The Health 202: There’s a simple way to solve the opioid crisis


There’s a quick and simple way President Donald Trump could immediately help Americans addicted to opioids – but it’s not part of the emergency declaration the president issued yesterday at the White House.

Here it is: allow Medicaid to start paying for treatment at large institutions for mental disease (known as IMDs). Under a current policy known as the “IMD exclusion,” people on Medicaid can’t get substance abuse treatment at facilities with more than 16 beds.

Treatment advocates, governors and medical providers have lobbied heavily to remove this exclusion, which has been in place since the Medicaid program was created half a century ago. Back then, there was a big push to deinstitutionalize mental-health patients in favor of integrating them into communities.

But now – as the nation grapples with an opioid abuse crisis that claims the lives of around 100 people every day – the overriding concern is how to help these patients break from their addictions, which often requires 24-hour monitoring over a period of several weeks, rendering residential settings crucial to the overall effort.

Trump’s opioid commission, led by New Jersey Gov. Chris Christie, R, identified removing the IMD exclusion as the top way to make treatment available to patients immediately. “This is the single fastest way to increase treatment availability across the nation,” the report said.

Yesterday, the president declared opioid abuse a public health emergency – a move that allows the federal government to more quickly direct resources toward the effort by giving states more flexibility in how they use federal funds and expanding the use of telemedicine treatment, my colleagues Jenna Johnson and John Wagner reported.

“Addressing it will require all of our effort, and it will require us to confront the crisis in all of its real complexity,” Trump said during a speech in the East Room of the White House. “As Americans, we cannot allow this to continue. It is time to liberate our communities from the scourge.”

But “liberating” residential facilities from Medicaid’s bed limits is, to the people who run them, a no-brainer way to combat the opioid abuse epidemic. Even before the Affordable Care Act expanded Medicaid, the federal health insurance program for the poor was the country’s single largest source of coverage for those with substance abuse disorders.

For example, the Gateway Foundation, which bills itself as the country’s largest nonprofit provider of addiction treatment, could treat opioid abusers at its chain of clinics across Illinois and Delaware if the exclusion were lifted. Right now, none of its 43 clinics meet the bed limitations; its smallest center has 44 beds and its largest has 125 beds.

“The type of person who needs to go residential is too sick to do [treatment] in the community,” the group’s president, Tom Britton, told me.

Trump couldn’t erase the exclusion, because it’s written into law. But he could direct the Department of Health and Human Services to issue all 50 states waivers from it. West Virginia obtained just such a waiver this month, and New Jersey, Illinois, Indiana, Kentucky and Michigan are still awaiting word on their applications.

Of course, Congress could also vote to repeal the IMD exclusion – although the Congressional Budget Office has estimated it would cost an additional $40 billion to $60 billion over a decade. A bipartisan group of eight senators – led by Sen. Dick Durbin (D-Ill.) introduced legislation in May that would somewhat ease it by raising the 16-bed limit to a 40-bed limit.

“By maximizing Medicaid coverage gains and offering treatment for people suffering from addiction – rather than simply arresting them or turning them away from help – we can reduce crime, save money, improve health, and save lives,” the senators wrote.



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