The country’s broadening crisis of heroin and pain pill overdoses comes at a time when many centers for addiction treatment in the United States are operating at capacity. In the St. Louis region, providers report wait times of three weeks or more. A spike in addictions means more people seeking treatment, but at the same time, providers are constricted in their ability to expand.
During a Tuesday hearing of the House Committee on Oversight and Government Reform, U.S. Rep. William Lacy Clay, D-University City, hit upon one federal rule that is at least partially to blame: a section of the Social Security Act restricting most in-patient mental health treatment programs that serve Medicaid patients to 16 beds.
“If you’re on Medicaid, you’re treated like a second-class citizen, unable to access what may be the appropriate care for your substance use disorder,” Clay said during a line of questioning with the Health Commissioner of Baltimore.
The rule, known as the IMD exclusion, has been a part of the Social Security Act since it was enacted in 1965. (IMD stands for Institutions for Mental Disease.) It prevents non-elderly adult patients with health insurance through Medicaid programs from receiving mental health care in a facility with more than 16 beds.
“I think a generous view is that [lawmakers] were concerned about just housing people like the old Victorian mental hospitals from the 19th century,” said Howard Weissman, the executive director of the St. Louis branch of the National Council on Alcoholism and Drug Abuse. “I think a slightly more cynical view is that people didn’t want large mental hospitals in their neighborhoods.”
The result, providers say, are fewer options for patients covered by Medicaid, who are almost entirely low-income, disabled or pregnant.
“I’ve never seen anything like this. It's way beyond anything I’ve ever had to deal with,” said Mike Morrison of Bridgeway Behavioral Health. He added that access to addiction treatment seemed more available even during the crack epidemic of the late 1980s.
“We are limited to 16 beds in our medical detox facility in the middle of a heroin crisis, when we get dozens of requests for help for detox every day. It’s tragic,” Morrison said.
A recent review of residential programs for behavioral health found that St. Louis-area providers accepting Medicaid patients shed 35 beds between 2007 and 2014, though the numbers are not available for programs dedicated solely to substance abuse. Heroin deaths in the area more than doubled in that same period.
Medical advances have allowed for more outpatient detox programs, Morrison said, but for many patients with co-occurring mental illnesses or challenging life circumstances, residential treatment is the best option.
In Weissman’s mind, the solution lies in the hands of Congress.
“It is, in my view, essential that the government does something to help local treatment facilities increase their capacity," he said. "Congress could fully repeal the IMD exclusion, but that’s a pretty big, dramatic thing. They could raise the bed limit above 16, or they could exclude substance abuse disorders from the definition of ‘mental disease.'"
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