Insurance Is Supposed to Cover Addiction Treatment, But It's Still a Nightmare
The barriers insurance companies place in the way of treatment are killing people.
Fighting Words is Tonic's opinion column. Send pitches to firstname.lastname@example.org.
During an overdose epidemic so large that it is cutting overall life expectancy in the US, you’d think that insurance companies and the healthcare system would be bending over backwards to get people into evidence-based treatment—especially since we have two drugs that are proven to cut the death rate by at least half. In reality, they are doing the opposite. And the barriers they place in the way of treatment are killing people.
The story of Bill Williams’ son, William, who died of an overdose at 24 in 2012 sadly illustrates nearly all of these barriers—and while there have been some minor improvements since then, in many states, unfortunately, the overall picture remains bleak. Too many insurers, treatment programs, and hospitals are failing people with addiction and their families—and routinely violating federal laws, especially those known as “parity laws” intended to make coverage for addiction and other mental illness equivalent to that for physical disorders.
The last time he sought help, William went to Beth Israel Hospital in New York City, asking for an inpatient detoxification program, his father tells me. Despite the fact that William was physically dependent on opioids, his insurer said that inpatient care was “medically unnecessary” and he was told to try an outpatient methadone program, which he refused.
It’s true that medication would have been the better option, clinically. Detox programs that taper people to opioid abstinence have not been shown to reduce overdose death risk—and without further support, may actually increase it. However, when people are physically dependent on opioids and do not want medication, being hospitalized for detox can give them at least a short period of safety that can be used to get them into longer-term care. If they’re at risk of overdose and, like William, have previously been unsuccessful at outpatient care, inpatient stabilization certainly should have been a covered option.
And keeping William in care at that point might have actually helped him accept medication: He had told his father that he didn’t want to be on methadone because it harms bones and teeth, which is a myth that a competent counselor could have debunked with data. Alternatively, he could have been given a shot of long-acting naltrexone (Vivitrol), which he’d taken successfully at times in the past and which would have protected him from overdose for at least a few weeks.
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Instead, he was given no actual care—and later that day, he overdosed in a Starbucks and was taken to St. Luke’s hospital, where he was released as soon as he became medically stable. Once again, he didn’t get any addiction treatment—and his parents didn’t even know that he’d been seen.
Four days later, he had a fatal overdose and was hospitalized for six weeks before his parents were advised to take him off life support. “The irony there is that the insurance company spent far more on six weeks in the hospital than they would have for detox,” Williams says.
Prior to his last attempt to get treatment, William had been through several ineffectual and uncoordinated programs. In one, he was prescribed Vivitrol—but basically pushed out of the treatment program he attended because he didn’t quit smoking weed. This is a criminally negligent policy that needs to be stopped: We don’t cut people with diabetes off from insulin because they overeat or don’t manage their disease the way we think they should.
His father says the family also wasn’t informed that, when Vivitrol wears off after about a month, the risk of overdose is extremely high. William had received his last Vivitrol injection—from a different doctor—about a month before he had his final series of overdoses. Patients need informed consent about the risks and benefits of all medications—and they need to be told that only long-term methadone and buprenorphine are proven to reduce overdose mortality.
“William died of institutional indifference,” his father tells me. New York State has since made some changes—prompted in part by his parents’ activism. As of 2016, insurers must allow 14 days of inpatient treatment for opioid addiction while decisions about further coverage are made. And, perhaps most importantly, they can no longer require “prior authorization” before covering addiction medications. All three types—methadone, buprenorphine (Suboxone), and long-acting naltrexone (Vivitrol) must be covered—and access must be immediate.
But sadly, even in New York—a state that’s known for having relatively strong regulations—these kinds of abuses remain common, despite provisions in the Affordable Care Act that were supposed to increase access.
For example, before her son Vincent died of a fentanyl overdose in 2017 at age 25, Sharon Richmond fought repeatedly to get him the help he wanted. According to a recent op-ed she wrote for Newsday, one rejection of care even had the temerity to deny inpatient treatment because her son had “supportive” family. Three days of detox were covered at one point—but not life-saving medication like methadone or buprenorphine.
While these two cases occurred in New York, similar stories can be found across the country. Because there is little evidence to support residential care without medication for opioid addiction—and widespread fraud among treatment providers—parents and patients have to fight every step of the way.
Meanwhile, insurers continue to act with impunity because distressed, stigmatized, and often severely ill patients and their families are not—to put it mildly—in a great position to fight for their rights when they need them most. Many families don’t even know what their rights are, and are struggling to sort myth from fact about medications and figure out the best treatment to seek.
When informed families come together, however, it can make a real difference. One of the best weapons is lawsuits—Bill Williams, for example, is currently in settlement negotiations in the case he filed against his insurer.
Money can’t bring back lost loved ones, of course, but a few big losses could deter future harm caused by insurers and providers. Insurers that insist on prior authorization for standard-of-care medication need to be sued. Providers that deny access to medication—and don’t offer informed consent about the fact that only medication cuts the death rate in half—need to be sued. Providers that cut medication or expel patients from opioid addiction care because of marijuana use need to be sued. Sober houses that discriminate against people taking addiction medication need to be sued.
We need to make insurers realize that people with addiction are valued—and that failing to treat addiction appropriately will cost them, big time. The only way that this will truly change is if we hit them where it hurts.
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