Medicare needs to cover the full spectrum of care for substance use disorders

Imagine if Medicare covered treatments for stage 1 or stage 4 cancers, but nothing in between. Absurd, right? Yet that is how Medicare approaches treatment for substance use disorders for its 64 million beneficiaries.

This federal health insurance program currently pays for only the least intensive level and most intensive level of substance use care, denying millions of people access to other forms of evidence-based and lifesaving treatments, such as intensive outpatient and residential treatment. This policy makes no sense, especially amid the escalating overdose crisis, which has a disproportionately deadly effect on older Black people.

Substance use disorders do not disappear when people turn 65, nor are they any less of a threat to younger people with disabilities, who are also covered by Medicare. An estimated 1.7 million Medicare beneficiaries are living with diagnosed substance use disorders. Without access to treatment, most of them will likely get sicker, particularly those with other chronic and progressive illnesses. And with that, their care gets more expensive.

A recent study that one of us (E.W.) co-authored showed that high costs, including lack of insurance coverage for treatment, are a key barrier that Medicare beneficiaries identify for not accessing the care they need to treat substance use disorders.

This Medicare policy is penny wise and pound foolish. Medicaid and the Veterans Health Administration both cover comprehensive treatment for substance use disorders. Among the major government-sponsored health care payers, only Medicare fails to provide the full range of medically necessary coverage.

What’s more, Medicare is not subject to the federal Mental Health Parity and Addiction Equity Act, which requires Medicaid and most private insurance plans to cover mental health and substance use disorder services on a par with the coverage they provide for other medical services. So why does the second-most used health insurance in our country deny the people who rely on it an equitable opportunity to receive lifesaving health care?

Cost considerations should not and need not prevent the addition to Medicare coverage of critically missing therapies and practitioners. According to a new study conducted by RTI International, a nonprofit research institute, in partnership with the Legal Action Center, which one of us (E.W.) works for, adding to Medicare coverage for residential programs, intensive outpatient programs, and licensed and certified counselors would be nearly offset by the savings. The total net cost would be approximately $362 million per year. Given Medicare’s annual budget of $829 billion, this figure represents a nominal budget line for the program, with enormous potential benefit for participants and their families.

For all these reasons, it’s time for Medicare to cover the full range of substance use disorder treatment services and providers. It makes sense both financially and in terms of promoting equitable access to quality care.

Fortunately, there is growing bipartisan agreement in Congress to address this urgent problem. To do this right, future legislation should incorporate several key principles endorsed by the organizations we are affiliated with: the Legal Action Center, Medicare Rights Center, and Center for Medicare Advocacy:

• Apply the Mental Health Parity and Addiction Equity Act to Medicare Parts A and B to eliminate limits to the length and settings of care, utilization management-associated barriers such as continuing care authorization, and restrictive reimbursement practices.
• Apply the Parity Act to Medicare Parts C and D to eliminate restrictive utilization management — including those related to accessing needed prescription medications — and provider network, contracting, and reimbursement practices.
• Authorize coverage of the full continuum of evidence-based substance use disorder treatment services, including intensive outpatient programs, partial hospitalization programs for a primary substance use disorder diagnosis, and residential treatment, to ensure that beneficiaries get the appropriate level of evidence-based care in the least restrictive and least expensive settings.
• Authorize coverage of community-based substance use disorder treatment settings in order to greatly expand capacity and allow for the delivery of care in the most common — and often most accessible — settings.
• Authorize coverage of all licensed mental health and substance use disorder treatment providers and establish adequate reimbursement rates, which will also significantly expand the behavioral health workforce.

Parity for treating substance use disorders should have been applied to Medicare long ago to ensure that older adults and people with disabilities can access and afford the full scope of treatment and providers they need and deserve.

By enacting these changes, Congress can usher in a historic and desperately needed modernization of Medicare, helping millions of individuals with substance use disorders get vital care while eliminating discriminatory treatment practices and ultimately saving countless lives.

Fred Riccardi is the president of the Medicare Rights Center. Judith Stein is the executive director of the Center for Medicare Advocacy. Ellen Weber is the senior vice president for health initiatives at the Legal Action Center, which convenes the Medicare Addiction Parity Project.