For decades, if people on Medicaid wanted to get treatment for drug or alcohol addiction, they almost always had to rely solely on money from state and local sources.
Now, in a dramatic shift, the federal government is likely to chip in, too. The agency that governs Medicaid is proposing to cover 15 days of inpatient rehab per month for anyone enrolled in a Medicaid managed care plan.
But in Pennsylvania, those who work in the addiction field aren't happy with that news. While it's a good start, they say, only 15 days of residential care isn't nearly enough time for many people addicted to heroin, opioids, alcohol or other drugs to get clean and stay that way.
"Where they came up with the 15 days, I don't know, but it's not based on research" says Mike Harle, head of the nonprofit treatment program Gaudenzia, which serves about 20,000 patients a year in Pennsylvania, Maryland and Delaware. In just 15 days, he says, you can't expect to achieve a positive outcome.
"Do you know how expensive that would be, with no outcome?" Harle says. "We wouldn't want to do it. We would not want to do it."
Up until now, the state of Pennsylvania has used an obscure provision in the federal law to get federal reimbursement for much longer rehab stays for some people. Pennsylvania officials worry that the loophole will likely go away if the new Medicaid proposal is enacted.
In its guide to drug addiction treatment, the National Institute on Drug Abuse says:
Individuals progress through drug addiction treatment at various rates, so there is no predetermined length of treatment. However, research has shown unequivocally that good outcomes are contingent on adequate treatment length.
Dr. Jeffery Samet, a professor at Boston University's Clinical Addiction research unit, says there's been little funding for research that gets at the optimal length of an inpatient stay, in terms of effectiveness. And in the absence of good data, private insurance plans are all over the map in terms of how many inpatient days they will cover.
Considering that Medicaid hasn't funded residential treatment programs at all, up until now, 15 days is a good start, says Cindy Mann, a former top administrator at the federal Centers for Medicare and Medicaid Services, which governs Medicaid.
"Maybe it's half a loaf for someone who needs 30 days," says Mann, who now works for Manatt Health Solutions, a law and consulting firm. "But it's half a loaf of new federal dollars that could be available."
Chris Benedetto, a 30-year-old who started using heroin when he was 13 years old, in Scranton, Pa., says he needed much more than 15 or even 30 days in rehab to kick his drug habit.
"I was really young," Benedetto says. "I actually was arrested in school." He bounced from school to probation to jail to rehabilitation. Benedetto says he knew how to play the treatment game, fooling his family and others that he was doing well, even when he was still using drugs, or about to slip.
"I'm good at putting on that mask," he says.
Eventually, in 2009, Benedetto got into an inpatient facility and stayed there for five months of supportive therapy, thanks to Pennsylvania's looser interpretation of federal restrictions. Benedetto says the longer rehab stay is what finally enabled him to kick his drug habit.
"For that amount of time, in that environment, I will show up," Benedetto says. He's now been clean for more than five years, and works as an assistant to an addiction counselor.
Samet says he likes the idea that Medicaid will start covering at least some inpatient treatment. But he also wants to make sure that doctors and patients consider outpatient programs, which can be highly effective for some people, and are less expensive.
"It's the challenge of public policy," he says. I think this is why the feds go into this kind of work — because a lot of good can be done." But, he adds, he doesn't want residential programs to become the default style of treatment, just because the option is now available.
"The risk of it being taken advantage of is real," by both patients and providers, Samet says.
Former federal administrator Mann says the proposed change still allows state governments to pay for as much treatment as they think a patient needs — just as they have been doing all along.
"The state and the locals are completely free to finance that stay if they think it's the right place for somebody to be," she says.
And if they're still not happy, she adds, states can put together innovative treatment programs to apply for more federal money.
This story is part of NPR's partnership with local member stations and Kaiser Health News.
KELLY MCEVERS, HOST:
For decades, if someone on Medicaid wanted treatment for drug or alcohol addiction, they almost always had to rely on money from state and local sources. Now a big change - the federal government is considering chipping in. In one state though, this isn't welcome news. Ben Allen of member station WITF explains.
BEN ALLEN, BYLINE: It always sounds bureaucratic to hear Medicaid rule change, but this could start to transform drug and alcohol addiction treatment. The federal agency that oversees Medicaid known as CMS is proposing to cover 15 days a month of inpatient treatment for anyone in a Medicaid managed care plan. That's a version of Medicaid managed by insurance companies.
CINDY MANN: This was a big step forward for CMS to get to the 15 days.
ALLEN: Cindy Mann is a former top administrator at CMS who now works for Manatt Health Solutions, a law and consulting firm. Insurance companies and states are all over the map for how many days they'll pay for, but federal law restricted Medicaid funding for any length of stay. So, Mann says...
MANN: Maybe it's half a loaf for somebody who needs 30 days but it's half a loaf of of new federal dollars coming in that could be available.
ALLEN: Most states will gladly take what they can. But this story gets more complicated in one state. For years, Pennsylvania has been using an obscure provision to get federal reimbursement for rehab stays much longer than 15 days. Take Chris Benedetto. He's 30 years old and started shooting heroin at age 13.
CHRIS BENEDETTO: I was really young, so I actually was arrested in school. I was doing outpatient, and then I went directly to inpatient because I had no way of stopping.
ALLEN: Growing up in Scranton, he bounced from school to probation to jail to rehabs. He knew how to play the treatment game.
BENEDETTO: I'm good at, like, putting on that mask. I'm good at, like, everybody around me - you know, my sibling, my dad - everybody was like man, he's doing good every time.
ALLEN: But then in 2009, he got into an inpatient facility and didn't have to leave before he was ready because of Pennsylvania's Medicaid maneuver, which state officials fear will no longer be an option if the proposed rules go through. Turns out he needed more than five months in rehab.
BENEDETTO: For that amount of time and in that type of environment, you know, I will show up.
ALLEN: Now he's been clean for more than five years and works as an assistant to an addiction counselor. Mike Harle is the head of treatment nonprofit Gaudenzia, which serves about 20,000 patients a year in Pennsylvania, Maryland and Delaware. He's thinking about Chris Benedetto and others when he says this...
MIKE HARLE: Where they came up with the 15 days, I don't - but it's not based on research. Fourteen days has no outcome. You know how expensive that would be with no outcome? We wouldn't want to do it. We would not want to do it.
ALLEN: Cindy Mann says the feds are trying to push the limit by allowing 15 days, and experts haven't found that magic number for treatment. Dr. Jeffrey Samet, a professor at Boston University's Clinical Addiction research unit, says no one really wants to fund studies looking at the best length for stays. Still, he likes the fed's idea. Samet just wants to make sure less-expensive outpatient treatment gets considered, too.
JEFFREY SAMET: It's the challenge of public policy. So I think this is why the feds go into this type of work because a lot of good can be done. But it can be edgy, and the risk of it being taken advantage of is real.
ALLEN: Cindy Mann says states can continue to pay for as much treatment as they think a patient needs just as they have been doing.
MANN: The state and the locals are completely free to continue to finance that stay if they think that it's the right place for somebody to be.
ALLEN: And if they're still not happy, states can put together innovative treatment programs to apply for more federal money. For NPR News, I'm Ben Allen in Harrisburg. Transcript provided by NPR, Copyright NPR.