The waiting list for Medicaid patients to receive treatment at Rimrock is 160 names long. And yet on any given day, 16 to 20 beds at the addiction center’s main facility sit empty.
That’s due to an obscure federal law that limits Medicaid dollars from paying for treatment at any mental health or substance abuse center with more than 16 beds. Rimrock’s main center has 42.
And while providers like Rimrock were recently assured that state applications for exemption from the rule would be fast-tracked, no one is holding their breath.
Filling empty beds
The 16-bed limit was enacted in 1965. According to Rimrock CEO Lenette Kosovich, it was aimed at cutting down on the type of harsh and ineffective mental health care depicted in Ken Kesey's 1962 novel "One Flew Over the Cuckoo’s Nest," in which patients were forced into submission using harsh measures like electroshock therapy as punishment. By keeping facilities small enough, officials had hoped to steer away from mass institutionalization.
Instead, the law has forced organizations like Rimrock to turn away people paid for by Medicaid, who make up the majority of the center’s patients.
That became a big problem, Kosovich said, when the Montana Legislature expanded Medicaid eligibility in 2015, extending coverage to 84,000 more Montanans.
And along with the increase in coverage goes an increase in need for treatment, as drug abuse rates climb. Felony drug possession cases in Yellowstone County went from 198 in 2012 to 546 in 2016.
To get around the law, Rimrock has opened various small, residential treatment homes in Billings. In total, Rimrock has 60 beds in these homes. The level of care is the same as that provided at the main facility, although it's more expensive, due to economies of scale.
If Rimrock weren’t limited by the 16-bed law, it could easily fill the empty spots at the main facility, mixing in Medicaid patients with the self-pay and privately insured who are currently treated there.
Looking for solutions
When President Donald Trump declared the opioid crisis a public health emergency in late October, he said federal officials would fast-track state applications for waivers to the 16-bed law. Both the Trump and Obama administrations have encouraged states to apply for the waivers as a way to expand access to treatment.
In Montana, where meth abuse greatly overshadows opioid abuse, Rimrock has been pushing state health officials for months to apply.
The Department of Public Health and Human Services is in the early stages of gathering information on the issue, and will conduct internal discussions before making a decision, a spokesman said in an email to The Billings Gazette.
California, Maryland, Massachusetts, New York and West Virginia have already received a waiver, according to The Pew Charitable Trusts, and several other states, including Arizona, Indiana, Illinois, Kentucky, Michigan, Utah and Virginia, have applied.
The process can take more than a year, Kosovich said, and while the president's promise to fast-track applications was good news, there’s no clarity on what the new timeline could be.
Another possible avenue for relief comes from legislation lawmakers introduced in May in Congress. The bill would repeal the 16-bed limit, but no votes or hearings have been scheduled.
Sen. Jon Tester, D-Mont., is a co-sponsor on the Senate bill. Sen. Steve Daines, R-Mont., and Rep. Greg Gianforte, R-Mont., have not signed on as sponsors.
Rimrock officials have raised the issue with Gov. Steve Bullock’s office and both senators. (Gianforte was not yet in office when the organization made its pitch.)
Kosovich said there are only a handful of treatment centers in Montana like Rimrock that are large enough to be affected by the law, but even so, lifting the ban would make a difference.
“It would be huge,” she said.
Drug use, particularly meth use, in Billings and the surrounding areas has fueled a dramatic spike in child abuse and neglect cases, overwhelming foster care resources, and has ushered in a spate of petty theft and burglaries where people steal to fund their addiction.
“There’s not one aspect of society that isn’t affected by this,” Kosovich said.