Governor Stands Up To Heroin

MONTPELIER, Vt. — In a sign of how drastic the epidemic of drug addiction here has become, Gov. Peter Shumlin on Wednesday devoted his entire State of the State Message to what he said was “a full-blown heroin crisis” gripping Vermont.

“In every corner of our state, heroin and opiate drug addiction threatens us,” he said. He said he wanted to reframe the public debate to encourage officials to respond to addiction as a chronic disease, with treatment and support, rather than with only punishment and incarceration.

“The time has come for us to stop quietly averting our eyes from the growing heroin addiction in our front yards,” Governor Shumlin said, “while we fear and fight treatment facilities in our backyards.”

Last year, he said, nearly twice as many people here died from heroin overdoses as the year before. Since 2000, Vermont has seen an increase of more than 770 percent in treatment for opiate addictions, up to 4,300 people in 2012.

Addiction Blogs

Governor Shumlin, a Democrat now in his second term, used his State of the State Message last year to focus almost entirely on education. This year, he appears to be one of the first, if not the only, governor to use his message, all 34 minutes of it, to focus exclusively on drug addiction and detail its costs, in dollars and lives.  More about Peter Shumlin

Law enforcement officers were among those in the audience for Gov. Peter Shumlin’s address on Wednesday. He urged treating addiction as a disease needing treatment, not just punishment.

Such speeches mark the opening of a legislative session and traditionally feature some pomp and back-patting as governors lay out their broad agendas for the year to come. Here, the mood in the packed House chamber of the Statehouse was somber as lawmakers considered the scope of the drug problem.

While it may be acute in Vermont, it is not isolated. In the past few years, officials have reported a surge in the use of heroin in New England, with a sharp rise in overdoses and deaths, as well as robberies and other crimes common among addicts. Those same statistics are being replicated across the country. Lawmakers in virtually every state are introducing legislation in response to what is rapidly being perceived as a public health crisis.

“The Centers for Disease Control and most national experts agree there’s an epidemic of drug overdose deaths in America,” Dr. Harry L. Chen, Vermont’s health commissioner, said in an interview. He said the rate of overdose deaths across the country had tripled since 1990.  CDC Statistics on Drug Overdose

“Nationwide, more people die of drug overdoses than from motor vehicle crashes,” he said.
Dr. Chen said the highest rates of substance abuse were found in New England and the Northeast. No one really knows why, he said, except that the region is a wide-open market for dealers with easy access from New York, Boston and Philadelphia. Law enforcement can be spotty in the rural areas up here, and users are willing to pay top prices.

A $6 bag of heroin in New York City fetches $10 in southern New England and up to $30 or $40 in northern New England, law enforcement officials said. The dealer gets a tremendous profit margin, while the addict pays half of what he might have to pay for prescription painkillers, which have become harder to obtain.

Democrats, who control both houses of the Legislature, lauded the governor’s single-minded focus.  “He hit it absolutely right,” said Senator Richard Sears, chairman of the Judiciary Committee. “I’ve been dealing with addicted folks for years and have seen the increase in crime related to this addiction problem.”

Republicans were not impressed, saying that Governor Shumlin should have made room for other big issues confronting the state, especially problems with the rollout of its health care exchange.

She said that the governor’s proposal for what would be the nation’s first single-payer health insurance plan had also caused considerable confusion and controversy and that the speech was both “a missed opportunity” to address it and “a way to change the subject.”

Regardless, the picture Mr. Shumlin painted was grim. Every week, he said, more than $2 million worth of heroin and other opiates are trafficked into Vermont. And nearly 80 percent of inmates in the state are jailed on drug-related charges.

The governor made a plea for more money for treatment programs, noting that incarcerating a person for a week costs the state $1,120, while a week of treatment at a state-financed center costs $123. He asked for money to expand treatment centers, where more than 500 addicts are on waiting lists. He also called for rapid intervention programs so that addicts could be directed to treatment as soon as they see the blue lights flashing from police cars — supposedly the moment when they are most likely to accept help. To discourage high-volume dealers from coming into the state, he is seeking tougher laws.

Mr. Shumlin also wants to encourage discussions on ways to prevent addiction in the first place. He is providing a grant for an entourage from “The Hungry Heart” to visit every high school in the state.

The group will include Skip Gates of Skowhegan, Me., whose son Will, a science major at the University of Vermont and a ski racer, died of a heroin overdose in 2009. “I never knew any human being could feel this much pain,” Mr. Gates says in the movie of his son’s death. “It has redefined the rest of my life.”

Thinking Outside the Box to Curb Gun Violence

This is such an important piece of news, but I doubt that you will see it on the 6 o'clock news in your city.  It's fair to say, I think, that all of the mass shootings that have taken place were committed by people who had previously had some contact with the mental health system.  It's also fair to say that some of them didn't get the treatment they needed because their insurance (if they had any) wouldn't pay for it.  Now that changes and mental illness will be treated no differently than appendicitis.  It's a lengthy article, but well worth your time reading it.

Rules to Require Equal Coverage for Mental Ills

By JACKIE CALMES and ROBERT PEAR

Published: November 8, 2013 NY Times

WASHINGTON — The Obama administration on Friday will complete a generation-long effort to require insurers to cover care for mental health and addiction just like physical illnesses when it issues long-awaited regulations defining parity in benefits and treatment.

The rules, which will apply to almost all forms of insurance, will have far-reaching consequences for many Americans. In the White House, the regulations are also seen as critical to President Obama’s program for curbing gun violence by addressing an issue on which there is bipartisan agreement: Making treatment more available to those with mental illness could reduce killings, including mass murders.

In issuing the regulations, senior officials said, the administration will have acted on all 23 executive actions that the president and Vice President Joseph R. Biden Jr. announced early this year to reduce gun crimes after the Newtown, Conn., school massacre. In planning those actions, the administration anticipated that gun control legislation would fail in Congress as pressure from the gun lobby proved longer-lasting than the national trauma over the killings of first graders and their caretakers last Dec. 14.

“We feel actually like we’ve made a lot of progress on mental health as a result in this year, and this is kind of the big one,” said a senior administration official, one of several who described the outlines of the regulations that Kathleen Sebelius, the secretary of health and human services, will announce at a mental health conference on Friday in Atlanta with the former first lady Rosalynn Carter.

While laws and regulations dating to 1996 took initial steps in requiring insurance parity for medical and mental health, “here we’re doing full parity, and we’ve also taken steps to extend it to the people covered in the Affordable Care Act,” the senior official said. “This is kind of the final word on parity.”

With the announcement, the administration will make some news that is certain to be popular with many Americans at a time when Mr. Obama and Ms. Sebelius have been on the defensive for the bungled introduction of the insurance marketplaces created under the Affordable Care Act.

According to administration officials, the rule would ensure that health plans’ co-payments, deductibles and limits on visits to health care providers are not more restrictive or less generous for mental health benefits than for medical and surgical benefits. Significantly, the regulations would clarify how parity applies to residential treatments and outpatient services, where much of the care for people with addictions or mental illnesses occurs.

Any geographic or facility-type limitations would have to be comparable for medical and mental health benefits. For example, an administration official said, an insurer “can’t say you can only get substance-abuse treatment in state but you can go anywhere for medical/surgical.”

The regulations, which specifically put into effect the 2008 Mental Health Parity and Addiction Equity Act, would affect most Americans with insurance — roughly 85 percent of the population — whether their policies are from employer plans, other group plans, or coverage purchased in the market for individual plans.

The final parity rules do not apply to health plans that manage care for millions of low-income people on Medicaid. However, the administration has previously issued guidance to state health officials saying that such plans should meet the parity requirements of the 2008 law.

The parity law does not apply to Medicare, according to Irvin L. Muszynski, a lawyer at the American Psychiatric Association.

The rules have been awaited since the 2008 law by patient advocate groups. As it happened, the groups’ complaints about regulatory delays were the subject of a Senate hearing on Thursday. Interest picked up further last month as individuals could begin enrolling in the new insurance marketplaces, or exchanges, provided under Mr. Obama’shealth care law.

Under that law,treatment for mental health and substance abuse is among 10 categories of benefits considered essential and thus mandatory in plans marketed in the new exchanges to individuals and small groups. Although many insurers already provide extensive mental health coverage, some have found ways to get around existing rules and to deny payment for treatment, Senator Richard Blumenthal, Democrat of Connecticut, said the five-year delay in issuing a final rule had real-world consequences. “In mental health, uncertainty kills,” he said. “If an individual poses a threat to himself or others, he cannot be told he will get the care he needs as soon as his insurance company decides what ‘parity’ means.”

Insurance companies have raised concerns about the expense involved in paying for the lengthy and intensive courses of treatment that the final regulations address. But experts have said the rules are not expected to significantly add to the cost of coverage because so few patients require these levels of care. 

Mental health services are scarce in many parts of the country, particularly for children, so experts have questioned whether changes in the law will have much impact in practice.

Former Representative Patrick J. Kennedy of Rhode Island, a co-sponsor of the 2008 law, said the rules could particularly help veterans. “No one stands to gain more from true parity than the men and women who have served our country and now need treatment for the invisible wounds they have brought home from Iraq and Afghanistan,” he said.

Administration officials consulted closely with mental health groups. “What we are hearing is very positive,” said Andrew Sperling, a lobbyist at the National Alliance on Mental Illness, based on what he had been told of the final language.

Under the 2008 law, treatment limits — like restrictions on the number of doctor visits or days in a hospital — cannot be more restrictive for mental health benefits than for medical and surgical benefits. But interpretation of the law left much in question.

For example, Mr. Sperling said, policyholders can easily determine whether numerical limits on doctor visits are comparable in their plans for mental and medical health care. But, he said, it is more difficult to challenge “nonquantitative limits” — like some insurers’ requirements that people get their authorization before seeing a psychotherapist.

The provision of the rule that will seek to clarify the amount of transparency required of health plans “is important,” Mr. Sperling said. Patients advocates say they need to be able to see the criteria by which insurers find a particular service to be medically necessary, so policyholders can judge whether standards for mental health treatments are more restrictive.

Carol A. McDaid, the leader of a coalition of patients and providers of mental health and addiction services, said: “This is the beginning, not the end, of our work to make the vision of the law a reality. We have to make sure that the law and the rules are fully enforced.”

Insurers and business trade groups said they did not know enough about the rules to comment.

Dr. Paul Summergrad of Tufts University, president-elect of the American Psychiatric Association, said he hoped the final rules would end “the uniquely discriminatory form of prior authorization and utilization review” applied to emergency care for patients with mental illness.

A person who has a heart attack or pneumonia and goes to a hospital will routinely be admitted, with electronic notice sent to the insurer on the next business day, Dr. Summergrad said. By contrast, he said, if a person who is profoundly depressed and tried to commit suicide goes to a hospital, an emergency room doctor must call a toll-free telephone number, “present the case in voluminous detail and get prior authorization.”

State insurance commissioners will apparently have the primary responsibility for seeing that commercial insurers comply with the parity standards. They already have their hands full, however, enforcing new insurance market rules, and in some states insurance regulators are considered close to the industry.

“We need enforcement,” Mr. Kennedy said in an interview. “The notion of delegating this to the states, which are looking to the federal government for direction, is problematic.”