This article is not meant to diagnose or provide medical advice—that responsibility lies with physicians. The author is not a licensed medical professional.
spent her life trying to lift the stigma on mental illness and addiction, with her death casting a rare light on what is often only whispered about in the corner at family dinners. The late advocate and actress told Vanity Fair in 2009, “If you claim something, you can own it. But if you have it as a shameful secret, you’re fucked.”
Her first stint in rehab came years after she was first diagnosed with bi-polar disorder, after she nearly overdosed. Long-term rehabilitation is often the most effective treatment when it comes to taking control of a mental disorder or addiction, but if you’re not a well off or famous person who can afford private rehabilitation, there are limited options available to you. This is especially true if you receive assistance from Medicaid.
As Republican lawmakers work to repeal the Affordable Care Act (ACA), it begs the question: with mental health care a complex puzzle on its own, how will it stand up to potential Medicaid cuts under a Trump presidency?
Medicaid is a joint federal and state program that provides health coverage for low-income adults, families and children, pregnant women, the elderly and people with disabilities.
More than 72.5 million Americans receive Medicaid, making it the country’s single largest source of health coverage. A coverage provision of the ACA is the expansion of Medicaid eligibility to more qualified adults, making care more accessible to the masses.
Last June, the Substance Abuse and Mental Health Services Administration (SAMHSA) published its directories of mental health treatment facilities and drug and alcohol abuse treatment facilities. These serve as listings of federal, state and local government facilities and private facilities that provide mental health and substance abuse treatment services, respectively.
Of these 23,138 facilities, just about 4,199 offer long-term treatment, according to my research, meaning you live as a resident for an extended period of time (anywhere from 30 days to a few months). Of this group, I found 2,431 that accept Medicaid insurance.
Chances are if you are not swimming in cash, you might have limited options available near home if either you or a loved one requires intensive treatment in order to heal.
Problems with Finding Care
“I travel two and a half hours to the psychiatric facility in Charleston, where I still go for outpatient therapy and outpatient ECT,” said Allison Williford, who has Type I Bipolar Disorder. Williford has been through three hospitalizations, outpatient rehabilitation for alcohol and drug abuse, and has been undergoing electroshock therapy since March 2015.
Though she has private insurance, Williford still runs into issues when it comes to locating a provider. “There are a lot of places in the U.S. that have extremely limited access, or they have doctors who can’t or won’t handle certain cases. I’ve personally experienced it,” she revealed. “I’ve had outpatient psychiatrists who have told me flat out they don’t treat patients with bipolar disorder, or patients who have a history of hospitalization. It can be extremely discouraging, and when you’re already suffering from a mental illness, it just makes you want to give up even more.”
In Orlando, my current city, there are not many inpatient facilities that accept Medicaid. According to my heavy research, two of them are hospitals that only accept patients admitted through the emergency department. As a nurse from Florida Hospital for Behavioral Health told me over the phone, they’re not meant to be long-term solutions. Most patients are gone in a matter of days.
The facility I visited, Aspire Health Partners’ Center for Drug-Free Living, is a rehabilitation and addiction-receiving center that focuses on mental health and substance abuse treatment and provides detoxification and stabilization for adults.
Located in the Parramore District, one of Orlando’s poorest neighborhoods, there was a liquor store just two doors down—a confusing sign for an abuser who might not even be on the road to recovery yet. I parked in a small lot that offered five available spots. There were more cars parked beyond a large chain link fence, which loomed forebodingly as I was buzzed through via an intercom system.
Under HIPAA Law, facilities do not permit outsiders to get past the lobby unless you are with a family member who has been admitted. I stepped into the tiny white lobby and picked an admission packet off a nearby table.
In addition to letting the reader know that they will be provided with medical scrubs to wear during their stay, the packet provided a list of items you’re permitted to bring into your unit. This included five pairs of socks, five pairs of underwear, one pair of pajamas, one pair of shoes and up to $5 in cash (“preferably change”). Other attached documents include an optional Certification of Homelessness.
Individuals that are admitted to the detox facility stay for up to seven days before they are referred to another program to continue their treatment. The problem? There aren’t many local options left after that point.
When I called the National Alliance on Mental Illness’ Orlando chapter, they gave me the same advice they give those who are seeking treatment for either themselves or loved ones and dealing with insurance issues: just start calling. Chances are though, after you’ve called several facilities, that you might need to leave your area in order to seek treatment. If you hadn’t already given up on your search.
“There aren’t many long-term facilities in the U.S. anymore, especially state facilities, as many of them have been shut down in the last 30 years or so,” said Williford. “There’s been a huge lack of funding toward psychiatric care, so beds are incredibly limited.”
Mental Health Care’s Battle with Insurance Companies
So why does our most common form of medical insurance, which 22.7 percent of the country uses, leave so few choices for mental health care?
Adela Hathaway M.S., LMHC, NCC and mental health counselor at Park Avenue Integrative Counseling in Winter Park, Florida, spoke to me about the reluctance of many practitioners and facilities to accept Medicaid. First, you have to be approved to accept Medicaid in order to get paid through Medicaid. But the problems don’t stop there. Medicaid has very strict documentation guidelines; Hathaway recounted a story about a colleague who used the incorrect date and time format on her notes and treatment plans and was fined as a result. While meant to help guard against Medicaid fraud, these stringent procedures also inspire reluctance among practitioners and facilities to accept it as a form of payment.
Medicaid also mirrors insurance companies by not paying the full cost of care back to caregivers … if the facilities even get paid at all. Hathaway has another colleague who is still waiting for payment from a private insurance company for services rendered over a year ago.
“I do not currently accept insurance due to the difficulty of being accepted on insurance plans and adhering to all of their guidelines. I choose to do private pay because it’s a lot less stress and hassle,” said Hathaway. “I would rather give someone a discounted session rate than have to deal with an insurance company. It just makes more sense to me.”
As a result, larger hospitals tend to be the main facilities to accept Medicaid. However, the setting that many hospitals offer can be conducive to positive healing. Williford’s last two hospitalizations were in Charleston, and she describes the hospital as having a more institutional feel, with not all patients being there voluntarily.
Additionally, there is a limited amount of space available in these hospitals. If a unit has 30 beds dedicated to behavioral health, 10 are reserved for Medicaid/Medicare recipients, while 10 are reserved for veterans and 10 are reserved for patients who are paying privately. Obviously, it can be difficult to find a treatment site with any dedicated beds for your demographic available.
The good news is that self-pay beds do not normally outnumber the amount available to those with government insurance. Most self-pay patients, according to Hathaway, do not want to receive care at facilities such as the Center for Drug-Free Living to begin with. “There is a clear difference in government funded rehab centers and private pay centers. Those who can afford a different level of care most often choose a private pay facility,” she said.
So What is Treatment Like at a Private Facility?
Mountainside Treatment Center is a nationally acclaimed alcohol and drug addiction treatment center in Canaan, Connecticut that does not accept Medicaid. Jason Arsenault, a previous patient, now works with the private facility as an outreach support specialist.
Arsenault spent 33 days at the private center for treatment for a crystal meth addiction: five days in detox and 28 in the residential program. The admissions department at Mountainside handled most conversations with his insurance company after Arsenault’s initial outreach, with the remaining balance covered in part by a loved one. He pointed out that insurance companies dictate where people need to get treatment or where they need to detox from, so individuals can very likely be at the mercy of their insurers in terms of choosing a center.
“The first few days of treatment were scary. I started out in a five-day detox,” recalled Arsenault. “I was facing a lot of anxiety and even denial. I questioned if I really needed to be there.”
What many don’t know is that many rehabilitation programs, especially those that work with Medicaid, will not be able to accept you as a patient unless you are currently going through a detox program and/or have the substance in your system. There is an exception if you’re paying your own way. This means that there might be limited time to get your affairs in order if a patient is not self-funded and chooses to enroll voluntarily. “I’ve had to tell clients before that you need to get some [substance] back in your system to be admitted into a detox facility, which just sounds totally asinine,” said Hathaway.
Located in an idyllic setting, Mountainside Treatment Center offers a wide range of advanced, evidence-based substance abuse treatments paired with family wellness programs and holistic addiction treatments, including acupuncture, yoga and what their website calls “adventure-based counseling.”
A typical day at Mountainside will begin with breakfast, followed by activities like meditation, group therapy and spiritual enhancement. After lunch comes individual counseling and specific group counseling—think stress relief and anger management, trauma-sensitive groups and 12-step education. In the evenings residents eat dinner and enjoy physical activities such as group sports and runs, as well as movie nights.
“It was a welcoming and comfortable environment, and the team was very receptive to my specific, individual needs,” continued Arsenault. “Those first few days I couldn’t do much of anything but sleep. And as I started to feel better, they started to ramp up what programs I could get involved with.”
The saying is true—you get what you pay for.
At many private facilities, such as Orlando Recovery Center, treatment can run anywhere from $300 to $1,100 per day. With a potential $33,000 cost for 30 days of treatment, it’s not always a viable option for many who lack private insurance or another reliable payment method.
When asked whether she has ever run into issues paying for treatment, Williford replied, “Too many times to count. When I was doing the outpatient drug and alcohol program, I had trouble affording it. My insurance didn’t cover it. I also seem to have a never-ending payment plan with the facility in Charleston.”
Arsenault counsels that there are ways to access help even if you can’t afford private treatment. “Not everyone that is sober has gone through residential treatment to get to that place,” he said. “Don’t let cost be a barrier to you making this important change in your life.”
So What Needs to Be Done?
All three agreed that education and transparency is the most important thing that needs to be done in order to improve mental health care in the United States. Topics such as suicide don’t always make for polite dinner conversation, but many would be surprised to know how many of their friends have been affected by this traumatizing act.
“We need a movement that spotlights the human side of addiction,” said Arsenault. “We’re not just statistics, we are human—and we need to do storytelling around this very human issue. We need to let people know that addiction is not a shameful thing—it’s a chronic disease.”
The second area that needs to be addressed is the hold that insurance companies put on mental health care professionals and facilities. “Allow medical providers and clinicians to be able to do their job without a lot of the parameters that oftentimes come with insurance companies,” said Hathaway. “Insurance companies oftentimes will say, ‘Well, for this type of disorder or code, you can only get up to six sessions a year.’ That’s not really fair. Understand that it might not be wrapped up in the pretty box and bow that insurance companies sometimes lump it in. I don’t think that they understand mental health enough. Anybody who has actually dealt with someone who is addicted would look at a 10-day or three week program and think that it’s absolutely ridiculous.”
Everybody is a case-by-case basis, and Hathaway continued to explain that the problem with mental health is that it’s not like dealing with other medical issues. If a patient is diagnosed with high blood pressure, they take a test and are then often put on medication and monitored.
“After a few follow ups, once you’re good, you’re out the door. There is no formula for what happens with mental health. So people need to stop treating it like there is going to be a formula.” We think Fisher would agree.
Raven Brajdic is a writer, cat roommate and copious black tea drinker living in Orlando, Fla.