through a State 
     plan amendment, to, notwithstanding section 1905(a), provide 
     medical assistance for services furnished in institutions for 
     mental diseases and for other medically necessary services 
     furnished to eligible individuals with opioid use disorders, 
     in accordance with the requirements of this subsection.
       ``(2) Payments.--
       ``(A) In general.--Amounts expended under a State plan 
     amendment under paragraph (1) for services described in such 
     paragraph furnished, with respect to a 12-month period, to an 
     eligible individual with an opioid use disorder who is a 
     patient in an institution for mental diseases shall be 
     treated as medical assistance for which payment is made under 
     section 1903(a) but only to the extent that such services are 
     furnished for not more than a period of 30 days (whether or 
     not consecutive) during such 12-month period.
       ``(B) Clarification.--Payment made under this paragraph for 
     expenditures under a State plan amendment under this 
     subsection with respect to services described in paragraph 
     (1) furnished to an eligible individual with an opioid use 
     disorder shall not affect payment that would otherwise be 
     made under section 1903(a) for expenditures under the State 
     plan (or waiver of such plan) for medical assistance for such 
     individual.
       ``(3) Information required in state plan amendment.--
       ``(A) In general.--A State electing to provide medical 
     assistance pursuant to this subsection shall include with the 
     submission of the State plan amendment under paragraph (1) to 
     the Secretary--
       ``(i) a plan on how the State will improve access to 
     outpatient care during the period of the State plan 
     amendment, including a description of--

       ``(I) the process by which eligible individuals with opioid 
     use disorders will make the transition from receiving 
     inpatient services in an institution for mental diseases to 
     appropriate outpatient care; and
       ``(II) the process the State will undertake to ensure 
     individuals with opioid use disorder are provided care in the 
     most integrated setting appropriate to the needs of the 
     individuals; and

       ``(ii) a description of how the State plan amendment 
     ensures an appropriate clinical screening of eligible 
     individuals with an opioid use disorder, including 
     assessments to determine level of care and length of stay 
     recommendations based upon the multidimensional assessment 
     criteria of the American Society of Addiction Medicine.
       ``(B) Report.--Not later than the sooner of December 31, 
     2024, or one year after the date of the termination of a 
     State plan amendment under this subsection, the State shall 
     submit to the Secretary a report that includes at least--
       ``(i) the number of eligible individuals with opioid use 
     disorders who received services pursuant to such State plan 
     amendment;
       ``(ii) the length of the stay of each such individual in an 
     institution for mental diseases; and
       ``(iii) the type of outpatient treatment, including 
     medication-assisted treatment, each such individual received 
     after being discharged from such institution.
       ``(4) Definitions.--In this subsection:
       ``(A) Eligible individual with an opioid use disorder.--The 
     term `eligible individual with an opioid use disorder' means 
     an individual who--
       ``(i) with respect to a State, is enrolled for medical 
     assistance under the State plan (or a waiver of such plan);
       ``(ii) is at least 21 years of age;
       ``(iii) has not attained 65 years of age; and
       ``(iv) has been diagnosed with at least one opioid use 
     disorder.
       ``(B) Institution for mental diseases.--The term 
     `institution for mental diseases' has the meaning given such 
     term in section 1905(i).
       ``(C) Opioid prescription pain reliever.--The term `opioid 
     prescription pain reliever' includes hydrocodone products, 
     oxycodone products, tramadol products, codeine products, 
     morphine products, fentanyl products, buprenorphine products, 
     oxymorphone products, meperidine products, hydromorphone 
     products, methadone, and any other prescription pain reliever 
     identified by the Assistant Secretary for Mental Health and 
     Substance Use.
       ``(D) Opioid use disorder.--The term `opioid use disorder' 
     means a disorder that meets the criteria of the Diagnostic 
     and Statistical Manual of Mental Disorders, 4th Edition (or a 
     successor edition), for heroin use disorder or pain reliever 
     use disorder (including with respect to opioid prescription 
     pain relievers).
       ``(E) Other medically necessary services.--The term `other 
     medically necessary services' means, with respect to an 
     eligible individual with an opioid use disorder who is a 
     patient in an institution for mental diseases, items and 
     services that are provided to such individual outside of such 
     institution to the extent that such items and services would 
     be treated as medical assistance for such individual if such 
     individual were not a patient in such institution.''.

     SEC. 3. PROMOTING VALUE IN MEDICAID MANAGED CARE.

       Section 1903(m) of the Social Security Act (42 U.S.C. 
     1396b(m)) is amended by adding at the end the following new 
     paragraph:
       ``(7)(A) With respect to expenditures described in 
     subparagraph (B) that are incurred by a State for any fiscal 
     year after fiscal year 2020 (and before fiscal year 2025), in 
     determining the pro rata share to which the United States is 
     equitably entitled under subsection (d)(3), the Secretary 
     shall substitute the Federal medical assistance percentage 
     that applies for such fiscal year to the State under section 
     1905(b) (without regard to any adjustments to such percentage 
     applicable under such section or any other provision of law) 
     for the percentage that applies to such expenditures under 
     section 1905(y).
       ``(B) Expenditures described in this subparagraph, with 
     respect to a fiscal year to which subparagraph (A) applies, 
     are expenditures incurred by a State for payment for medical 
     assistance provided to individuals described in subclause 
     (VIII) of section 1902(a)(10)(A)(i) by a managed care entity, 
     or other specified entity (as defined in subparagraph 
     (D)(iii)), that are treated as remittances because the 
     State--
       ``(i) has satisfied the requirement of section 438.8 of 
     title 42, Code of Federal Regulations (or any successor 
     regulation), by electing--
       ``(I) in the case of a State described in subparagraph (C), 
     to apply a minimum medical

[[Page H5339]]

     loss ratio (as defined in subparagraph (D)(ii)) that is at 
     least 85 percent but not greater than the minimum medical 
     loss ratio (as so defined) that such State applied as of May 
     31, 2018; or
       ``(II) in the case of a State not described in subparagraph 
     (C), to apply a minimum medical loss ratio that is equal to 
     85 percent; and
       ``(ii) recovered all or a portion of the expenditures as a 
     result of the entity's failure to meet such ratio.
       ``(C) For purposes of subparagraph (B), a State described 
     in this subparagraph is a State that as of May 31, 2018, 
     applied a minimum medical loss ratio (as calculated under 
     subsection (d) of section 438.8 of title 42, Code of Federal 
     Regulations (as in effect on June 1, 2018)) for payment for 
     services provided by entities described in such subparagraph 
     under the State plan under this title (or a waiver of the 
     plan) that is equal to or greater than 85 percent.
       ``(D) For purposes of this paragraph:
       ``(i) The term `managed care entity' means a medicaid 
     managed care organization described in section 
     1932(a)(1)(B)(i).
       ``(ii) The term `minimum medical loss ratio' means, with 
     respect to a State, a minimum medical loss ratio (as 
     calculated under subsection (d) of section 438.8 of title 42, 
     Code of Federal Regulations (as in effect on June 1, 2018)) 
     for payment for services provided by entities described in 
     subparagraph (B) under the State plan under this title (or a 
     waiver of the plan).
       ``(iii) The term `other specified entity' means--
       ``(I) a prepaid inpatient health plan, as defined in 
     section 438.2 of title 42, Code of Federal Regulations (or 
     any successor regulation); and
       ``(II) a prepaid ambulatory health plan, as defined in such 
     section (or any successor regulation).''.

  The Acting CHAIR. No further amendment to the bill, as amended, shall 
be in order except those printed in part D of House Report 115-766. 
Each such further amendment may be offered only in the order printed in 
the report, by a Member designated in the report, shall be considered 
as read, shall be debatable for the time specified in the report 
equally divided and controlled by the proponent and an opponent, shall 
not be subject to amendment, and shall not be subject to a demand for 
division of the question.


                  Amendment No. 1 Offered by Mr. Rush

  The Acting CHAIR. It is now in order to consider amendment No. 1 
printed in part D of House Report 115-766.
  Mr. RUSH. Mr. Chair, I have an amendment at the desk.
  The Acting CHAIR. The Clerk will designate the amendment.
  The text of the amendment is as follows:

       In section 2, strike ``individuals with opioid use 
     disorders'' and insert ``individuals with targeted suds''.
       In the subsection (l) proposed to be added by section 2 of 
     the bill to section 1915 of the Social Security Act, strike 
     ``eligible individuals with opioid use disorders'' each place 
     it appears and insert ``eligible individuals with targeted 
     SUDs'' each such place.
       In the subsection (l) proposed to be added by section 2 of 
     the bill to section 1915 of the Social Security Act, strike 
     ``eligible individual with an opioid use disorder'' each 
     place it appears and insert ``eligible individual with a 
     targeted SUD'' each such place.
       Page 5, beginning on line 19, strike ``individuals with 
     opioid use disorder'' and insert ``eligible individuals with 
     targeted SUDs''.
       Page 6, beginning on line 1, strike ``eligible individuals 
     with an opioid use disorder'' and insert ``eligible 
     individuals with targeted SUDs''.
       Page 6, line 7, insert before the period the following: 
     ``and to determine the appropriate setting for such care''.
       Page 7, line 12, strike ``opioid use disorder'' and insert 
     ``targeted SUD''.
       In the subsection (l)(4) proposed to be added by section 2 
     of the bill to section 1915 of the Social Security Act, 
     strike subparagraph (D), redesignate subparagraph (E) as 
     subparagraph (D), and add at the end the following:
       ``(E) Targeted sud.--
       ``(i) In general.--The term `targeted SUD' means an opioid 
     use disorder or a cocaine use disorder.
       ``(ii) Cocaine use disorder.--The term `cocaine use 
     disorder' means a disorder that meets the criteria of the 
     Diagnostic and Statistical Manual of Mental Disorders, 4th 
     Edition (or a successor edition), for either dependence or 
     abuse for cocaine, including cocaine base (commonly referred 
     to as `crack cocaine').
       ``(iii) Opioid use disorder.--The term `opioid use 
     disorder' means a disorder that meets the criteria of the 
     Diagnostic and Statistical Manual of Mental Disorders, 4th 
     Edition (or a successor edition), for heroin use disorder or 
     pain reliever use disorder (including with respect to opioid 
     prescription pain relievers).''.
       Strike all that follows after section 2 and insert the 
     following:

     SEC. 3. PROMOTING VALUE IN MEDICAID MANAGED CARE.

       Section 1903(m) of the Social Security Act (42 U.S.C. 
     1396b(m)) is amended by adding at the end the following new 
     paragraph:
       ``(7)(A) With respect to expenditures described in 
     subparagraph (B) that are incurred by a State for any fiscal 
     year after fiscal year 2020 (and before fiscal year 2024), in 
     determining the pro rata share to which the United States is 
     equitably entitled under subsection (d)(3), the Secretary 
     shall substitute the Federal medical assistance percentage 
     that applies for such fiscal year to the State under section 
     1905(b) (without regard to any adjustments to such percentage 
     applicable under such section or any other provision of law) 
     for the percentage that applies to such expenditures under 
     section 1905(y).
       ``(B) Expenditures described in this subparagraph, with 
     respect to a fiscal year to which subparagraph (A) applies, 
     are expenditures incurred by a State for payment for medical 
     assistance provided to individuals described in subclause 
     (VIII) of section 1902(a)(10)(A)(i) by a managed care entity, 
     or other specified entity (as defined in subparagraph 
     (D)(iii)), that are treated as remittances because the 
     State--
       ``(i) has satisfied the requirement of section 438.8 of 
     title 42, Code of Federal Regulations (or any successor 
     regulation), by electing--
       ``(I) in the case of a State described in subparagraph (C), 
     to apply a minimum medical loss ratio (as defined in 
     subparagraph (D)(ii)) that is at least 85 percent but not 
     greater than the minimum medical loss ratio (as so defined) 
     that such State applied as of May 31, 2018; or
       ``(II) in the case of a State not described in subparagraph 
     (C), to apply a minimum medical loss ratio that is equal to 
     85 percent; and
       ``(ii) recovered all or a portion of the expenditures as a 
     result of the entity's failure to meet such ratio.
       ``(C) For purposes of subparagraph (B), a State described 
     in this subparagraph is a State that as of May 31, 2018, 
     applied a minimum medical loss ratio (as calculated under 
     subsection (d) of section 438.8 of title 42, Code of Federal 
     Regulations (as in effect on June 1, 2018)) for payment for 
     services provided by entities described in such subparagraph 
     under the State plan under this title (or a waiver of the 
     plan) that is equal to or greater than 85 percent.
       ``(D) For purposes of this paragraph:
       ``(i) The term `managed care entity' means a medicaid 
     managed care organization described in section 
     1932(a)(1)(B)(i).
       ``(ii) The term `minimum medical loss ratio' means, with 
     respect to a State, a minimum medical loss ratio (as 
     calculated under subsection (d) of section 438.8 of title 42, 
     Code of Federal Regulations (as in effect on June 1, 2018)) 
     for payment for services provided by entities described in 
     subparagraph (B) under the State plan under this title (or a 
     waiver of the plan).
       ``(iii) The term `other specified entity' means--
       ``(I) a prepaid inpatient health plan, as defined in 
     section 438.2 of title 42, Code of Federal Regulations (or 
     any successor regulation); and
       ``(II) a prepaid ambulatory health plan, as defined in such 
     section (or any successor regulation).''.

  The Acting CHAIR. Pursuant to House Resolution 949, the gentleman 
from Illinois (Mr. Rush) and a Member opposed each will control 5 
minutes.
  The Chair recognizes the gentleman from Illinois.
  Mr. RUSH. Mr. Chair, I yield myself such time as I may consume.
  Mr. Chair, I rise today to offer my amendment that finally addresses 
a longstanding and discriminatory gap in coverage and expands treatment 
options for those suffering from addiction.
  This House, Mr. Chairman, should be commended for its work on opioid 
addiction, but let us not forget that we have insidiously ignored 
another pervasive and catastrophically destructive addiction that is 
known as crack cocaine.
  To remedy this, Mr. Chairman, my amendment would expand the bill to 
include those individuals suffering from cocaine use disorder and 
explicitly clarifies the inclusion of cocaine base, more commonly known 
as crack cocaine, which, along with opiates, is a double-barrel cause 
of drug-related deaths in communities like mine all across this Nation.
  Too often, Mr. Chairman, this House seems to only have focused on 
issues when they have affected the majority, the White population. This 
leaves vulnerable, non-White, minority Americans without any chance to 
escape from their illness and their resulting suffering.
  Too often, Mr. Chairman, the government's response to minority 
Americans has been mass incarceration instead of treatment. Too often, 
Mr. Chairman, crises that impact the African American communities are 
seen as a criminal justice problem, while those that affect the White 
community are seen as a public health problem. That phenomenon changes 
today.

[[Page H5340]]

  I know opponents of this amendment will say that we should be 
expanding coverage to all those suffering from addiction. I 
wholeheartedly agree, Mr. Chairman, with that statement. However, while 
more remains to be done, today's action is a step in the right 
direction.
  This is an important moment for those who have been addicted to crack 
and have been denied such access to treatment. Today they will finally 
get relief as we make historic progress in the fight against addiction 
and the injustice that continues to tear communities apart.
  For this reason, I urge all my colleagues on both sides of the aisle 
to join me in supporting this worthwhile and meaningful amendment.
  Mr. Chair, I reserve the balance of my time.
  Mr. WALDEN. Mr. Chair, I claim the time in opposition to the 
amendment, though I am not opposed to the amendment.
  The Acting CHAIR. Without objection, the gentleman from Oregon is 
recognized for 5 minutes.
  There was no objection.
  Mr. WALDEN. Mr. Chair, I yield myself such time as I may consume.
  Mr. Chair, I rise today in support of the Rush amendment to H.R. 
5797, the IMD CARE Act. Earlier today, I spoke in support of the 
underlying bill. It will make a meaningful change to the way Medicaid 
covers opioid use disorder for its beneficiaries.
  The amendment offered by my friend and colleague from Illinois, 
Representative  Bobby Rush, will expand on that definition. It will 
allow Medicaid to provide coverage for individuals seeking treatment 
from cocaine and crack cocaine usage.
  Looking at just 2016, opioids and cocaine caused 82 percent of all 
drug overdose deaths in the United States. Cocaine alone kills more 
than 10,000 Americans a year. News outlets have also reported fentanyl 
being mixed in with cocaine, further complicating this tragic opioid 
crisis.
  This is an issue that Mr. Rush has passionately led on in the 
committee, on the floor, and at home in his community.

                              {time}  1415

  We discussed it in the hearing room and at length in private while 
working to fine-tune this legislation so that the best possible version 
can become law.
  So I want to thank Mr. Rush for this amendment, and I want people to 
know that it really will improve and expand the scope of this bill.
  Mr. Chairman, I urge my colleagues to adopt this amendment and 
support the underlying bill, which will dramatically aid in our 
response to the opioid epidemic for all Americans, wherever they live.
  Mr. Chairman, how much time do I have remaining?
  The Acting CHAIR. The gentleman from Oregon has 3\1/2\ minutes 
remaining.
  Mr. WALDEN. Mr. Chairman, I yield 1 minute to the gentleman from New 
Jersey (Mr. Pallone), the ranking Democrat on the committee.
  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.
  Mr. WALDEN. Mr. Chairman, I conclude my comments by expressing my 
disappointment that I have yet to persuade my friend from New Jersey to 
support the underlying bill, although I appreciate his support of the 
Rush amendment.
  We know that our Governors, we know that our State Medicaid 
directors, and we know those most involved in helping those with 
addiction have pled with us to change this antiquated law so that 
people of all colors, of all backgrounds, from anywhere in this 
country, especially the low-income, can get access to meaningful, 
modern, and helpful assistance to overcome their addiction. That is 
what this bill does.
  Mr. Chairman, I encourage my colleagues to support the amendment, and 
I encourage them to support the underlying bill.
  Mr. Chairman, I yield back the balance of my time.
  Mr. RUSH. Mr. Chairman, may I inquire as to how much time I have 
remaining.
  The Acting CHAIR. The gentleman from Illinois has 1\1/2\ minutes 
remaining.
  Mr. RUSH. Mr. Chairman, before I close, I want to, in a most sincere 
and humble way, thank Chairman Walden for his outstanding leadership on 
this matter, and for his breadth of understanding of the difficulties 
that my constituents have as a result of the omission from treatments 
for crack cocaine and other similar addictions.
  I do understand the ranking member on the full committee's problems 
and concerns. I do understand, and I accept it. But, Mr. Chairman, we 
have to go forward on this particular amendment and on final passage.
  Mr. Chairman, I thank Congressman Walden, and all of the staffs, for 
working with my staff on this critically important issue.
  Mr. Chairman, I yield back the balance of my time.
  The Acting CHAIR. The question is on the amendment offered by the 
gentleman from Illinois (Mr. Rush).
  The amendment was agreed to.


                 Amendment No. 2 Offered by Mr. Kildee

  The Acting CHAIR. It is now in order to consider amendment No. 2 
printed in part D of House Report 115-766.
  Mr. KILDEE. Mr. Chairman, I have an amendment at the desk.
  The Acting CHAIR. The Clerk will designate the amendment.
  The text of the amendment is as follows:

       Page 6, line 19, strike ``and''.
       Page 6, line 23, strike the period at the end and insert 
     ``; and''.
       Page 6, after line 23, insert the following:
       ``(iv) the number of eligible individuals with any co-
     occuring disorders who received services pursuant to such 
     State plan amendment and the co-occuring disorders from which 
     they suffer; and
       ``(v) information regarding the effects of a State plan 
     amendment on access to community care for individuals 
     suffering from a mental disease other than substance use 
     disorder.''.

  The Acting CHAIR. Pursuant to House Resolution 949, the gentleman 
from Michigan (Mr. Kildee) and a Member opposed each will control 5 
minutes.
  The Chair recognizes the gentleman from Michigan.
  Mr. KILDEE. Mr. Chairman, this legislation requires States to submit 
a report on the number of patients served for opioid use disorder at 
institutions for mental diseases, their length of stay, and the care 
they received after they were discharged. My amendment would add two 
requirements to that report.
  The first additional element addresses co-occurring disorders. My 
amendment would require that States include information on the number 
of individuals suffering from these disorders, as well as the type of 
specific disorders from which they suffer.
  Co-occurring disorders are a terrible situation in which a person is 
simultaneously experiencing a mental illness and a substance use issue. 
This is especially prevalent in our veteran population, with the VA 
estimating that about one-third of veterans seeking treatment for 
substance use disorder also meet the criteria for post-traumatic stress 
disorder.
  Co-occurring disorders can be especially difficult for doctors to 
diagnose because of how complex symptoms can be, with one often masking 
the symptoms of the other.
  As of 2016, the Substance Abuse and Mental Health Services 
Administration estimates that more than 8 million

[[Page H5341]]

adults in the U.S. had co-occurring disorders. Half of them did not 
receive proper treatment, and around one-third received no care for 
mental illness or substance use disorder.
  If we are going to get these individuals the help they need and 
deserve, we are going to need to know what care is needed and how large 
the existing treatment gap really is. My amendment will help to provide 
that data.
  The second element of my amendment requires information on access to 
community care for individuals suffering from a mental illness other 
than substance use disorder.
  For decades, our country has shifted mental healthcare services away 
from institutional care into community health providers. That is 
substantial progress that we certainly don't want to reverse or 
endanger.
  Make no mistake, passing this legislation will have a direct effect 
on access to community care for people with mental diseases. We should 
know how much and to what extent that is the case. My amendment will 
provide Congress with the data on whether that access is increasing or, 
as a result of this potential legislation, decreasing.
  We should not, in efforts to combat this epidemic, inadvertently 
create uncertainty or greater harm for other groups of people, 
especially such vulnerable groups as those with mental illness. My 
amendment will provide Congress with greater information for us to know 
if we are doing just that.
  Mr. Chairman, I urge my colleagues to support this amendment, and I 
reserve the balance of my time.
  Mrs. MIMI WALTERS of California. Mr. Chairman, I claim the time in 
opposition, but I am not opposed to the amendment.
  The Acting CHAIR. Without objection, the gentlewoman is recognized 
for 5 minutes.
  There was no objection.
  Mrs. MIMI WALTERS of California. Mr. Chairman, I yield myself such 
time as I may consume.
  Mr. Chairman, I thank the gentleman from Michigan (Mr. Kildee), my 
colleague, for offering this amendment to H.R. 5797.
  This amendment seeks to add several components to a State report that 
is included in H.R. 5797. I appreciate Mr. Kildee's work on this 
amendment. I think that this information would be valuable, and I am 
happy to accept the amendment. However, I want to note that we will 
need to talk to States about the information this amendment would have, 
and then report. Changes may have to be made, depending on that 
feedback.
  I am committed to working out the technical details of the amendment 
as we move into conference.
  Mr. Chairman, I yield to the gentleman from New Jersey (Mr. Pallone).
  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.
  Mrs. MIMI WALTERS of California. Mr. Chairman, I yield back the 
balance of my time.
  Mr. KILDEE. Mr. Chairman, I appreciate the comments of both of my 
colleagues.
  This is an effort to make sure that, as we take on this epidemic, 
whatever path we may take, we do so in a way that gets us the best 
information we can to determine whether or not we are making the 
progress that this intends. We have our thoughts about that. This 
legislation, and this particular amendment, would ensure that Congress 
has the information it needs.
  I encourage my colleagues to support the amendment, and I yield back 
the balance of my time.
  The Acting CHAIR. The question is on the amendment offered by the 
gentleman from Michigan (Mr. Kildee).
  The amendment was agreed to.


               Amendment No. 3 Offered by Mr. Fitzpatrick

  The Acting CHAIR. It is now in order to consider amendment No. 3 
printed in part D of House Report 115-766.
  Mr. FITZPATRICK. Mr. Chairman, I have an amendment at the desk.
  The Acting CHAIR. The Clerk will designate the amendment.
  The text of the amendment is as follows:

       Page 6, line 7, insert before the period the following: 
     ``or criteria established or endorsed by the State agency 
     identified by the State pursuant to section 1932(b)(1)(A)(i) 
     of the Public Health Service Act''.

  The Acting CHAIR. Pursuant to House Resolution 949, the gentleman 
from Pennsylvania (Mr. Fitzpatrick) and a Member opposed each will 
control 5 minutes.
  The Chair recognizes the gentleman from Pennsylvania.
  Mr. FITZPATRICK. Mr. Chairman, I yield myself such time as I may 
consume.
  Mr. Chairman, I intend to withdraw the amendment, but I want to take 
a moment to highlight an issue of critical importance to my home State 
of Pennsylvania where communities across the Commonwealth have been 
suffering from the scourge of the opioid crisis.
  First, I want to thank the committee for tackling the IMD exclusion 
problem. We must ensure access to treatment to get people suffering 
with addiction on the road to recovery. Going forward, we must ensure 
that States have the flexibility that they need to provide access to 
treatment and not unintentionally create obstacles or bureaucratic 
barriers to care.
  This is exactly what I had in mind when I introduced my Road to 
Recovery Act last year. I worked with various stakeholders across the 
Nation and in Pennsylvania, including Pennsylvania State Representative 
Gene DiGirolamo and Deb Beck, the head of the Drug and Alcohol Service 
Providers Organization of Pennsylvania.
  I determined that States deliberately tailoring criteria to meet 
their unique situation, whether it be specific local realities or 
socioeconomic factors, need flexibility and should not be bound solely 
to the proprietary criteria of one organization--which, in fact, 
endorsed my Road to Recovery Act that included this same State 
flexibility criteria provision.
  I am concerned for Pennsylvania and other similarly situated States 
that could be left behind, especially in the public patient and 
residential treatment context.
  For instance, in Pennsylvania, we currently use the Pennsylvania 
client placement criteria tool for determining the appropriate level of 
care for an individual seeking treatment or already within 
Pennsylvania's treatment system. And there are simply differences 
between the ASAM standard specified in this bill and the criteria used 
by my home State of Pennsylvania.
  Additionally, in States that may be transitioning to the ASAM 
guidelines, much work is needed to implement these changes. So, States 
need the flexibility and assurances to be able to address facility 
needs during this transition period. This would ensure access to care 
if the State sees a necessity for it.
  Furthermore, the CMS guidance for the States applying for 1115 
waivers already gives the ability to use either the ASAM criteria or 
other patient placement assessment tools.
  A manual published by SAMHSA discusses the ASAM criteria and notes 
the following: ``. . . The ASAM criteria were not as applicable to 
publicly funded programs as to hospitals, practices of private 
practitioners, group practices, or other medical settings. Therefore, 
some States supplemented or adapted ASAM criteria.''
  The same manual goes on to say that several States have adopted 
variations of the ASAM criteria to fit their systems and that many 
States have made significant improvements in the ASAM criteria to make 
them more appropriate to their systems and easier to use.

                              {time}  1430

  So as you can see, Mr. Chairman, one size, or, in this case, one 
criteria, might not fit all for States that need

[[Page H5342]]

to tailor their criteria for their specific public health needs.
  I look forward to working with the committee and with the Senate in 
conference to ensure that States have the flexibility that they need to 
provide access to care.
  Mr. Chair, I yield such time as he may consume to the gentleman from 
Oregon (Mr. Walden).
  Mr. WALDEN. Mr. Chair, I thank Mr. Fitzpatrick and his team for 
agreeing to work with us on this issue. Unfortunately, this well-
thought-out amendment would significantly alter the quality standards 
we have built into the base bill, and such a change would require more 
substantial vetting with key stakeholders than we have time for at this 
point.
  Because of that, we are not in position of being able to accept the 
amendment at this time. However, we do feel that Mr. Fitzpatrick has 
made a good start, so I will have our team do a comprehensive vetting 
of the language and work with stakeholders to see if this is something 
we could add as we move into conference with the Senate.
  Mr. Chair, I thank the gentleman for his work and I look forward to 
continuing to work with him on this and other issues and with the 
Senate as we continue work on this legislation.
  Mr. FITZPATRICK. Mr. Chair, I appreciate the remarks from the 
chairman.
  I yield back the balance of my time.
  Mr. Chair, I ask unanimous consent to withdraw the amendment.
  The Acting CHAIR. Is there objection to the request of the gentleman 
from Pennsylvania?
  There was no objection.
  The Acting CHAIR. The amendment is withdrawn.
  There being no further amendments, under the rule, the Committee 
rises.
  Accordingly, the Committee rose; and the Speaker pro tempore (Mr. Poe 
of Texas) having assumed the chair, Mr. Mitchell, Acting Chair of the 
Committee of the Whole House on the state of the Union, reported that 
that Committee, having had under consideration the bill (H.R. 5797) to 
amend title XIX of the Social Security Act to allow States to provide 
under Medicaid services for certain individuals with opioid use 
disorders in institutions for mental diseases, and, pursuant to House 
Resolution 949, he reported the bill, as amended by that resolution, 
back to the House with sundry further amendments adopted in the 
Committee of the Whole.
  The SPEAKER pro tempore. Under the rule, the previous question is 
ordered.
  Is a separate vote demanded on any further amendment reported from 
the Committee of the Whole? If not, the Chair will put them en gros.
  The amendments were agreed to.
  The SPEAKER pro tempore. The question is on the engrossment and third 
reading of the bill.
  The bill was ordered to be engrossed and read a third time, and was 
read the third time.


                           Motion to Recommit

  Ms. CASTOR of Florida. Mr. Speaker, I have a motion to recommit at 
the desk.
  The SPEAKER pro tempore. Is the gentlewoman opposed to the bill?
  Ms. CASTOR of Florida. I am opposed in its current form.
  The SPEAKER pro tempore. The Clerk will report the motion to 
recommit.
  The Clerk read as follows:

       Ms. Castor of Florida moves to recommit the bill H.R. 5797 
     to the Committee on Energy and Commerce with instructions to 
     report the same back to the House forthwith with the 
     following amendment:
       Strike all that follows after section 1 and insert the 
     following:

     SEC. 2. MEDICAID STATE PLAN OPTION TO PROVIDE SERVICES FOR 
                   CERTAIN INDIVIDUALS WITH SUBSTANCE USE 
                   DISORDERS IN QUALIFIED INSTITUTIONS FOR MENTAL 
                   DISEASES.

       Section 1915 of the Social Security Act (42 U.S.C. 1396n) 
     is amended by adding at the end the following new subsection:
       ``(l) State Plan Option To Provide Services for Certain 
     Individuals in Qualified Institutions for Mental Diseases.--
       ``(1) In general.--With respect to calendar quarters 
     beginning during the period beginning January 1, 2019, and 
     ending December 31, 2023, a State may elect, through a State 
     plan amendment, to, notwithstanding section 1905(a), provide 
     medical assistance for addiction treatment services and other 
     medically necessary services furnished to eligible 
     individuals with substance use disorders who are patients in 
     qualified institutions for mental diseases, in accordance 
     with the requirements of this subsection.
       ``(2) Payments.--
       ``(A) In general.--Subject to subparagraph (B), amounts 
     expended under a State plan amendment under paragraph (1) for 
     services described in such paragraph furnished, with respect 
     to a 12-month period, to an eligible individual with a 
     substance use disorder who is a patient in a qualified 
     institution for mental diseases shall be treated as medical 
     assistance for which payment is made under section 1903(a) 
     but only to the extent that such services are furnished for 
     not more than a period of 30 days (whether or not 
     consecutive) during such 12-month period.
       ``(B) Conditions.--As a condition of receiving payment 
     under this paragraph, a State shall satisfy each of the 
     following:
       ``(i) Coverage of continuum of care recommended by asam.--
     Provide medical assistance under the State plan for all nine 
     levels of the continuum of care recommended, as of the date 
     of the enactment of this section, by the American Society of 
     Addiction Medicine.
       ``(ii) Coverage of newly eligible individuals.--Provide for 
     making medical assistance available under the State plan to 
     all individuals described in subclause (VIII) of section 
     1902(a)(10)(A)(i).
       ``(C) Clarification.--Payment made under this paragraph for 
     expenditures under a State plan amendment under this 
     subsection with respect to services described in paragraph 
     (1) furnished to an eligible individual with a substance use 
     disorder shall not affect payment that would otherwise be 
     made under section 1903(a) for expenditures under the State 
     plan (or waiver of such plan) for medical assistance for such 
     individual.
       ``(3) Definitions.--In this subsection:
       ``(A) Addiction treatment services.--The term `addiction 
     treatment services' means, with respect to a State and 
     eligible individuals with substance use disorders who are 
     patients in qualified institutions for mental diseases, 
     services that are offered as part of a full continuum of 
     evidence-based treatment services under the State plan (or a 
     waiver of such plan), including residential, non-residential, 
     and community-based care, for such individuals.
       ``(B) Eligible individual with a substance use disorder.--
     The term `eligible individual with a substance use disorder' 
     means an individual who--
       ``(i) with respect to a State, is enrolled for medical 
     assistance under the State plan (or a waiver of such plan);
       ``(ii) is at least 21 years of age;
       ``(iii) has not attained 65 years of age; and
       ``(iv) has been diagnosed with at least one substance use 
     disorder.
       ``(C) Qualified institution for mental diseases.--
       ``(i) In general.--The term `qualified institution for 
     mental diseases' means an institution described in section 
     1905(i) that--

       ``(I) has fewer than 40 beds;
       ``(II) is accredited for the treatment of substance use 
     disorders by the Joint Commission on Accreditation of 
     Healthcare Organizations, the Commission on Accreditation of 
     Rehabilitation Facilities, the Council on Accreditation, or 
     any other accrediting agency that the Secretary deems 
     appropriate as necessary to ensure nationwide applicability, 
     including qualified national organizations and State-level 
     accrediting agencies; and
       ``(III) employs at least one provider who, for purposes of 
     treating eligible individuals with a substance use disorder--

       ``(aa) is licensed to prescribe at least one form of each 
     type of medication-assisted treatment specified in clause 
     (ii);
       ``(bb) provides, with respect to the prescription of any 
     such medication-assisted treatment, counseling services and 
     behavioral therapy; and
       ``(cc) can discuss with any such individual the risks, 
     benefits, and alternatives of any such medication-assisted 
     treatment so prescribed.
       ``(ii) Types of medication-assisted treatment specified.--
     For purposes of clause (i), the types of medication-assisted 
     treatment specified in this clause are each of the following:

       ``(I) Methadone.
       ``(II) Buprenorphine.
       ``(III) Naltrexone.

       ``(D) Other medically necessary services.--The term `other 
     medically necessary services' means, with respect to an 
     eligible individual with a substance use disorder who is a 
     patient in a qualified institution for mental diseases, items 
     and services that are provided to such individual outside of 
     such institution to the extent that such items and services 
     would be treated as medical assistance for such individual if 
     such individual were not a patient in such institution.''.

     SEC. 3. PROMOTING VALUE IN MEDICAID MANAGED CARE.

       Section 1903(m) of the Social Security Act (42 U.S.C. 
     1396b(m)) is amended by adding at the end the following new 
     paragraph:
       ``(7)(A) With respect to expenditures described in 
     subparagraph (B) that are incurred by a State for any fiscal 
     year after fiscal year 2020 (and before fiscal year 2025), in 
     determining the pro rata share to which the United States is 
     equitably entitled under subsection (d)(3), the Secretary 
     shall substitute the Federal medical assistance percentage 
     that applies for such fiscal year to the State under section 
     1905(b) (without regard to any adjustments to such percentage 
     applicable under such section or any other provision of law) 
     for the percentage that applies to such expenditures under 
     section 1905(y).
       ``(B) Expenditures described in this subparagraph, with 
     respect to a fiscal year to

[[Page H5343]]

     which subparagraph (A) applies, are expenditures incurred by 
     a State for payment for medical assistance provided to 
     individuals described in subclause (VIII) of section 
     1902(a)(10)(A)(i) by a managed care entity, or other 
     specified entity (as defined in subparagraph (D)(iii)), that 
     are treated as remittances because the State--
       ``(i) has satisfied the requirement of section 438.8 of 
     title 42, Code of Federal Regulations (or any successor 
     regulation), by electing--
       ``(I) in the case of a State described in subparagraph (C), 
     to apply a minimum medical loss ratio (as defined in 
     subparagraph (D)(ii)) that is at least 85 percent but not 
     greater than the minimum medical loss ratio (as so defined) 
     that such State applied as of May 31, 2018; or
       ``(II) in the case of a State not described in subparagraph 
     (C), to apply a minimum medical loss ratio that is equal to 
     85 percent; and
       ``(ii) recovered all or a portion of the expenditures as a 
     result of the entity's failure to meet such ratio.
       ``(C) For purposes of subparagraph (B), a State described 
     in this subparagraph is a State that as of May 31, 2018, 
     applied a minimum medical loss ratio (as calculated under 
     subsection (d) of section 438.8 of title 42, Code of Federal 
     Regulations (as in effect on June 1, 2018)) for payment for 
     services provided by entities described in such subparagraph 
     under the State plan under this title (or a waiver of the 
     plan) that is equal to or greater than 85 percent.
       ``(D) For purposes of this paragraph:
       ``(i) The term `managed care entity' means a medicaid 
     managed care organization described in section 
     1932(a)(1)(B)(i).
       ``(ii) The term `minimum medical loss ratio' means, with 
     respect to a State, a minimum medical loss ratio (as 
     calculated under subsection (d) of section 438.8 of title 42, 
     Code of Federal Regulations (as in effect on June 1, 2018)) 
     for payment for services provided by entities described in 
     subparagraph (B) under the State plan under this title (or a 
     waiver of the plan).
       ``(iii) The term `other specified entity' means--
       ``(I) a prepaid inpatient health plan, as defined in 
     section 438.2 of title 42, Code of Federal Regulations (or 
     any successor regulation); and
       ``(II) a prepaid ambulatory health plan, as defined in such 
     section (or any successor regulation).''.

  Mrs. MIMI WALTERS of California (during the reading). Mr. Speaker, I 
reserve a point of order on the motion to recommit.
  The SPEAKER pro tempore. A point of order is reserved.
  The Clerk will continue to read.
  The Clerk continued to read.
  Ms. CASTOR of Florida (during the reading). Mr. Speaker, I ask 
unanimous consent to dispense with the reading.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentlewoman from Florida?
  There was no objection.
  The SPEAKER pro tempore. The gentlewoman from Florida is recognized 
for 5 minutes in support of her motion.
  Ms. CASTOR of Florida. Mr. Speaker, this is the final amendment to 
the bill. It will not kill the bill or send it back to committee. If 
adopted, the bill will immediately proceed to passage, as amended.
  Mr. Speaker, the House has been debating legislation to combat the 
opioid epidemic. While many of the bills we heard last week and this 
week are fine, together they fail to meet the challenge of this very 
serious public health crisis where in America today, we are losing 
about 40,000 lives a year due to opioid addiction.
  Now, in the Energy and Commerce Committee over the past few months, 
we have had numerous hearings and heard from all sorts of experts and 
families and the DEA and health providers. And then back home, families 
have been educating us on the challenges of dealing with opioid 
addiction.
  Families and public health experts and the medical community, they 
have reached a consensus that we need a more comprehensive approach to 
tackle the opioid epidemic that includes prevention, community-based 
treatment, and integrated recovery plans. But it is very difficult for 
us to be proactive in a meaningful way on the opioid crisis when the 
Republicans and the White House continue to press us backwards when it 
comes to access to affordable healthcare.
  Just last week, the Trump administration launched a new attack on 
Americans with preexisting conditions, and that includes families 
struggling with opioid addiction. President Trump and the GOP asked a 
Federal court to strike down the protection that prevents insurance 
companies from denying coverage or charging more for a preexisting 
condition.
  This would be a devastating blow to those suffering from addiction, 
not to mention cancer or diabetes or a heart condition or more. This 
would leave more families without insurance and more families without 
addiction treatment.
  President Trump and the GOP were not successful last year in ripping 
health coverage away from families across this country through 
legislation, so now they are trying to do this through the court 
system: take away the guarantee of health coverage for millions of 
Americans with preexisting conditions. This is wrong and it will make 
the opioid epidemic worse. Instead, we should be working together to 
develop and fund a comprehensive robust plan to combat and treat 
addiction.
  Mr. Speaker, this is why I am proposing an amendment to strengthen 
the underlying bill. My amendment, most importantly, makes the 5-year 
limited repeal of the IMD exclusion for individuals with substance use 
disorders contingent on the State expanding Medicaid. It is based on 
the most up-to-date research and everything we know about how important 
Medicaid and Medicaid expansion is to treating opioid addiction.
  Mr. Speaker, Medicaid is central to treating addiction, because 
families can get early intervention and treatment, including the 
important medical-assisted treatment. In fact, Medicaid serves four out 
of ten of nonelderly adults with opioid addiction.
  According to a 2016 study by the National Council on Behavioral 
Health, about 1.6 million people with substance use disorders now have 
coverage because they live in one of the 31 States at the time that 
expanded Medicaid. So they are more likely to receive treatment, 
including access to naloxone and other drugs that help them stay off 
the opioids.
  The Agency for Healthcare Research and Quality highlighted the 
importance of Medicaid expansion in increasing insurance coverage among 
people with opioid use disorders just recently. They found that the 
share of hospitalizations in which the patient was uninsured fell 
dramatically in States that had expanded Medicaid, from over 13 percent 
in 2013 to just 2.9 percent 2 years later after those States expanded 
Medicaid. The steep decline indicates that many uninsured people coping 
with opioid addiction gained coverage through Medicaid expansion.
  Medicaid is part of the solution to the opioid crisis, and 
Republicans should not irresponsibly press to cut millions of 
Americans, take away their lifeline as they propose massive cuts again 
to Medicaid.
  The Republican budget came out just yesterday. Surprise, surprise. 
Again, they go after families who rely on Medicaid, not just Medicaid 
expansion that has been so important to treating folks who suffer from 
addiction, but families, children, our neighbors with disabilities, 
folks that rely on skilled nursing care, the Republican budget released 
yesterday says $1.5 trillion in cuts to those families. That is not 
going to help solve the opioid epidemic.
  Republicans in Congress cannot, on one hand, say we are facing up to 
the addiction crisis, and on the other say we are taking away your 
healthcare, whether it is Medicaid or preexisting conditions.
  Mr. Speaker, I urge approval of my motion, and I yield back the 
balance of my time.
  Mrs. MIMI WALTERS of California. Mr. Speaker, I withdraw my point of 
order.
  The SPEAKER pro tempore (Mr. Mitchell). The reservation of a point of 
order is withdrawn.
  Mrs. MIMI WALTERS of California. Mr. Speaker, I claim the time in 
opposition to the motion.
  The SPEAKER pro tempore. The gentlewoman from California is 
recognized for 5 minutes.
  Mrs. MIMI WALTERS of California. Mr. Speaker, the Energy and Commerce 
Committee has worked hard to make this monumental first step in 
removing a decades-old barrier.
  Currently the law prohibits Medicaid beneficiaries aged 21 to 64 from 
receiving care in an institution for mental disease, or IMD. This 
prohibition was set into law in the 1960s, long before the opioid 
crisis, and the time to repeal it in a targeted manner is now.
  Now is the time, because 115 Americans are dying each day from 
opioid-related deaths. Now is the time, because

[[Page H5344]]

on average, 1,000 people are treated in emergency rooms for opioid 
misuse.
  I am happy to work with my colleagues on expanding addiction 
treatment services, but that should not distract from what we are 
considering today: increasing access to specialized inpatient treatment 
for the most vulnerable in society who are struggling with an opioid 
addiction.
  We are helping to ensure that people get the care they need in the 
midst of this crisis, and most importantly, it will save lives.
  A recent MACPAC report clearly stated that the Medicaid IMD exclusion 
acts as a barrier for individuals with an opioid use disorder and is 
one of the few instances in Medicaid where Federal financial 
participation cannot be used for medically necessary and otherwise 
covered services for a specific Medicaid enrollee population receiving 
treatment in a specific setting.
  The IMD CARE Act is vital to helping our communities end the opioid 
epidemic by removing that barrier. This bill provides for a targeted 
repeal of the IMD prohibition. The bill gives States a quicker 
alternative than Medicaid waivers to provide this much needed care. 
This bill was carefully crafted to ensure that patients are not being 
held in IMDs for longer than necessary and the bill also includes an 
offset.
  For these reasons, the National Governors Association and the 
American Hospital Association support the bill.
  Numerous stakeholder groups have identified the IMD exclusion repeal 
as one of the most significant reforms we can make to end the opioid 
crisis.
  This is such a critical first step.
  Mr. Speaker, I urge my colleagues to oppose this motion to recommit 
and to vote ``yes'' on final passage.
  Mr. Speaker, I yield back the balance of my time.
  The SPEAKER pro tempore. Without objection, the previous question is 
ordered on the motion to recommit.
  There was no objection.
  The SPEAKER pro tempore. The question is on the motion to recommit.
  The question was taken; and the Speaker pro tempore announced that 
the noes appeared to have it.
  Ms. CASTOR of Florida. Mr. Speaker, on that I demand the yeas and 
nays.
  The yeas and nays were ordered.
  The SPEAKER pro tempore. Pursuant to clause 8 of rule XX, further 
proceedings on this question will be postponed.

                          ____________________