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In New Jersey, Governor Chris Christie has proudly spoken of his support for mandatory drug treatment for first-time arrestees, and that drug addiction, as a disease, should be given medical attention, not punished. But Christie has also come under attack for opposing the construction of state-supported drug treatment centers in the Garden State. In 2013, only 10 percent of people seeking drug treatment in New Jersey could be accommodated. The statistic speaks to the current state of New Jersey’s substance abuse and mental health treatment industry, and it’s a big problem faced by a number of other states across the country.1
MSNBC explains the worrying reality: As a matter of routine, people across the United State are denied access to mental health facilities because of a lack of beds.
On a nationwide level, hospitals have institutionalized fewer patients for mental health treatment, which, combined with the ever-present threat (and occasional reality) of budget cuts, means that the number of psychiatric beds available has been on a slow decline. This is the result of a decades-long trend of moving away from state-funded psychiatric wards and toward community-based, privatized, outpatient care models. Notwithstanding the logic behind the shift, critics have claimed that not enough has been done to fill in the resultant void. The American Hospital Association reports that over half of the counties in the United States do not have practicing psychiatrists, psychologists, or social workers. The AHA further discovered that only 27 percent of community hospitals have organized, inpatient psychiatric units.
Out in the countryside, the situation is even more dire. Patients living in rural areas have to travel long distances to get help, and emergency services cannot easily get to patients who live far away from highways and urban infrastructure.
Only 27% of community hospitals have organized, inpatient psychiatric units.
The American Hospital Association estimates that there has been a 13 percent drop in the number of hospital beds in standalone psychiatric hospitals between 2002 and 2011.2
A big reason for scaling back hospital beds during that time period was because of the 2008 recession. When Chris Christie launched his presidential campaign in June 2015, CNN reported that unlike its neighbors, New Jersey was yet to shrug off the economic ruin of the recession and recover the jobs it lost.3
Christie took office as governor of New Jersey in January 2010, and in an attempt to jumpstart his state’s flagging economy, he cut government spending for social programs. The goal was to avoid raising taxes, but his $32.9 billion budget plan unveiled in 2013 had no provisions for expanding a program that would give judges the authority to legally send severely mentally ill patients to treatment, despite a spokesman saying Governor Christie was completely committed to the program. Many people in the New Jersey were surprised that Christie allocated nothing to expand the outpatient commitment program, despite marking $12.8 million for other treatment and housing programs for those with mental health needs.4
In November 2013, NorthJersey.com wrote in detail about the shortage of facilities and resources available to people and their families in desperate need of treatment. One such story was about a 24-year-old woman from Woodcliff Lake in Bergen County, who was driven around by her parents for hours as they searched for a treatment center that could admit her.5
There are many cracks in the state of New Jersey’s substance abuse and mental health treatment industry, and the young woman fell through one of them. Her parents’ insurance programs refused to cover the medical detox process in an emergency room, and rehabilitation centers would not work with her until she had been detoxed. The detox facilities that could be found had waitlists that lasted for days. One hospital in Summit had “hallways full of addicts,” in various throes of withdrawal, forced to wait for beds and for insurance applications to be cleared. The young woman’s father was told that if he paid in cash, his daughter might get a room the following morning.
New Jersey has not been immune to the opioid epidemic that has devastated middleclass and suburban communities across the country. At least 33 percent of those struggling with addiction in the Garden State are denied access to treatment resources that could save their lives. In 2009, treatment facilities had to turn away at least 30,000 adults and 15,000 adolescents due to a shortage of resources, as well as high costs and insurance obstacles.
Those who do receive treatment rotate through emergency rooms and rehab programs, unable to receive a full course of treatment due to insurance limitations, not having enough money on hand, or being turned out because of relapse. NorthJersey.com writes that even the best insurance plans do not cover impatient stays for more than 14 days. Families are left with the choice of paying upwards of tens of thousands of dollars themselves (on treatment, but also travel expenses) or pulling their loved one out of treatment.
Treatment facilities had to turn away at least 30,000 adults and 15,000 adolescents…
The National Council on Alcoholism and Drug Dependence attributed the treatment shortfall in New Jersey to insufficient funding and insufficient beds. This comes at a time when the abuse of heroin and prescription painkillers is at record highs. From 2008 to 2013, the number of behavioral health concerns (as a result of substance abuse) that have led to emergency room visits has doubled, and hundreds of people have died as a result of overdoses.
The National Council on Alcoholism and Drug Dependence attributed the treatment shortfall in New Jersey to insufficient funding and insufficient beds.
The federal government has mobilized, with the Affordable Care Act making substance abuse treatment available to more low-income and middle class people. Regulations require insurance companies to give care for substance abuse and mental health the same level of coverage that surgical and medical health concerns receive.
NorthJersey.com explains that middleclass families may have to bear the biggest cost of addiction treatment. On the one hand, this demographic does not qualify for public services that cover the uninsured; on the other, most families can’t afford to pay $1,000 a week out of pocket for private inpatient care.
But many of those changes will not see the light of day until the end of the decade – if they ever see the light of day at all. And even if the plans go through, many people will still struggle to qualify. Care plans managed by Medicaid will not accept the regulations put forward by the Obama administration, and the bureaucratic confusion will likely cause even more delays and setbacks for families looking to get their loved ones treated.
Most families can’t afford to pay $1,000 a week out of pocket…
One woman from Jefferson, New Jersey, explains that after three years of trying to keep her son off heroin, she is $90,000 in debt. Finding an available treatment bed was “almost impossible,” she said; and when she did find one, insurance rarely covered it.
The system, says NorthJersey.com, is broken, and it makes the tough situation of addiction even worse. But there are positive signs: Many treatment programs work, and a number of addicts are now sober. Bergen County public service officials try and secure beds for those in need. Recognizing the scope of the problem, state officials are coming together to combat the opioid epidemic.
There are reasons for cautious optimism; however, families are fighting an uphill battle. Fewer New Jersey hospitals offer detox treatment that people struggling with addiction need to start their recovery. Bergen Regional Medical Center’s 54 beds are almost always occupied, and the hospital sees as many as 18 new patients every day. Between 2007 and 2012, New Jersey emergency rooms experienced an 80 percent increase in the number of behavioral health cases, with substance abuse as a “major contributor” to that figure, according to the New Jersey Hospital Association.
But emergency rooms are forced to do little more than simply stabilize patients and release them, even though further treatment is urgently needed. Across the state, long-term inpatient and outpatient treatment programs cannot take patients who receive such little treatment.
Bergen Regional Medical Center’s 54 beds are almost always occupied, and the hospital sees as many as 18 new patients every day.
The coordinator of the Bergen County Office of Alcohol and Drug Dependency lamented that parents have to resort to driving for hours, going from one treatment center to another, desperately trying to find one that can take their child.
Given the numbers, it’s not surprising that many can’t. Between July 2012 and July 2013, state-licensed treatment centers took in nearly 85,000 patients, almost half of whom needed help for heroin and prescription painkiller addictions, more than any other drug.
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Chris Christie won plaudits for expanding New Jersey’s drug court program, which puts qualifying drug offenders through treatment, not prison. It’s a system praised by politicians and drug advocates, but it also sends increasing numbers of people to mandatory care programs, which in turn puts a heavier burden on treatment centers that receive public funding. There is speculation that the 102 state treatment facilities in New Jersey may be at a bursting point.
There is speculation that the 102 state treatment facilities in New Jersey may be at a bursting point.
A large part of the problem stems from the sensitive and delicate nature of addiction. Substance abuse and mental health are still poorly understood, with many in the public and private sector believing that addiction is a moral failing, not a medical concern. Issues of treatment are often mishandled by politicians and legislatures who are more concerned with the political implications of wading into the subject (such as the overlap between mental health and gun violence, a topic Christie addressed as part of his presidential campaign, or the cross-section between addiction and race).
For insurance companies, it tends to be a question about the bottom line. Speaking to NorthJersey.com, a spokeswoman for Aetna explained that her company prefers when patients are rehabilitated in an environment that is most like the situation in which the patient lives. The coverage Aetna provides will be geared toward ensuring that a patient will go home or into a community-based treatment program.
While that approach is not without logic, it is at odds with the advice of addiction experts and treatment programs themselves, which insist that removing addicts from their environment – not sending them back to the same places and people that might have contributed to their addiction – is the kind of long-term treatment that is required. One father recounted how a rehab center told him that his daughter needed long-term residential care, but his insurance program would only cover intensive outpatient care.
The father said that insurance companies do their best to “get people out of rehabilitation as soon as possible,” so much so that his daughter overdosed 24 hours after her discharge. In 2013 alone, Ocean County recorded almost 100 deaths related to heroin and prescription medication overdoses.
NJ.com writes than when a client gets one of the few thousand licensed substance abuse treatment beds (whether for a short-term or long-term inpatient stay), that client has won the “addicts’ lottery.” For tens of thousands of other people, it may be easier to win the national lottery. A 2013 report by the Substance Abuse and Mental Health Services Administration found that only 25 percent out of 179,000 people in New Jersey who were dependent on (or otherwise abused) illegal drugs received treatment.6… Only 25 percent out of 179,000 people in New Jersey who were dependent on (or otherwise abused) illegal drugs received treatment.
The director of admissions at a New Jersey-based treatment facility called the situation “woeful”; at his own facility, the waiting list for a bed has more than 300 names on it. What is widely considered the failure of local and state officials to keep up with the demand for treatment services had led to a situation where New Jersey can only treat a bare minimum of its residents who need mental health and substance abuse help.
Instead, patients and their families are put on hold for days or weeks until a bed opens up. But when struggling with a drug addiction, sometimes even a matter of days is too long to wait.
The last time New Jersey conducted an evaluation of its substance abuse and mental health treatment needs was in 2010. At the time, more than 31,000 people who needed access to treatment (approximately 37 percent of the total demand) could not get any help.
A professor and clinical social worker in addiction at Rutgers University tells NJ.com that navigating the insurance landscape for treatment is a “nightmare,” especially more so for people who don’t have insurance. Of the people who did receive substance abuse treatment in New Jersey in 2013, more than 60 percent did not.
Across the state, more and more people have been overdosing on heroin. In 2012, New Jersey’s 21 counties reported 591 deaths related to heroin, an increase from both 2011 and 2010. As of the date of the NJ.com story, 2013’s fatalities were on track to overtake those of 2012.
But even though there have been some encouraging responses to provide relief to New Jersey’s substance abuse and mental health treatment infrastructure, the goalposts keep getting moved. In January 2015, after a consultation with the New Jersey Department of Human Services, the Department of Health came to the decision that there were enough beds and services for psychiatric treatment to address the needs of the state. The DOH cancelled a previously issued call for applications from healthcare facilities, which would officially request services and resources that such facilities would need to operate (which would be the DOH’s task to regulate).
Without the applications, the hospitals and treatment centers would receive no additional assets to ease the burden of tens of thousands of people in desperate need of treatment. The move has prompted numbers of lawmakers across the state to ask why the Department of Health felt the need to tighten its belt. A spokesman for the DOH told the Courier-Post that the department would send a response to legislators.7
Through all the bureaucratic and legal wrangling, there still remains the human cost of the opioid epidemic and a paralyzed infrastructure. Business Insider writes of a young man from Blackwood, New Jersey, who was repeatedly rejected by treatment facilities because his insurance company refused to cover the expenses. In June 2010, the 26-year-old man went to an emergency room, but doctors turned him away, saying that since heroin withdrawal isn’t life-threatening, he could not be admitted. He was put on an IV to clean out his system, and then sent home.8
It took a lie – his sister saying that her brother was withdrawing from alcohol – that finally got the young man into treatment. Unlike heroin withdrawal, alcohol withdrawal can cause deadly seizures. The deception triggered the right red flags for an emergency admission, but treatment lasted only 17 days, at which point the funding from Camden County ran out. Three months later, the man was dead.
Heroin withdrawal is a traumatic and painful experience, but it is not directly deadly. For that reason, most insurance companies will not cover inpatient heroin detox or rehabilitation, saying that the treatment is not medically necessary (suggesting that inpatient care would be excessive), or that the client needs to relapse after outpatient rehab, in order to qualify for inpatient treatment.
As mentioned above, insurance companies favor home-based rehab, as this requires them to cover less expenses. Such a preference entails setting dangerous and impossible hoops for clients to jump through, like requiring a relapse before accepting an inpatient treatment claim.
A spokeswoman for America’s Health Insurance Plans (the national trade association that represents the health insurance industry) defended the reasoning, telling the Associated Press that the system exists because of “evidence-based standards of care” that have three criteria:
Similarly, the story of a man who eventually qualified for Medicaid (because treatment costs bankrupted his family), but was denied inpatient treatment coverage by the Medicaid-managed care company, Fidelis, illustrates the quagmire that clients and their families find themselves in, when substance abuse/mental health and the insurance industries collide.
In the legal process of the suit filed against the company by the man’s mother, Fidelis’s guidelines regarding “medical necessity” showed that the woman’s son met the criteria: risk of severe withdrawal, substantial risk of physical harm, etc. However, since the man was not suicidal, homicidal, or showing signs of psychosis, mania, or delusions, the law found in favor of Fidelis.
The company’s chief medical officer issued a statement that explained his organization’s decisions about substance abuse treatment are based on standards of care set out by state and national governments. “Denial of a specific level of care,” he wrote, “does not mean that no treatment is necessary.”
In this way, the insurance industry acknowledges that there is a serious problem with opioid abuse in New Jersey, but it also distances itself from paying more for it than it absolutely has to. Parents and families are thus left with little recourse but to pay out of their own pocket, or drive hundreds of miles, for hours on end, to find a facility that has a bed for their loved one.