Vindicator Logo

Federal law inhibits substance abuse treatment

Sunday, August 20, 2017

By Jordyn Grzelewski


Ten years into her heroin addiction and six months pregnant, Caitlin Dougherty was ready to get clean for good.

Dougherty had started shooting heroin at age 14. She’d been to rehab more than a dozen times and overdosed 22 times, she said.

Finally, she was done.

So, on Aug. 3, 2016, she went to a police department and asked for help.

Right away, someone tried to help Dougherty get into a treatment facility. Dougherty recalls going to numerous facilities in the Cleveland area and being turned away each time.

“Everyone said, ‘We can’t help you, we don’t have beds open,’” said Dougherty, now 25. “It was miserable. It was embarrassing. I was getting sicker by the minute. We tried from 9 in the morning until 7 at night.”

Finally, she found a facility in Cincinnati that would take her if she could get there that night. She packed up her things and made the several-hour trip with her parents.

It wasn’t Dougherty’s first attempt at rehab, but it was the one that worked. The mother of two has been clean since then, and said her life today is “absolutely amazing.”

“I can support myself, my kids,” said Dougherty, who splits her time between Perry and Painesville. “I have my own car now. I have a bank account. I have credit cards. My parents trust me to be home alone. They leave their wallets out at nighttime now.”

The difficulty she faced getting into treatment could have prevented her from getting to where she is today.

“If an addict is going in for help, they’re at their bottom to actually ask for help,” she said. “So when people get turned away from rehabs and they put them on a waiting list, that idea [of getting help] is out of your mind now.

“I know countless people [who] have died on a waiting list to get into rehab.”


A shortage of substance-abuse treatment beds is a problem in the Mahoning Valley.

Carolyn Givens, executive director of Neil Kennedy Recovery Centers, recently told The Vindicator that the clinic sometimes has a waiting list of up to 40 people.

The problem can trace its origins, at least in part, to the creation of the Medicaid program in 1965.

Since then, federal law has prohibited federal Medicaid payments to in-patient treatment facilities with more than 16 beds.

That provision, found in Section 1905 of the Social Security Act, is commonly referred to as the Medicaid Institution for Mental Diseases (IMD) exclusion.

“Currently, I have 16 beds that I use in my main campus at the clinic,” said Givens. “That’s a split, any given day, between detox and intensive in-patient and residential care. If I could expand, I could at least open 24 beds [total] in the main clinic.”

She said the IMD exclusion is a significant driver of waiting times at Neil Kennedy.

Experts say the intent of the IMD exclusion was twofold: To deinstitutionalize mental-health care, and make funding of that care a state responsibility.

“This rule was originally put in place with good intentions,” U.S. Sen. Rob Portman, a Cincinnati-area Republican, wrote in a column earlier this year. “It goes back to 1965 with the idea that larger institutional care for people who needed mental-health treatment was not as effective as care at smaller facilities. But a half century later, larger facilities are better capable than they used to be, and we’re in the midst of the worst drug crisis in American history, so this 16-bed limit just doesn’t make sense anymore.”

The unintended consequence 52 years later has been to limit access to treatment for victims of the current opioid crisis, which kills 142 Americans per day. President Trump recently declared the crisis a national emergency.

“The IMD exclusion blocks really critically important federal dollars for Medicaid-eligible people,” said Gabrielle de la Gueronniere, policy director for the Legal Action Center, a nonprofit law and advocacy organization that aims to improve policies for people dealing with addiction, HIV or criminal records. “Medicaid is hugely important to addiction treatment.”

Medicaid covers 50 percent of all addiction treatment in Ohio, according to information provided by the offices of Portman and U.S. Sen. Sherrod Brown, a Cleveland Democrat.

And according to data collected by the Ohio Department of Mental Health & Addiction Services, of the 3,198 total substance-abuse treatment beds in Ohio, 2,520 are in facilities with more than 16 beds and therefore not Medicaid-eligible.

The IMD exclusion’s impact on substance abuse treatment is widely recognized.

“The Commission has been urged by every governor, numerous treatment providers, parents, and non-profit advocacy organizations to eliminate the IMD exclusion within the Medicaid program,” notes a recent report from the Commission on Combating Drug Addiction and the Opioid Crisis, which the president created earlier this year.

So what can be done about it?


That same commission report recommends that the president waive the IMD exclusion.

“This will immediately open treatment to thousands of Americans in existing facilities in all 50 states,” it states.

It argues that while an act of Congress typically would be required, an emergency declaration would allow the Department of Health and Human Services Secretary to immediately grant waivers.

“This is the single fastest way to increase treatment availability across the nation,” the commission said.

The president has yet to indicate whether he will act on that recommendation.

Locally, mental-health and recovery officials have been clear about their view.

“While declaring a national emergency will increase public awareness, one of the biggest effects on treatment could be done with the IMD waiver,” Brenda Heidinger, associate director of the Mahoning County Mental Health & Recovery Board, recently told The Vindicator.

April Caraway, executive director of the Trumbull County Mental Health and Recovery Board, said this of the emergency declaration: “I hope it allows [communities] to work with the Center of Medicaid Services to lift that 16-bed cap for detox. That’s a federal rule, and with that cap, we have waiting lists at all our detox centers – people who need help.”

The Mahoning Valley’s elected officials have long recognized the need for reform.

U.S. Rep. Tim Ryan of Howland, D-13th, has been active on the issue. For the past several years, he has cosponsored legislation that would reform the IMD exclusion. The most recent iteration of the bill, introduced earlier this year, would eliminate the IMD exclusion.

And earlier this year, Portman and Brown together introduced a Senate bill that would increase the bed cap from 16 to 40.

“Red tape shouldn’t keep Ohioans from needed treatment and this simple fix will provide real relief to those struggling with addiction,” said Brown. “Ohioans on the front lines of the opioid epidemic tell me lack of beds at these facilities is the No. 1 barrier to getting folks on the path to recovery.”

If the efforts at reform are successful, experts say fewer people would be turned away from treatment, like Dougherty was.

Although it took her quite a few attempts to get clean, she wants others to know that it’s possible.

“Addiction isn’t a life sentence,” she said.