Affordable Care Act is a ‘game changer’ to reshape addiction rehab

From the Portland Tribune, September 18, 2013

It took Jerome Gilgan three stints in residential treatment before he started to get a handle on his drug addiction and his life of crime.

Gilgan was one of the lucky ones. He returning twice to the Volunteers of America men’s center in Northeast Portland because he was a career criminal considered among those at highest risk to re-offend. Most addicted criminals in Multnomah County never qualify for even one round of inpatient treatment.

The VOA center’s 52 beds are reserved for Multnomah County men on probation or parole. Gilgan had a history of arrests for burglary and drug dealing. Like most addicts, he found a stay at a residential center worked, for awhile. But each time he’d leave treatment and return to addiction and crime.

Jerome Gilgan, now an addiction counselor, needed three inpatient stints before he could control his addiction and stop committing crimes. Starting January, Medicaid will cover addiction treatment for low-income probationers and parolees.

Jerome Gilgan, now an addiction counselor, needed three inpatient stints before he could control his addiction and stop committing crimes. Starting January, Medicaid will cover addiction treatment for low-income probationers and parolees.

Gilgan has been clean and sober for 10 years and works as a certified drug and alcohol counselor at the VOA facility on Northeast Martin Luther King Jr. Boulevard. Just as important, he says, he has not committed a crime in that time.

Few societal issues are more intertwined than addiction and crime. A 2010 study by the National Center on Addiction and Drug Abuse found that more than 80 percent of the country’s inmates either are addicts or have a history of substance abuse.

But finding funds to treat convicted offenders historically has been a struggle for county community justice programs, which oversee probationers and parolees. The same 2010 study found that only about one in 10 inmates receives addiction treatment.

That is about to change, big time.

In January, the federal Affordable Care Act will transform the nation’s health care. Medicaid will cover addiction treatment for those who cannot afford private health insurance, including felons. If handled well, this new federal funding could permanently change the face of crime in Portland. In addition, treatment facilities such as the VOA center, as well as local outpatient drug and alcohol counselors, could soon be seeing a flood of new patients with criminal histories.

Portland police Chief Mike Reese calls the new Medicaid rules “a game changer.” But at this point, nobody is certain exactly who will get how much coverage, how other funds will be offset or affected, and what strings might be attached. And that’s keeping more than a few administrators up at night.

“We are scrambling to figure this out,” says Jeremiah Stromberg, Oregon’s assistant director for community corrections.

For example, at the VOA residential facility for high-risk offenders, men must stay six months to graduate. Gilgan says he needed the six months, which gave him time to get beyond the need to stop using drugs, and address the underlying psychological issues that had led him to commit crimes.

But once Medicaid begins to pay the bill for treatment at the VOA facility that will change, according to Pam Kelly, director of VOA’s public safety programs. Kelly says it is likely that stays will be reduced to one or two months.

That’s because Medicaid pays for health care, and federal administrators are likely to see one or two months of inpatient treatment, followed by less expensive outpatient treatment, as a sufficient health care solution.

While in the VOA center, in addition to addiction counseling, Gilgan received counseling aimed at changing thought patterns that contributed to his criminality, dealing with issues such as impulsivity and anti-social thinking. In the last two months of client stays the center ensures that clients have jobs and clean and sober living situations lined up before they leave.

Simply treating addiction doesn’t turn criminals into law-abiding citizens, according to Gilgan.

“A lot of times guys, once they stop using, they continue to do that criminality because you get the same high off the adrenaline rush, from how you plan (crimes). And most of them, that’s just how they survive,” Gilgan says.

Treating criminal tendencies

If Medicaid will not pay for treating criminality, additional money will have to be found to extend the inpatient stays of parolees and probationers, says Ginger Martin, deputy director for the Multnomah County Department of Community Justice, which oversees probationers and parolees. If not, Martin says, “We’re going to end up with sober criminals. And we don’t want clean and sober criminals.”

In addition, Kelly says, Medicaid might not pay for second and third chances for clients who, like Gilgan, have relapsed.

Currently, when parolees and probationers get addiction treatment in Multnomah County, 74 percent of the payment comes from the county general fund. About 10 percent is funded through state and federal grants, with the state picking up another 8 percent of the cost and the city of Portland paying 8 percent.

So potentially, when Medicaid pays 100 percent of the treatment cost for residents at the VOA center, Multnomah County could use the money it saves to extend the shorter Medicaid-funded stays. Or, the county could use that saved money to pay for clean and sober housing for those parolees and probationers after their residential stays. Or, the county could take that saved money and put it back into the general fund.

Nobody is quite sure what’s going to happen with that money, Martin says. And that’s why everybody is scrambling — Jan. 1 is fast approaching.

Who will qualify?

Also uncertain is how many parolees and probationers will qualify for Medicaid coverage. Martin estimates that somewhere between 40 and 60 percent will meet the low-income standard. Those that don’t, she points out, are likely to gain insurance coverage through one of the other new mechanisms supported by the Affordable Care Act.

Currently, few offenders considered at medium or low risk to re-offend get subsidized addiction treatment outside jail, but they also will receive Medicaid coverage. One problem: Low- and medium-risk offenders don’t have close supervision by parole and probation officers who can connect them with addiction treatment. They may never know of the opportunity, or how to access treatment, or be convinced they need it, unless Martin’s department makes some changes.

Still, the new rules could produce a rush of newly insured clients with criminal backgrounds asking for addiction treatment. Ramping up outpatient care won’t be too hard, Martin says. All that requires, basically, is that established addiction services agencies rent office space and hire new counseling and medical staff. But inpatient care requires building new facilities, and that is costly and time-consuming, Martin says.

“We’re not going to have enough residential treatment possibly, and not have enough outpatient treatment probably,” Martin says. It’s possible, she says, that even though more offenders will be covered for inpatient treatment, the shorter stays could move clients in and out quicker, so the demand for new residential beds might not be too great. Again, nobody knows for sure, she says.

But the real kink in the system, Martin says, is a component of addiction treatment many providers says is critical — clean and sober housing once clients have completed residential or outpatient treatment. Agencies such as Central City Concern operate large-scale apartment buildings for people in recovery. Increasingly, democratically run, drug and alcohol free Oxford Houses have become a go-to housing option for those just out of recovery. The demand for both could jump next year.

“I think that’s going to be a bottleneck,” Martin says.

Ed Blackburn, executive director of nonprofit Central City Concern, concurs.

Central City Concern operates more recovery housing than any other agency in Portland and he says there already is a 10-month waiting list for an apartment in one of their recovery buildings.

How much more demand could there be once the Affordable Care Act takes effect? “We don’t know,” Blackburn says. But it could be a great deal, he says, and agencies that deal with both addiction and those in the housing field have been talking to city and county officials about the issue.

“Here’s my message,” Blackburn says. “Don’t wait for an exact number. Let’s start building it. We can’t let a big number intimidate us and put us in a position of not doing anything.”

Blackburn is hoping that Multnomah County and the city of Portland put into recovery housing some of the money that might be saved when Medicaid pays more of the health care bills for the uninsured. Central City Concern has some buildings that could be converted to recovery housing, he says, but that won’t be cheap, it can’t happen overnight, and it will require a change in attitude among some of the system’s players.

Larry Jones (left) and Karl Colbert have been living at the VOA residential facility in NE Portland for over four months.

Larry Jones (left) and Karl Colbert have been living at the VOA residential facility in NE Portland for over four months.

“It (housing) is new territory for a lot of people whose careers have been in the medical field,” Blackburn says. “Some of them get it and some of them are still struggling with what is the role of housing in health care transformation.”

The VOA’s Kelly says everybody involved needs to get used to new thinking, and quickly.

“We’re on this fast track in Oregon and everyone’s meeting to try and figure this all out, but these timelines are kicking in,” she says.

VOA treatment facility likely to see more high-risk offenders

In 2008, the Volunteers of America men’s residential facility in Northeast Portland had a 71 percent success rate treating parolees and probationers considered to be of high and medium risk to commit new crimes. In 2010 the facility allowed in only high-risk men and its success rate dropped to 55 percent.

Greg Stone, program director the VOA center, worries that the success rate — basically the percentage of men graduating the six-month program — might drop further as more of the most difficult probationers and parolees gain Medicaid benefits and are sent to his facility for addiction treatment.

A residential treatment facility, Stone explains, develops a culture created by its clients, despite the best efforts of staff to control the environment. The VOA facility lost an advantage when it could no longer accept medium-risk addicts, according to Stone.

“The people who had a little more incentive, who were a little higher functioning, could come in and stabilize your community,” Stone says.

And the population of high-risk offenders that the VOA center treats increasingly is dominated by young opiate addicts, many hooked on heroin. Last year, 40 percent of the VOA facility’s residents were heroin addicts, up from 8.7 percent 13 years ago. These men are less likely to cooperate and more likely to try and chip — secretly use opiates while staying at the facility. And that, Stone says, makes it harder on all the clients.

“It creates pure hell and chaos for you. … You bring one guy in who brings (drugs) in and a lot of guys jump on board with him,” Stone says.

Stone isn’t going to get medium-risk offenders back into his client population. The county is primarily interested in lowering crime, and the most impact will occur if the most expensive treatment is reserved for addicted parolees and probationers most likely to re-offend, says Ginger Martin, deputy director for Multnomah County’s Department of Community Justice.

Martin says medium- and low-risk offenders don’t respond as well to the extended inpatient stays offered at the VOA center. Currently, Multnomah County does not pay for addiction treatment for low- and medium-risk offenders. Medicaid will pay starting in January, but Medicaid is unlikely to cover expensive inpatient treatment for those parolees and probationers when they could benefit from outpatient drug counseling.

Alternatively, Stone would like to see a different treatment model for the growing number of young heroin addicts on probation and parole — a locked facility where it would be harder for the clients to bring in opiates from outside.

Martin says Multnomah County rented space in Washington County for such a facility about 15 years ago. High-risk probationers and parolees with serious addictions had to agree to live there for six months, and if they decided to leave they had to give 24-hour notice. The notice was key because often, clients who asked to be released had gotten past their crisis and changed their minds before the 24 hours were up.

“It worked, people finished,” Martin says, adding that there simply isn’t county money for such a facility anymore. Ironically, Multnomah County currently has an empty facility that some have said could serve such a purpose — the mothballed Wapato Jail.

On a second alternative, both Stone, Martin and others agree — to an extent. If residential treatment centers are going to be increasingly dominated by high-risk heroin addicts, probation officers can help by removing the parolees and probationers who fail to cooperate.

High-risk offenders already have proven themselves more antisocial and more likely to break rules, Martin says. When an offender in treatment is found chipping, for instance, it is up to his parole officer to decide on a consequence. Typically parole and probation officers are reluctant to kick their clients out of treatment for one or two infractions, Martin says, because treatment at a facility like the men’s residential center is their best hope for change.

Ideally, Martin says, parole and probation officers will respond quickly with a not overly severe sanction, such as a day or two in jail and then back to the treatment facility. Probation and parole officers, with already large caseloads, somehow are going to have to find a way to more closely monitor many of their high-risk offenders, Martin says, and that won’t be easy.