Monday, April 27, was a day of celebration for many in Pennsylvania. It marked the beginning of Phase I of the state’s transition from Healthy PA to full Medicaid expansion.
For providers and consumers of drug and alcohol treatment services, the transition comes not a moment too soon. Healthy PA is former Gov. Tom Corbett’s version of expanded Medicaid that he created in favor of a traditional Medicaid expansion. Many providers are still reeling from the damage Healthy PA inflicted on them. We can only hope the same cannot be said about people with addiction who were caught in the middle. But the truth is, any barrier can easily derail someone from seeking or completing treatment for the disease and recovering.
As Pennsylvania moves forward with full Medicaid expansion, which will provide a comprehensive benefits package that includes a continuum of drug and alcohol treatment services, the road to accessing drug and alcohol treatment should be easier to travel. Still, it remains fraught with challenges and barriers, and there are miles to go until the process for getting into treatment–including getting healthcare coverage for it–is efficient and effective.
My Experience Accessing Treatment
In January 2012, I finally found the willingness to enter inpatient drug treatment for my disease. And therein lies one of the biggest barriers to recovery, an obstacle that no process can overcome: willingness. It comes at different times for different people. And when it comes, it usually doesn’t stay long. In many ways, treating addiction is a game of opportunity. When a person with the disease of addiction says, “I’m willing to get treatment,” the process of getting into treatment must be fast and near flawless. Otherwise, the window of opportunity closes fast, and not only is a chance at recovery lost, but life may be as well.
In many ways, treating addiction is a game of opportunity.
As I recall, the process for me to get into treatment was efficient. Someone gave me the name of a woman who I was told would help me. I called her, she conducted a phone screening and was at my home in the next day or two for an in-person assessment. From there, she worked the phones to find me the first available detox bed anywhere, and in another day or two, a van pulled into my driveway to take me to inpatient treatment.
The fact that I had private health insurance, not Medicaid, which in Pennsylvania is called medical assistance, may well have positively affected my experience. Commercial insurers, like Highmark, pay more money for treatment than does Medicaid, so private-pay patients are at a premium. Yet even with private insurance, it took several days for me to get to rehab. Those who work with people with addiction will tell you that many would have changed their minds had they had to wait days. They sometimes don’t wait hours.
Now imagine being a person without health insurance trying to access addiction treatment. Or thinking you had Medicaid that covered a continuum of drug and alcohol treatment services only to find you’d been moved out of that plan without your knowledge. Those are exactly the situations encountered by those seeking treatment for addiction under Healthy PA.
Even a shift to full Medicaid expansion won’t eliminate many of these barriers. The process is not efficient, and–though the treatment system works hard for patients–it’s not always effective, either. Healthy PA was an example of inefficiency and ineffectiveness at its worst.
A Brief History Lesson: Healthy PA
Healthy PA, a complex system that challenged even the sharpest Medicaid experts, essentially amounted to serious benefit cuts for many people, who, under the program, were either: 1) moved from Medicaid managed care to a fee-for-service (FFS) delivery system; or 2) were placed into the Private Care Option (PCO), which did not provide the level of care these “medically frail” individuals needed. (In the world of addiction, the medically frail are those diagnosed with a chronic substance use disorder or who were assessed through a health screening form as substance abusers potentially in need of higher levels of care.)
Although Healthy PA will be short-lived, the results for people with addiction seeking treatment were not good.
As Janice Meinert, a paralegal with the Pennsylvania Health Law Project and an addiction advocate who serves as a consultant to Message Carriers of Pennsylvania, Inc., explained to me, people who were moved from Medicaid managed care to FFS lost coverage of intensive outpatient (IOP) services, partial hospitalization, halfway house residency and nonhospital detox services. So, theoretically, a person in IOP could have been discharged from the treatment midway through because she no longer had coverage.
The same held true for those moved into the PCO category. Like those in the FFS program, not only were certain essential services not available or discontinued because of lack of coverage, even services covered by the PCO were difficult to obtain because many providers would not accept patients with PCO coverage, calling reimbursement rates “horrendous.”
On the treatment services provider side, many unknowingly continued providing services that their patients were no longer covered for, only to find out when they sought reimbursement there would be none, or at best it would be a complex, protracted process to get paid. Most providers, though, continued to provide services because it’s their mission to do so. Some got help from Single County Authorities (SCAs), who, as payers of last resort, provided gap funding but in the process hurt themselves by depleting their budgets. SCAs receive state and federal dollars through contracts with the Department of Drug and Alcohol Programs to oversee the delivery of drug and alcohol services at the local level.
A complicated situation, indeed. Imagine the plight of people with addiction caught up in this fiasco. Talk about barriers to treatment.
Full Medicaid Expansion and People With Addiction
Now that Phase I of full Medicaid expansion has begun, all new applicants will go quickly into a Medicaid managed care plan and get a comprehensive benefits package that includes a continuum of drug and alcohol treatment services. And people who were already covered by Medicaid before January 1 who had their benefits cut will be able to rejoin their old Medicaid managed care plan and get the more comprehensive benefits. The minute-long video below explains the transition from Healthy PA to traditional Medicaid expansion.
Still, even under full Medicaid expansion, access to drug and alcohol treatment remains a challenge. For example, people with the disease of addiction who present to an SCA without coverage may be asked to apply for Medicaid on their own before they come back for their in-person assessment. With the short window of opportunity I described earlier, the likelihood of a person with addiction applying for and doing the follow-up necessary to get enrolled in Medicaid is low. The probability that the person will come back for an assessment as much as a week later is low, too.
Some counties are piloting “fast-track” projects in which Medicaid application processing would be expedited for people with addiction. Such a process would certainly enhance access.
Medicaid expansion is without question a better path for people with addiction seeking treatment. But with a disease that affects people’s thought process in such a way that they often don’t believe they have a disease, opportunities to engage in treatment are fleeting.
We need to do more to take advantage of those opportunities. What are your ideas? What else should the addiction advocacy community be addressing? How can we continue to improve access?
Jason Snyder is the Executive Director of the Consumer Health Coalition, a Pittsburgh-based advocacy organization that works on behalf of underserved and at-risk populations to ensure access to quality, affordable health care. He is also a member of the Board of Directors of Gateway Rehab, a private, nonprofit organization focused on prevention, treatment, education, and research of substance abuse and alcoholism. Prior to his current position, he was a senior public affairs and communications executive with 20 years of experience in the nonprofit and for-profit sectors. He also is in long-term recovery from the disease of addiction.
