Do you have any idea how hard it is to deal with addiction and get treatment in America? I have gold plated insurance, am comfortably middle class, and I have been going through sheer hell trying to get into a facility. It’s almost like you have to show up with a syringe full of heroin dangling from your arm and a crack pipe in your mouth to get anyone to take you seriously…
Why is this so fucking hard? Am I just incompetent or is it this fucking bad everywhere?…Why is it that getting into rehab requires a fucking PhD in bullshit and the equivalent of a tax attorney’s knowledge of procedure? Isn’t getting clean tough enough? Jeebus
There are a couple of things in play. The first and biggest reason why JC is getting fucked over hard right now is that there are nowhere near enough rehab beds in this country. Most of this is historical in two aspects.
The first is that addictive diseases are now seen as medical issues with significant mental health components. Any other physical health problem would see it treated and paid for as a physical health problem. However diseases of addiction were long seen to be either mental health problems with minimally related physical health problems, or solely a matter of someone needing to sack up. That was the attitude when health insurance started to propogate. Early health insurance had minimal to no mental health coverage, and over the course of the past sixty years, mental health coverage was both slowly added to coverage and poorly paid.
The big policy change on this matter was the 2008 Mental Health Parity and Addiction Equity Act. This act required policies that cover groups of more than fifty (50) people to pay for mental health and recovery services at the same benefit level and same accessibility standards as any other physical health act. A side effect of the act is that providers in this field are slowly starting to see their commercial rates rise. Over the long term, this should mean more beds will be available. PPACA has a couple of policy changes that will decrease the degree of fucking over as well.
The other major policy driving that contributed to John being fucked over this year is the Medicaid Institutions for Mental Diseases exclusion policy:
The IMD exclusion is found in section 1905(a)(B) of the Social Security Act, which prohibits “payments with respect to care or services for any individual who has not attained 65 years of age and who is a patient in an institution for mental diseases” except for “inpatient psychiatric hospital services for individuals under age 21.” The law goes on to define “institutions for mental diseases” as any “hospital, nursing facility, or other institution of more than 16 beds [my emphasis], that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.” The IMD exclusion was intended to ensure that states, rather than the federal government, would have principal responsibility for funding inpatient psychiatric services.
Medicaid is one of the major payers for mental health services in this country. They don’t get to set policy for facilities that don’t bill Medicaid, but there are very few facilities (excluding celebrity rehab spas) that can’t afford to not bill Medicaid. This policy was designed to keep states from closing their state hospitals and long term mental health care facilities and dumping those people onto the Federally paid for portion of Medicaid. The side effect is the facilities that are out there are artificially limited to sixteen beds or less. There are a couple of work-arounds (mainly defining how multiple 16 bed pods are seperate facilities) but there are significant limitations on facilities.
So to recap; in patient rehabilitation and detox services have historically been seen as mental health services which means sporadic coverage at low rates. That is slowly changing. And those providers which do rehab and detox are limited to small facilities. More people have access to these services without supply increasing. And since John is usually a a functional individual on most measures (excluding mopping), he does not need emergency admittance, so he is getting fucked because there are nowhere near enough beds to help the people who need help but can get by at a lower quality of health and living without the service.