By Janell Ross
October 7, 2015
A trio of Washington Post stories this week detail the horrible toll of rising heroin addiction, along with the very much related issues of limited access to substance-abuse treatment and other forms of mental health care.
Among the saddest takeaways: People with means can send their kids to rehab, try to get them clean and sometimes shelter their public reputations. Sometimes, all of that fails; young people die.
Sometimes when the funds exist, as Patrick Kennedy wrote in his new book released this week, the honesty required to get help is not there or is too slow in coming. And for everyone else, access to drug detox and rehabilitation treatment -- the gold standard for addiction management -- are only as accessible as what their insurance companies and charity will cover. The odds of survival and recovery for these people are even slimmer. The most recent federal data indicates the number of people who overdosed and died due to heroin grew 39 percent between 2012 and 2013. In the latter year, more than 8,000 people died.
But wait, you might say, isn't there a 2008 law that was supposed to address this? Yes. But, it seems it did not. What about the mental health care parity mandates that went into effect in January 2014, under Obamacare? Well, results there can at best be described as mixed.
The Affordable Care Act has boosted the number of Americans with health insurance coverage but has not resolved the disparate way in which many insurers treat the costs of mental and physical health care, according to an April report released by the National Alliance on Mental Illness. The report found that federal changes (part of the Affordable Care Act) mandating so-called parity between mental and physical health-care benefits do not, in practice, exist for the vast majority of Americans who are insured. The Alliance study surveyed nearly 3,000 people living with mental illness, addiction or family members trying to access care. And the Alliance's researchers dug deep into the details -- co-pays, what is an is not covered, deductibles and medication -- available to people enrolled in 84 health insurance plans offered in 15 states.
And what the research team found should be truly disturbing in a country in the throes of a heroin crisis.
It turns out that people across the country are struggling to find therapists and psychiatrists who participate in their health insurance plans. They also face more frequent coverage and treatment denials from their health insurance companies for mental health care than for other services and must clear multiple hurdles to maintain a steady supply of mental health care medication. Sometimes, they pay higher out-of-pocket costs for these drugs when compared to others.
On top of that, information about which services and treatments are covered and which medical providers participate in mental health care networks is often difficult to find before one is actually enrolled. And those determined to get some kind of mental health care or substance abuse treatment must often pay so much out of pocket that treatment becomes impossible.
Perhaps most troubling of all, it seems that on some of those fronts, the problems are actually slightly worse for those covered by the sometimes-subsidized plans created under the Affordable Care Act than for those obtaining coverage the more conventional way -- through employers.
As one survey respondent put it: “My insurance will pay my primary care doctor more for a 10-minute appointment for the flu than it will allow my psychiatrist for an hour-long treatment session. For this reason, my own psychiatrist, along with many others, no longer accepts insurance.”
The situation is not good. In fact, it's dire in a country where nearly 20 million Americans struggle with substance abuse and 42.5 million adults live with some form of mental illness, according to a Mental Health America report released in November 2014.
It's also a strange state of political affairs. In the aftermath of the shooting in Roseburg, Ore., that killed nine, better access to mental health seems to be one of the only points of agreement between people who support stricter gun control measures and those who oppose them. And moving away from a punishment-only model for the drug war has become a matter of agreement on both side of the political aisle as well.
At least five presidential candidates -- Hillary Rodham Clinton (D), Carly Fiorina (R), New Jersey Gov. Chris Christie (R), Sen. Rand Paul (R-Ky.) and former Florida governor Jeb Bush -- have expressed support for expanding treatment options and policies that regard addiction as a disease rather than a crime. But, as The Washington Post reported this weekend, the share of substance abuse treatment patients receiving in-facility care covered by health insurance dropped to 10 percent in 2014, down from 22 percent the previous year.
There is, it seems, more desire to talk about funding substance abuse treatment than desire to actually fund it. However, in March, the administration did announce plans to expand funding for emergency overdose prevention medications in hopes of reducing the growing number of people dying of heroin overdoses.
Federal and state insurance and health care industry regulators are supposed to share responsibility for monitoring health insurance plans. But it seems that the slow pace of developing specific regulations to govern commercial insurance and government health insurance programs such as Medicaid have not helped.
It took the Obama administration nearly three years to develop rules for private insurance plans. Those rules went into effect in January 2014. They have been widely described as dizzying and enforcement-limited. The public comment period for a set of rules governing Medicaid ended in June. It might be a while yet before any rules become formal requirements. Adding to the problem: Reaming reserves of social stigma around needing, seeking or advocating for mental health care, and the layers of shame and recrimination grow even more dense when it comes to substance abuse treatment.
The situation is so bad that Obama administration drug czar Michael Botticelli told The Washington Post that up to 80 percent of heroin addicts are never treated.
As the debate over mental health ramps up, expect to hear more about this very timely -- in more ways than one -- issue.