Can Montana get a grip on addiction?

By Mara Silvers | Montana Free Press

In late January, when Mary Windecker got up to testify in front of the budget committee considering how to fund Montana’s addiction and mental health treatment programs, her words cut through a typically bureaucratic proceeding to present an uncomfortable bottom line.

“You’re all familiar now with some of the statistics across the state,” she said. “Montana scores at the highest of every indicator we don’t want to be in.”

Windecker, director of the nonprofit Behavioral Health Alliance of Montana, was talking about the state’s suicide rates. And the percentage of children who are removed from their homes because of a parent’s alcohol or drug use. She was also talking about the disturbing spike in meth related crimes in recent years.

During that same period, Windecker noted, the state’s reimbursement rates for health care providers have remained low, and reliable access to treatment has suffered from past budget cuts. She urged lawmakers to help change these trends, partly by supporting Gov. Greg Gianforte’s $23.5 million plan to expand substance treatment and prevention programs across the state.

“We will be remiss if we miss this opportunity in the next four years to really fill in the continuum [of care] and address these stats where we are so high,” Windecker said.

While Montana’s Medicaid expansion has increased access to health care for roughly 90,000 residents and helped create a reliable payment model for providers, administrators and policy experts continue to point out gaps in care for substance use disorders, ranging from prevention programs to crisis intervention and rehabilitation. The Gianforte administration has indicated that mending that patchwork system is a priority, characterizing the drug problem as an epidemic that is “tearing apart” Montana families and communities.

“There are devastating consequences to this crisis,” Gianforte said in his recent State of the State address. “Our treatment facilities are filling up, some unable to take new patients. Our corrections institutions are filling up with people, who, after losing a battle against addiction, resort to increasingly violent crimes … Our schools see our young people drop out as addiction overtakes them. Addiction leaves them falling farther and farther behind in their education and farther off the path to a better life.”

Windecker isn’t alone among treatment providers in urging lawmakers to support the portion of Gianforte’s budget proposal known as the HEART Fund. The plan would use $7 million annually in special revenue sources, including marijuana tax and tobacco settlement funds, to leverage about $18 million in federal Medicaid reimbursement for specific substance use prevention and treatment programs. In testimony to the state Legislature and interviews with Montana Free Press, several behavioral health advocates and policy experts who reviewed the proposal agreed it could fill crucial gaps in Montana.

Details of the plan’s programs, which would be administered by the Department of Public Health and Human Services, have yet to be spelled out through legislation. And, despite the widely positive reaction to Gianforte’s vision, the success of the proposal depends on many factors that remain in flux. For instance, the governor’s budget does not include a proposal to increase reimbursement rates for behavioral health providers, which some critics say could hamstring his pledge to provide more services at all.

Additionally, securing a DPHHS budget adequate to maintain existing benefits and treatment programs for a growing Medicaid caseload is not guaranteed. In January, the Joint Subcommittee on Health and Human Services agreed to a “starting point” for the DPHHS budget that was substantially lower than Gianforte’s proposal. While some lawmakers explained the maneuver as a responsible way to examine how taxpayer dollars are distributed, opponents on the committee and from health care organizations characterized the lower starting point as the beginning of an arduous negotiation to build critical services back into the budget.

“We want to urge this subcommittee to really support and think through restoring this budget … back to the governor’s [proposed] budget,” said Stacey Anderson, policy director for the Montana Primary Care Association, in public testimony. “We also want to urge the support for the HEART initiative. Certainly increasing services on the [substance use disorder] side and the mental health side is going to be critical for Montana to continue to make improvements in those areas.”

THE SCOPE OF THE PROBLEM

Roughly 22,000 people go to Montana hospitals or emergency rooms every year because of drugs and alcohol. According to recent federal data, an estimated 90,000 teens and adults in Montana have a substance use disorder. In line with national averages, more than 90% of Montanans with alcohol and drug use disorders do not receive treatment.

Addiction is central to the struggle of many overloaded social systems, including courts, jails and prisons and child welfare management. Many officials and representatives of those sectors readily agree that addressing the seismic issue of drug and alcohol use in Montana, particularly methamphetamine, should be a priority.

“The one thing that [parental custody] determination cases have in common almost universally is meth use,” said Montana Supreme Court Chief Justice Mike McGrath during a separate legislative budget hearing earlier this year. “With meth what we find … 90% plus of the cases that we have on these child abuse and neglect terminations involve methamphetamine. And most of the time, both parents are addicted. The entire family often is addicted. The kids will be born with meth in their system.”

The perennial challenge, according to public health experts and service providers, is how to change those trends within an overburdened and sometimes fragmented treatment landscape. The state currently operates three facilities with a limited number of beds for adults with severe mental health issues and substance use disorders, including the Montana Chemical Dependency Center in Butte, and contracts for services with more providers around the state. But behavioral health experts indicate that many people at risk of or experiencing substance use disorders stand to benefit most from early intervention and treatment at the community level — services that have historically been funded in part through a federal block grant.

“Prior to Medicaid expansion, people often couldn’t get treatment, and because many services were funded through the block grant, the money simply ran out,” said Zoe Barnard, administrator for DPHHS’ Addictive and Mental Disorders Division in a recent presentation to lawmakers. “When people can’t get treatment, they end up in crisis or in trouble.”

Medicaid expansion has helped stretch the availability of behavioral health services across the state, Barnard explained. By making it possible for more providers to bill Medicaid for the treatments they administer, the dollars from federal block grants, as well as from alcohol and tobacco taxes, go further to help fund prevention and treatment at a local level. Since 2015, Barnard’s division calculates, nearly 100,000 Montana Medicaid recipients have received treatment for mental illnesses or substance use disorders, the vast majority of whom have been enrolled under Medicaid expansion.

If used strategically, advocates say, Medicaid expansion can be an even more impactful tool for supercharging the state’s investment in prevention and treatment, eventually supplying Montanans with essential services.

“There certainly still aren’t enough intensive outpatient or residential treatment beds for people who are further along the spectrum,” said Aaron Wernham, executive director of the Montana Health Care Foundation. The state could also be doing more, he said, to incentivize primary care providers to screen for substance use disorders and offer early intervention to prevent a crisis before it happens.

Some of these solutions are what the Gianforte administration hopes to jump start through the HEART Fund, Wernham explained, largely by taking advantage of options available through the Medicaid system.

A NEW PROPOSAL

Montana’s network of substance use prevention and treatment is currently funded by a combination of federal block grants, alcohol and tobacco tax revenue and Medicaid. The HEART plan would use specific revenue streams to leverage Medicaid funding for newly eligible services. (For programs under both standard Medicaid and Medicaid expansion, the federal government provides an improved match on the dollars invested by a state. That calculation effectively boosts the amount of state and federal funds available for Medicaid-eligible services.)

The state plans to tailor what kinds of treatment are reimbursable through Medicaid by applying for waivers from the federal Centers for Medicaid and Medicare Services. That approach, as opposed to amending the state’s available benefits package for all Medicaid recipients, allows states to control costs by targeting specific populations that may benefit from discrete programs. Those new waivers, according to officials from DPHHS and the governor’s office, can allow providers to bill Medicaid for crucial services, including crisis intervention for methamphetamine and certain kinds of intensive outpatient care. By funneling Medicaid dollars to fill different parts of the spectrum of care, Montana’s traditional resources, such as federal block grants and alcohol tax revenue, could be repurposed to address additional needs.

“HEART funding would simply augment and expand existing funding to more fully address substance abuse disorders in our communities,” wrote state Budget Director Kurt Alme in response to emailed questions about the proposal. “As an example, there will be more block grant funding available to communities for prevention because some of the services that are currently funded by block grant will become Montana Medicaid Services.”

DPHHS officials told MTFP the department does not have a set date for when it plans to submit its waiver proposal to the federal government, and did not say how long the review and approval of that submission might take. Until that point, the state could theoretically move forward with other plans for expanding prevention and treatment, depending on how lawmakers allocate funding during the legislative session. Some of the non-Medicaid components included in the HEART Fund, according to DPHHS, include community-based prevention programs, jail-based treatment, and a pilot project to implement “regional crisis hubs” for substance use intervention.

In addition to submitting a waiver to the federal Medicaid system, the HEART Fund plans to tap new sources of special revenue — specifically taxes raised from adult-use marijuana and a recent tobacco settlement — to support prevention and treatment programs. Those changes in funding do need to be secured through new legislation, partly to move marijuana revenues away from conservation, as was outlined by the ballot initiative voters approved in November. Rep. Llew Jones, R-Conrad, chair of the House Appropriations Committee, told reporters in January that a ballot initiative is no guarantee of how the Legislature will decide to allocate funding.

Forthcoming legislation will also provide more details as to how specific HEART Fund programs would be structured and implemented. Representatives for DPHHS and the governor’s budget office told lawmakers on the appropriations subcommittee that those bills are being drafted and have not yet been assigned to a sponsor.

RECEPTION FROM LAWMAKERS

Members of the Joint Subcommittee on Health and Human Services have not yet issued recommendations as to how the holistic budget for the Department of Public Health and Human Services should be funded, or whether the new HEART Fund proposals from the governor’s office should be approved. Some lawmakers, however, have said they see the proposal as a potentially promising way to tackle an old problem.

“It’s definitely hopeful for me,” subcommittee member Rep. Frank Garner, R-Kalispell, said of the HEART Fund. Garner, a former law enforcement officer, said, “We’ve spent a lot of time trying to arrest our way out of this. Now I talk to my sons who are policemen who are arresting the sons of the men I was arresting before. And that to me is a pretty stark message about how people end up in the circumstances they do. I think we have to look for new alternatives. And I think one of those is to treat the underlying issues and put more resources toward it.”

Other behavioral health experts and some lawmakers have said that despite its promises of expanded treatment options, the governor’s budget does not go far enough to help the mental health and substance use treatment industry rebound after the substantial budget cuts of 2017. In the hearing for the Addictive and Mental Disorders Division before the budget subcommittee in late January, Rep. Mary Caferro, D-Helena, raised concerns that the governor’s plan would be ineffectual  without increasing Medicaid reimbursement rates for providers. In a competitive health care market, many advocates characterize Montana’s shortage of qualified behavioral health professionals as a problem inherently connected to the state’s low Medicaid rates. Without competitive reimbursement opportunities, industry representatives say, Montana may struggle to expand its workforce and provide adequate treatment programs for the state’s population.

“I’m curious how access will be maintained or increased when the budget does not call for any increase in Medicaid provider rates,” Caferro said. “What is the plan to actually be able to implement these programs when currently the situation doesn’t allow for [enough providers to meet] the need today?”

In response, a representative for DPHHS said the department is committed to promoting a “quality network” of service providers, regardless of whether rate increases are included in the next biennium’s budget.

Beyond the governor’s HEART proposal, it is unclear whether the subcommittee will agree to finance the complete requested budget of DPHHS’ Addictive and Mental Disorders Division, which includes a roughly 31% increase in spending for the next biennium, largely in federal Medicaid funds. The division’s request includes a significant $122 million increase for anticipated benefits and claims to serve the state’s growing Medicaid caseload.

Barnard, the administrator for AMDD, said she considers the increases for existing services essential to the governor’s overall goal of improving substance use disorder treatment.

“To simply approve the HEART Fund without approving the other packages, the other Medicaid packages, won’t get us to where we need to get in order to effect a change,” Barnard said in a recent phone interview. “If you put more money in there just for the HEART Fund, but you don’t account for the caseload growth, we’re not going to be able to add new services.”

Other health policy experts agree that the HEART Fund, while promising, would be just one component necessary to strengthen Montana’s behavioral health infrastructure. Wernham, of the Montana Health Care Foundation, described the governor’s proposal as a way to ensure that, as with medical treatment for other diseases, there will be specific types of care in Montana for people with substance use disorders, no matter when they need treatment or where they are geographically. In essence, Wernham said, the HEART Fund could help Montana capitalize on the state’s decision to expand Medicaid six years ago.

“You wouldn’t look to Medicaid expansion and then hope two years later that substance use is no longer a problem in the state. Medicaid expanded and now we’re building the system that that allows,” Wernham said. “Even building the system of prevention and treatment is probably a five- to 10-year process. And then you hope that you’ll start to really be able to measure the improvement in disease outcomes for people … We’ve come a distance and we’ve got plenty further to go.”

The Montana Healthcare Foundation, whose executive director is quoted in this story, is a financial supporter of Montana Free Press