Pubdate: Fri, 11 Jul 2014
Source: New York Times (NY)
Copyright: 2014 The New York Times Company
Author: Abby Goodnough


EAST HAZEL CREST, Ill. - On its surface, the Affordable Care Act 
seems like a boon for addiction treatment centers like the South 
Suburban Council on Alcoholism and Substance Abuse, housed in a 
no-frills former hotel outside Chicago.

The law allowed states to expand Medicaid to many more low-income 
people, meaning that drug addicts and alcoholics who were previously 
ineligible could now receive coverage for substance abuse treatment, 
which the law has deemed an "essential health benefit."

But there is a hitch: Under an obscure federal rule enacted almost 50 
years ago, Medicaid covers residential addiction treatment in 
community-based programs only if they have 16 or fewer beds. The 
South Suburban Council's main treatment program has 48. So the very 
people who might have flowed through its doors in search of care will 
not be coming. And the same problem faces many other centers, which 
typically are larger than 16 beds, experts say.

The quirk in the law could have a significant impact on substance 
abuse treatment in Illinois and the 25 other states that have 
expanded Medicaid under the health care law. While millions of 
low-income addicts have been promised access to treatment through the 
expansion, the rule will most likely prevent many from entering 
residential programs, a more intensive form of care, even as heroin 
addiction is surging in many states.

In California, for instance, nine out of 10 addiction treatment beds 
are in programs too large to get Medicaid reimbursement.

"For some addicts, there is an undeniable and essential need for 
residential treatment," said Allen Sandusky, the South Suburban 
Council's chief executive. "The A.C.A. is going to mess that up badly 
unless this problem is acknowledged and addressed."

The rule was intended to prevent Medicaid funds from covering 
treatment in state psychiatric hospitals, which were far more common 
when it was written in 1965. The federal government considered such 
treatment a state responsibility, and it included residential 
programs for substance abuse under the exclusion.

"The federal government basically said to the states, 'We're not 
going to pay for your institutional care,' " said Becky Vaughn, 
executive director of the State Associations of Addiction Services, 
which represents treatment providers. "Addiction services never 
should have been wrapped into that because we are not long term."

Any change to the rule would have to come from Congress, because it 
is a provision of Medicaid law. Treatment centers and state Medicaid 
directors have called for changing or repealing it, but the odds are 
low, partly because Congress seems unwilling to tackle any health 
care issues this year, and partly because this one could prove expensive.

Aaron Albright, a spokesman for the Centers for Medicare and Medicaid 
Services, said most substance abuse treatment for new Medicaid 
enrollees was being provided on an outpatient basis. Such treatment 
usually consists of one or more group counseling sessions a week - 
enough for some, but inadequate for the severely ill, said Paul 
Samuels, director of the Legal Action Center, a nonprofit group in 
New York that advocates for people with addiction.

States and treatment providers are now scrambling to accommodate 
those who need residential treatment without running afoul of the 16-bed rule.

In Washington State, four existing treatment centers are downsizing 
to 16 beds and four new ones are opening at that size this summer to 
ensure at least some access - 128 beds - for new Medicaid enrollees. 
California and New York plan to seek waivers from the Obama 
administration that would allow Medicaid reimbursement for 
residential treatment in larger facilities.

Kentucky is trying to determine whether programs with multiple 16-bed 
units must be counted as one entity, and thus be subject to the rule.

Until now, many states have financed at least some residential 
treatment for the poor and uninsured with a mix of federal block 
grant and state funds. But Mr. Samuels said he feared that states may 
no longer want to foot the bill for addicts who enroll in Medicaid, 
which is paying 100 percent of costs for the expansion population.

Illinois, for one, has decided to stop using a mix of state general 
revenue and federal block grant funds for residential addiction 
treatment for people who have enrolled in Medicaid under the law, 
putting providers with more than 16 beds in a quandary.

Haymarket Center, a large treatment provider in Chicago, has eaten 
the costs of residential treatment for more than 40 newly eligible 
Medicaid enrollees so far this year, said Jeffrey Collord, a 
spokesman. "We are not turning people away right now," he said. "But 
I don't know how long we can continue to do that, to provide services 
and not get paid for them."

The South Suburban Council has so far been able to treat new Medicaid 
beneficiaries in its smaller 16-bed unit by making it coed instead of 
for women only. But its larger 48-bed unit cannot accept clients on Medicaid.

So far the juggling has worked. But as more and more of South 
Suburban Council's clients enroll in Medicaid, as is expected, the 
program will have to start turning away many of the new Medicaid 
enrollees - leaving it, paradoxically, unable to fill its beds, Mr. 
Sandusky said.

His program receives $143 per patient per day for what is typically a 
28-day stay, or about $4,000. The reimbursement rate must also 
increase for programs like his to survive, he said.

Mr. Sandusky and other substance abuse experts say that many of their 
patients - typically referred by jails, courts, probation 
departments, emergency rooms and mental health agencies - need the 
stability and intensive care of residential treatment, and would 
probably fail in outpatient programs. Even intensive outpatient 
treatment, which may be several hours a day, several days a week, is 
not sufficient for many in this population, Mr. Sandusky said.

"The majority of our clients are in crisis," Mr. Sandusky said. "They 
are the clients who present the most challenging issues for our 
communities and systems."

Pete Kurpios, 41, started using heroin two years ago and was referred 
to the South Suburban Council by a hospital after he intentionally 
overdosed and spent days in a coma. "I've tried outpatient and that 
didn't work out," said Mr. Kurpios, who added that he had signed up 
for Medicaid but was still waiting for confirmation of enrollment. "I 
had too much time on my hands."

Jim McCarthy, 53, who was also in treatment at the South Suburban 
Council last month, said his addiction to alcohol and heroin recently 
cost him his painting business. "Here you've got people watching over 
you when you might not be capable of watching over yourself," he said.

In California, where only about 10 percent of the 18,155 beds at 
residential addiction treatment programs are in centers with 16 or 
fewer beds, officials tried unsuccessfully to persuade the Obama 
administration to soften the rule, saying in a February letter that 
"California is severely limited in its ability to provide this 
benefit to Medi-Cal beneficiaries."

Now the state is pursuing a waiver that would, among other things, 
allow those newly eligible for Medicaid under the Affordable Care Act 
to get residential treatment in larger programs. In the meantime, the 
state will provide a new intensive outpatient treatment benefit for 
the Medicaid expansion population, said Karen Baylor, deputy director 
of mental health and substance use disorder services at the 
California Department of Health Care Services.

In Ohio, Tracy Plouck, director of the state's Department of Mental 
Health and Addiction Services, said 72 percent of the state's 2,538 
addiction treatment beds were in programs too large for Medicaid 
reimbursement under the rule, known as the Institutions for Mental 
Disease exclusion. "It's a serious access challenge," she said. "I 
firmly believe there are providers that would increase their capacity 
but for concerns about the I.M.D."

Larry Brand, 59, who recently completed a monthlong stay at the South 
Suburban Council, said outpatient treatment would have felt much 
riskier because he would not have had a round-the-clock support 
system. Mr. Brand, who is eligible for Medicaid under the health care 
law but has not yet signed up, said he had been in and out of prison 
after stealing to support his cocaine habit. He is determined not to 
return there.

"There's no drugs and no alcohol here," he said, "so it's like a safe 
haven for me. If I would have stayed out there and tried to do it on 
my own, I can't say what would have happened. But here I am today, 
clean and sober, and I've got a good start."
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