There’s long been an imbalance in the number of Montanans who need help beating alcoholism and drug abuse and the amount of treatment programs available.
Lately, those consequences are showing up in the state’s foster care system. The number of children needing care due to drug use problems in their parents has doubled since 2010, and the number of babies born drug-affected has tripled since then.
Those numbers are from a new report by the Montana Healthcare Foundation, which also says the state now has a golden opportunity to dramatically increase the availability of drug and alcohol treatment services.
I talked about that with the foundation’s CEO, Dr. Aaron Wernham.
Dr. Aaron Wernham: Right now our treatment system is really not meeting the need, so we did this report because we see a huge opportunity to strengthen the state's prevention and treatment of substance abuse, and we think that'll be one of the most cost effective health interventions we could invest in
Eric Whitney: Can you give me a thumbnail to convince me that this really is a big problem?
AW: Right now we know that only about 7 percent of people in Montana that have a diagnosable problem with addiction are getting treatment, and the health department estimates that somewhere around 4,000 people are out there actively seeking treatment without being able to get in.
There are acutually only two facilities in the state that offer an services for pregnant women or young parents. It's clear there's a lot of unmet need.
EW: It seems like that imbalance has been around for a while. Why is that?
AW: Substance abuse has really been treated very differently than any other medical problem, for a long time in this state. We've funded most of the treatment that's available through a federal block grant, and then through some general fund and alcohol tax dollars. So the budget has been fixed at a specific level, and only state approved treatment facilities, of which there are 32, have really received that funding. Now, with the Medicaid expansion, there's an opportunity for any health care provider that has the skills to begin providing substance abuse treatment.
Another way of looking at this is, right now, we're spending money right out of the general fund to provide treatment services. With Medicaid expansion that allows us to basically bring in $9 of Medicaid funding for every $1 of general fund that we spend.
EW: Money that the state has been spending on treatment services can now be billed to Medicaid, so the state will save that money? Do I have that right? And what happens to that money?
AW: What happens to the money will be a question for the state to resolve, but it is resulting in savings already, even in the first year of the expansion. And we'd expect the savings to accellerate if Medicaid expansion remains in place. Those savings could be re-purposed, for example, to strengthen prevention or peer support programs that are shown to be effective and also cost effective. It could also be used to fund other state needs.
EW: I guess any savings the state recognizes by having Medicaid pay for substance abuse services, you would argue that any of those state savings should be re-invested into prevention or treatment for substance abuse?
AW: I think the way we would look at that is, there are many needs in the state, and it's really up to the legislature and the health department to decide where the need is greatest. I think we would certainly advocate for strengthening prevention. Not enough is invested on the prevention side, and we know that dollars that are invested in prevention tend to yield cost savings in terms of reduced police costs, reduced recidivism and reduced health care costs.
EW: In terms of how the Medicaid expansion is helping with Montana's substance abuse treatment problems, there's really only six months worth of data at this point on how this new source of funding is impacting things?
AW: We are seeing already some practices beginning to expand their services to include substance abuse treatment. That's already a very early sign that this is resulting directly in increased access. We'll certainly have to wait longer to see just how much impact Medicaid expansion would have on access, and then, in turn, what sort of outcomes we're seeing. That may take a couple of years.
EW: Do you have an estimate for how much additional money this Medicaid expansion will bring in to fund treatment services in Montana, and is that enough to increase the supply enough to meet the need?
AW: I think it's probably too early to tell where things would level out. I think that in fiscal year 2016 we saw about $4.3 million of federal and state Medicaid spending on substance abuse, and that was a big increase from prior years. But I suspect that Medicaid spending will continue to grow as a proportion of what the state spends on substance abuse treatment.
EW: I think when people think about substance abuse treatment, they think of maybe a stand-alone sort of recovery or addiction treatment center. That many not be the best way for these dollars to be invested?
AW: Our stand-alone treatment centers have been a lifeline for people with addictions for decades, and continue to be the backbone of the current system. But we are increasingly seeing primary care practices, community health centers, tribal health centers, taking up substance abuse as really a part of what happens in a primary care office, and I think that's the direction I would expect and hope we'd see the state go with Medicaid expansion. And then if you need referrals for more serious or in-depth treatment, that's where the specialty centers would come in.
EW: If patients are starting to show up at these primary care practices or clinics with Medicaid benefits, are those benefits they're bringing with them enough to allow clinics to hire additional staff to meet the treatment needs?
AW: So, we do think that the business model will work for many health care providers. Every practice is going to have to make that calculation for themselves. Historically there's been a lot of uncompensated care in the ERs of our rural hospitals,and many times the people who are coming in the most frequently are people with an underlying, un-diagnosed mental illness or substance use disorder. And now that we have some resources, we should be looking at: How do we treat that problem, and then maybe that'll help the person's asthma or diabetes get in better control so they're not in the ER all the time. Ultimately that's going to save a lot of cost as well.
EW: What do you think the significant barriers are to this opportunity reaching it's full potential?
AW: Montana's a big state, there's a lot of rural communities that struggle to recruit and retain health care providers, and this is not going to necessarily going to be a rapid fix, just because we now have more people with health coverage. It's going to take a thoughtful approach, where each community is going to decide for itself who's in the best position here to begin enhancing the services we have. How do we preserve the strengths of the current treatment facilities at the same time as being able to add some providers that can be on the front line and begin to address this problem more effectively.
And, for each community, developing the business model that's going to work and sustain these services is going to take some time.
EW: Do you have a sense that at this point there are some, many, a lot of Montanans out there who have these new Medicaid benefits, and they want to go get treatment services, but they can't find someone who can go do that for them?
AW: That is our impression. The 4,000 people seeking treatment number that we have in this report is a very rough estimate. When we talk to critical access hospitals and rural hospitals around the state, many of them will list substance abuse as issue number one or number two for their communities, in terms of the challenges that they face.
I think that what's happening is, because people aren't able to get into treatment, the next step often ends up being in an encounter with law enforcement, and when you talk to law enforcement, they're often saying, we don't have anywhere to get people who want to have treatment either.
EW: If politically the powers that be decide that the Medicaid expansion goes away, what will that mean in terms of Montana's ability to respond to its residents' needs for drug and alcohol treatment services?
AW: Just in the first year of Montana's Medicaid expansion we saw 70,000 people gain coverage, and people already beginning to be able to use Medicaid to pay for substance abuse treatment. I expect that if Medicaid expansion is reversed that we would see access going back to much closer to our current baseline, which I think everybody agrees has not been adequate for this problem.