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Op-Ed: Landmark Opioid Bill Feels Unfinished Without Full Repeal of IMD Exclusion

Restriction limits access for Medicaid enrollees to life-saving community-based treatment and recovery assistance

Robert J. Budsock
Robert J. Budsock

With overwhelming bipartisan support, both the U.S. Senate and House of Representatives recently passed legislation aimed at combating the devastating opioid epidemic that our country is currently facing — the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. The bill, a comprise agreed upon between the Senate and House, represents the most comprehensive action ever taken to fight the raging opioid epidemic. It is expected that the President will sign the final bill into law.

This is a landmark bill that combines a bill by the same name passed by the House in June, with the Senate’s recent Opioid Crisis Response Act (OCRA) of 2018.

The bill is aimed at helping individuals by providing recovery and treatment services while giving law enforcement agencies resources and funding needed to further fight the ongoing opioid epidemic. The passage of the bill shows that an overwhelming majority in both arms of Congress recognize the great challenge that we face in fighting the deadly epidemic. Significantly, this bill once and for all acknowledges substance use disorders as not a “moral failing,” but a chronic disease that requires ongoing and long-term support. The bill also expands essential programs designed to arm first responders with the overdose reversal agent, Narcan, as well as eliminates some of the red tape on who can prescribe medications to treat opioid addiction.

Severely limits treatment for Medicaid enrollees

Most notably, the bill lifts some of the strictest restrictions of the harmful and decades-old Medicaid Institutions for Mental Diseases (IMD) Exclusion. The Medicaid IMD exclusion currently blocks federal Medicaid financing for treatment provided to individuals in mental health and substance use disorder residential treatment facilities with over 16 beds — a restriction that severely limits established and proven community-based programs like Integrity House from serving so many of those in greatest need of community-based treatment and support.

The IMD exclusion 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.” Under the law, institutions for mental diseases are defined as any, “hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases…”

Although originally intended to encourage states to provide decentralized community-based mental health services rather than rely on inpatient services, in practice the law prohibits low-income individuals from receiving comprehensive residential care at established facilities with proven treatment models. The temporary five-year suspension of the IMD exclusion included in the bill provides a solution for states to expand access to residential treatment for Medicaid enrollees who need substance abuse treatment — a change that has been long advocated by those who are battling the scourge of addiction and current opioid epidemic on the front lines.

Thirty days in residential treatment

The SUPPORT act lifts the IMD exclusion for substance use disorders for residential treatment but allows for 30 days of residential treatment. And although this represents a giant step forward, the bill falls short of a complete repeal of this antiquated and harmful policy. As an optimist, I am confident the evidence will show that a permanent elimination of this rule, without an artificial limit on length of stay, will prove effective, and help to save many lives.

Substance use disorders, and opioid abuse in particular, continue to have a devastating impact on communities and families across New Jersey and throughout the United States. The human toll within our state alone is unacceptable. With over 2,000 lives lost to overdose this year already, we are beyond the point of splitting hairs over days spent in a treatment facility.

The passage of the SUPPORT for Patients and Communities Act represents a strong, positive and decisive step toward advancing effective, community-based treatment programs. But the raging and deadly opioid epidemic will undoubtedly require a full repeal of the Medicaid IMD exclusion to allow for expanded access to life-saving community-based treatment and recovery assistance to those most at risk. I urge Congress to take the next positive step and to make the full repeal of that exclusion permanent.

Robert J. Budsock is the president and CEO of Integrity House, one of the largest nonprofit providers of substance use disorder treatment in New Jersey. Integrity’s CARF-accredited, licensed and highly effective treatment community believes in a client-centered, holistic approach to treatment, offering integrated services and a full continuum of care.

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