On Oct. 26 last year, President Donald Trump declared the opioid epidemic -- which took more than 64,000 lives in 2016 -- a national emergency.
More specifically, he declared it a public health emergency, which can be used to ease some federal rules for the U.S. Department of Health and Human Services (HHS) to, among other things, make more people eligible for Medicaid or dispatch more medical professionals to the areas hit hardest by the drug crisis.
The declaration has already been extended twice, most recently on Tuesday. But health policy experts say it's unclear what -- if any -- HHS rules have been waived since the declaration. Moreover, Trump did not directly offer state and local governments more money to combat the drug crisis. Because of this, some say the declaration has been nothing more than an empty promise.
“We’ve seen no effect here in Baltimore from the emergency [declaration]," says Leana Wen, the city's health commissioner. "We could save so many more lives if we had more resources. We don’t need any more rhetoric."
Wen worked with members of Congress to take matters of money into their own hands.
Last week, U.S. Rep. Elijah Cummings and U.S. Sen. Elizabeth Warren introduced the Comprehensive Addiction Resources Emergency (CARE) Act. It would require the federal government to spend $10 billion a year for 10 years on the opioid crisis. A sizable portion of that would go directly to state and local governments: $4 billion a year to states and $2.7 billion to cities and counties. The money would not be dependent on Congressional approval every year.
So far, the bill has yet to drum up bipartisan support, but Wen says she's confident that Congress "will heed the calls of those of us on the frontline who know what we need to solve this public health crisis."
There are at least seven other bills floating around Congress to address the opioid epidemic. The most comprehensive with the most bipartisan support is the Comprehensive Addiction and Recovery Act (CARA) 2.0. It offers $1 billion more than current federal funding for treatment and prevention programs and would mandate a three-day limit for first-time opioid prescriptions.
Frustration over federal inaction is even boiling over within the president's own party.
Before Trump traveled to New Hampshire to talk about opioids, the state's Republican governor, Chris Sununu, reportedly confronted White House officials about the lack of funding to back up the emergency declaration.
"The president cannot come to New Hampshire without a plan that has substance," Sununu told White House aides, according to CBS News.
Trump still gave his scheduled speech there in March to unveil new initiatives to fight the opioid epidemic. He focused on cracking down on illegal immigration and drug dealers. Since then, Attorney General Jeff Sessions has directed federal prosecutors to seek the death penalty for some drug traffickers -- an impossible policy to enact in many states since 19 of them have outlawed capital punishment.
His focus on law-and-order tactics exasperated many health officials.
"I'm deeply concerned with the focus on incarceration. It goes against what science says, which is that addiction is a disease. We know that treatment works. The war on drugs doesn't," says Wen.
The plan the White House released after Trump's New Hampshire speech did include several bipartisan, health-focused efforts to combat the crisis -- but most of the ideas weren't new and there were few specifics about how to pay for them.
Before the emergency declaration, Trump assembled an opioid commission to explore the best tactics the federal government could deploy to stem the tide of overdoses. A final report was released in November, with some bipartisan recommendations, such as removing barriers to treatment and increasing access to drug courts that divert people struggling with addiction from jail.
But even those who worked on the commission's 138-page report have said that the administration has no plan to systematically address the epidemic. Patrick Kennedy, a former member of Congress on the commission, told CNN in January that it was a "sham."
“The emergency declaration has accomplished little because there’s no funding behind it. You can’t expect to stem the tide of a public health crisis that is claiming over 64,000 lives per year without putting your money where your mouth is," Kennedy said.
There have been some encouraging signs, however, that the federal government is serious about addressing the opioid epidemic.
The Trump administration has continued an Obama-era policy of approving waivers to let their Medicaid programs pay for addiction and mental health treatment in facilities larger than 16 beds -- which is normally prohibited under federal law. So far, the Trump administration has approved waivers from Indiana, New Jersey, Utah, Virginia and West Virginia. Five states -- Arizona, Illinois, Kentucky, Michigan and Wisconsin -- have pending waivers still.
And last month, Congress passed a federal spending bill that includes a $3.3 billion increase in funding for the opioid crisis. The $3.3 billion will go toward prevention, treatment and law enforcement activities across the Centers for Disease Control and Prevention (CDC), Substance Abuse and Mental Health Services Administration (SAMHSA), Department of Veterans Affairs and other entities that help state and local governments.
Many health policy experts, however, argue that it still isn't enough to make a meaningful impact. To put that in context, the federal budget for HIV care in 2017 was $32 billion.
"The Fiscal Year 2018 Omnibus Appropriations represents a down payment on shoring up the nation's public health infrastructure, but it also falls short on necessary resources to combat the nation's opioid crisis and associated infectious diseases," said the National Coalition of STD Directors in a statement.
Michael Kilkenny, physician director of West Virginia's Cabell-Huntington Health Department who was initially frustrated by the lack of direct funding from the White House, says the $3.3 billion from Congress is one step in the right direction.
Others are skeptical of the emergency declaration's impact on new funding.
Jay Butler, chief medical officer for Alaska’s health department, says his state received extra resources in the past six months from the CDC and SAMHSA to distribute more naloxone. But he says it’s hard to say if it’s a direct result of the declaration since much of the money was appropriated before Trump's announcement in October.
“I look at the declaration in the context of the overall response to the epidemic. Worst case, it’s been a communications tool,” says Butler.
Still, many are not satisfied, especially with the president's emphasis on criminalization.
"There is already so much stigma around addiction. There are people terrified of seeking help because they think they'll get punished, so you're criminalizing a generation of people," says Wen. "I want to see specific proposals, I want to see a concerted effort to fund them."