Sixty-four-year old Johnnie Davis has been treating his heroin addiction at the Bon Secours New Hope Treatment Center in West Baltimore for nearly 20 years.
“When I came here, I didn’t have no insurance,” he said. “And if I wasn’t here, I could imagine where my life would have turned because I was known for drugs — selling drugs.”
With no insurance and no job, Davis paid $8 a week for the Methadone program. The clinic later helped him get health coverage through Medicaid. For the last 18 years or so, his treatment has been covered in full.
Maryland is in the midst of an epidemic. More than 1,800 people died last year from overdosing on opioids, a 70-percent increase from the year before, according to data released last week by the state Department of Health and Mental Hygiene.
Medicaid covers roughly 20 percent of Maryland residents, but Medicaid patients make up a larger portion of the Marylanders grappling with addiction.
One in three people receiving treatment for addiction are on Medicaid, according to Baltimore City Health Commissioner Leana Wen.
State data show that of the nearly 1,100 people who died from opioid overdoses in 2015, about 65 percent were on Medicaid at some point since the beginning of 2011. The state doesn’t yet know how many Medicaid recipients were among last year’s overdose victims.
Heather Young, a nurse practitioner at Bon Secours’ three substance abuse treatment programs in Baltimore, estimated that about 70 percent of her roughly 700 patients receive medical assistance.
“Those are the easy patients,” Young said. “Once they’re on, we know we’re not going to every month have an issue with billing, or this month the insurance company allows it, next month they don’t.”
Medicaid also covers the cost of Naloxone, the drug used to reverse an overdose. In April, 12 of Young’s patients used their Naloxone kits to help someone who overdosed, she said.
“All 12 of those luckily, thank goodness, have medical assistance,” she said. “All that requires me is to send a refill to the pharmacy that they use, and I know that they can go get that kit, hassle-free, not having to pay some astronomical co-pay.”
It’s not entirely surprising that opioid addiction affects the state’s Medicaid population at such a high rate, said Colleen Barry, director of the Johns Hopkins University Center for Mental Health and Addiction Policy Research.
“It's always been the case that substance use disorder rates are higher among lower income individuals,” Barry said. “All of the factors that make life harder for folks on the lowest rungs are predisposing factors for addiction.”
The recent rise in opioid addiction rates is unique because it’s been driven in large part by an increase in prescriptions, Barry said. People at lower income levels are not alone in getting hooked on the drugs.
But income affects how people consume the drug and whether someone is likely to die from an overdose. Heroin is cheaper and more dangerous than prescription pills.
“Some of the most deadly forms of opiates use that are most likely, especially in the state of Maryland, to result in overdose death, like illicit Fentanyl-based opioids, you come into contact in a street context,” she said.
Two thirds of last year’s opioid-related deaths involved heroin, state data shows.
But most heroin users didn’t start out that way, said Maryland Medicaid Director Shannon McMahon. Three out of four started with prescription opioids.
The state’s Medicaid program is taking steps to reduce the number of patients who get prescriptions for opioids, with the hope that it will cut down on the number of heroin users.
“In lieu of pain medication, making sure that folks are getting physical therapy for their back pain, their neck pain, etc,” said McMahon.
She said the state is encouraging doctors to recommend opioid-alternatives such as Advil, and teaching patients to refuse opioids if they don’t think they need them.
Medicaid is also using the influence of its purse strings to improve treatment for those who are addicted. For example, last month the state began unbundling counseling and medication-assisted treatment — in which patients take regular doses of drugs like Methadone or Buprenorphine — so that providers could bill Medicaid separately for both.
“It creates an incentive for their provider to get them meaningfully connected to that behavioral health, that cognitive therapy, along with the medication,” McMahon said. “All of the research suggests that those two things together are the secret sauce, and the more that that happens, the less relapses we’ll see.”
This also tells Medicaid which providers are offering which services. The next step is creating a system that rewards addiction treatment providers for positive results, she said.
“We're in the middle of this opioid crisis. We know people are really and truly seeking this care,” she said. “We've created the environment from a financial perspective, from a service perspective, how can we get providers to do more and do more for people so that they're not having those relapses.”
But that evidence-based approach is still a ways off.
In the meantime, any cuts to Maryland’s Medicaid funding from the federal government would affect how the state covers addiction treatment.
The per-capita approach to Medicaid funding that Congress is considering would be devastating to the state’s ability to combat the opioid epidemic, said Barry.
“The establishment of addiction treatment as an essential health benefit through the Medicaid program is a critical way that we are combating the epidemic,” she said. “If people don't have access to insurance, how can we get them into effective treatment?"
The Affordable Care Act also established what Barry called “creative approaches” to Medicaid funding. One example allows Medicaid, in a small number of circumstances, to cover services that wouldn’t normally be covered — things like peer counseling and case management, which have been shown to help with addiction treatment.
“That’s a model that has existed for years in the health care sector, and it’s being financed now for the first time under the Affordable Care Act,” she said.
She said the program, called Health Homes, is in a sort of pilot status in Maryland, but she advocated for expanding it. It would be cut under the proposal currently before the Senate.