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John Corlett is president and executive director of The Center for Community Solutions.  Guest columnist John Corlett is president and executive director for The Center for Community Solutions, a non-profit, non-partisan think tank.  Ohio Governor...

Ohio has opportunity to remove barrier to addiction treatment: John Corlett, The Center for Community Solutions

John Corlett is president and executive director of The Center for Community Solutions.  Guest columnist John Corlett is president and executive director for The Center for Community Solutions, a non-profit, non-partisan think tank.  Ohio Governor...

Ohio has opportunity to remove barrier to addiction treatment: John Corlett, The Center for Community Solutions
John Corlett is president and executive director of The Center for Community Solutions. 

Guest columnist John Corlett is president and executive director for The Center for Community Solutions, a non-profit, non-partisan think tank.

 Ohio Governor John Kasich has said frequently that among those Ohioans benefiting most from Medicaid expansion in Ohio were those with a severe and persistent mental illness and or an addiction.  During a Republican presidential debate last October, he told Fox News' Megyn Kelly, "I had the opportunity to bring resources back to Ohio. To do what? To treat the mentally ill."

By most accounts, Ohio's Medicaid expansion has made a tremendous difference in the lives of those battling mental illness and or addiction.  But a 50-year-old federal law, the Medical Institutions for Mental Disease (IMD) exclusion, has created a barrier to Ohio and other states wishing to provide short-term inpatient treatment via Medicaid, particularly for those battling substance abuse. The law prevents state Medicaid programs from paying for services provided to someone between the ages of 21 and 65 who is a patient in a behavioral health facility that has more than 16 beds. When the law was enacted, it reflected a long history of federal policy makers viewing the care of persons with mental illness as a state responsibility, and a preference for community‐based care over large institutions.

But now most concede it has created substantial obstacles for inpatient treatment, particularly for those with an addiction. Nowhere is this more apparent than the public health emergency created by the scourge of heroin and fentanyl, which is killing Cuyahoga County residents at a record pace this year

Early in April, drug overdoses resulted in 12 deaths in less than a week. Tom Gilson, Cuyahoga County's Medical Examiner, recently stated, "We have never seen anything comparable to what we're seeing now in this locale and in this country in general. It's truly an epidemic of enormous proportions." Law enforcement, judges, physicians, and treatment professionals have all identified the lack of treatment as a major contributor to the epidemic.

Tracy Plouck, director of Ohio's Department of Mental Health and Addiction Services, has said that 72 percent of Ohio's addiction and treatment beds are ineligible for Medicaid reimbursement because of the IMD exclusion rule.  She has been a national leader in the effort to repeal and/or modify the rule, and has had the support of Ohio's Medicaid Director John McCarthy. Despite the efforts of Plouck and others, Congress has not acted to repeal the law. A significant barrier to full repeal of the IMD exclusion has been the cost to the federal government, which the Congressional Budget Office has estimated to be anywhere between $40 billion and $80 billion annually.

But a partial solution is buried among 1,425 pages of final Medicaid Managed Care rules just released by the U.S. Centers for Medicare and Medicaid Services (CMS). Under these new rules, state Medicaid programs would be allowed to pay the cost, via their managed care contracts, of short-term stays in hospitals or sub‐acute facilities providing psychiatric or substance abuse treatment for less than 15 days a month or up to 28 consecutive days if spread over two months. Sara Rosenbaum, J.D., Chair of the Department of Health Policy at George Washington University School of Public Health and Health Services, has written that this provision could help address what she called "widespread reports of shortages in short-term inpatient mental health and substance use disorder treatment."

When the new rules go into effect in June, attention will turn to the Ohio Department of Medicaid as they seek to understand the new rules and determine whether and how to implement them in Ohio. The State will want to be careful that it doesn't create an incentive for institutional treatment when community-based treatment might suffice or be better for the patient.

Also, any changes will occur against a backdrop of numerous pending changes in how Ohio Medicaid pays for and provides behavioral health services. While it is likely that it will take time for these new rules to translate into increased availability of short-term behavioral health treatment, the need for fast action couldn't be clearer. Hundreds, if not thousands, of Ohioans are waiting for inpatient substance abuse treatment. And if they don't get it, they very well may end up dead.

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