Cook County's early experiment with Obamacare through its waiver-based "CountyCare" Medicaid program has been faltering in the delivery of a key benefit - substance abuse treatment.
The problem has prompted State Rep. Greg Harris (D-Chicago) and the Illinois Division of Alcohol and Substance Abuse to intervene to provide a solution.
Part of the dilemma has been an old Medicaid law clashing with the new.
Because of an oversight in the newly minted Affordable Care Act, those who require a residential stay as part of their substance abuse recovery are unable to use the vast majority of Illinois drug treatment residential programs which have 17 beds or more because they are prohibited from being Medicaid certified due to an older Medicaid law.
Years ago, the federal Medicaid program sought to prevent the warehousing of individuals who were struggling with drug and alcohol abuse in large residential facilities, limiting facility certification to 16 beds or less. But the architects of Obamacare failed to reconcile the new benefit with the old law.
So what does that mean?
Recently, an unemployed, homeless man who was living in a Chicago homeless shelter managed, through the help of a friend, to present himself at a suburban Cook County drug treatment agency, pleading for help to overcome his alcohol abuse. The assessment revealed that he needed residential treatment due to the severity of his condition.
The response from CountyCare's HMO provider? Denied.
The individual was denied because the residential program was not - and could not be - Medicaid certified because it has more than 17 beds.
Additionally, the man, struggling on his own to overcome his alcoholism, had taken no alcoholic drink in two days, and that presented a problem. The substance abuse treatment provider was told by the County's HMO, PsychHealth, that the client needed to fail first in outpatient care - he had to resume drinking - before a form residential treatment became a viable option.
The man complied. He began drinking again, leading the HMO to hospitalize him in a medical detox - a vastly more expensive option than residential treatment. And ACA picked up the bill.
Before CountyCare, this man would have received the less costly clinical detox in the provider agency's residential program for men under its contract with the Illinois Division of Alcohol and Substance Abuse.
When Harris, Chair of the House Human Services Appropriations Committee, learned of this problem in July, he flew to the phones within, literally, hours and contacted state officials to find a solution that would keep the County's health plan from floundering over a key benefit.
Complaints from substance abuse treatment providers and advocates about CountyCare had been already filtering back to Dr. Theodora Binion, the Director of the Illinois Division of Alcoholism and Substance Abuse who initiated contact with Cook County officials to sort out the mess.
One strategy that surfaced in the state and county meetings included seeking a federal Medicaid waiver to allow the State to obtain matching funds for different types of supportive and recovery housing.
The problem with a waiver strategy, according to Harris, is time.
"A waiver is a big deal. The state has to produce a lot of research to justify it. That takes a lot of time," said Harris, who has stayed on top of the issue through the summer.
While keeping a federal waiver option on the table to address other weaknesses in CountyCare, Binion, County officials, and HMO provider PyschHealth in the meantime have reached an agreement to provide funding for substance abuse treatment room-and-board costs to overcome the problems blocking time-sensitive care, Harris said.
"An agreement has been reached to cover room-and-board costs for people who are Medicaid clients and are being treated for substance abuse disorders," said Harris. "They are finalizing details on how to provide services and room-and-board costs also for those newly eligible Medicaid clients pending their final eligibility determination as well."
"It's tremendous that Rep. Harris and Dr. Binion got the room-and-board piece fixed," said Illinois Alcoholism and Drug Dependence Association CEO Sara Moscato Howe whose group has been working behind the scenes on the issue. "However, what is key is that the HMO must actually approve the service. Without patients in the beds, the room-and-board becomes a non-issue."
Nevertheless, Harris and Binion have, for now, secured a deal with the County to get cost-effective residential treatment, a key Obamacare benefit, back on track.
Both state officials deserve heaps of praise.