As psychiatrists, we are interested in providing good care to our patients. At times, we become aware of legislation that can have dramatic effects on our practices, on our careers, and on the lives of our patients.

During my psychiatric residency at Bellevue hospital in the 1980’s, I was frustrated by the seemingly insurmountable problems of patients with drug and alcohol addiction. Yet, they intrigued me as well. Why did otherwise rational-appearing persons engage in such self-destructive behavior? This was to become a major focus for my career. Three years after I finished my residency, the New York State Legislature passed a law defining a new category of drug treatment programs. These programs were called “medically supervised” and could, for the first time, receive insurance reimbursement. The law stipulated that these programs had to employ a physician with expertise in drug addiction as Medical Director, and all new patients were required to have a face-to-face interview with such a physician before being admitted.

A friend of mine told me about a small treatment program that had received one of these licenses, and was looking for such a physician. At first, the program did not think I could be of much use and mainly tolerated me as a legislative necessity. Over time, I examined hundreds of patients suffering from addiction to drugs and alcohol. I developed greater understanding of these patients, and I developed greater skill in treating them. The staff came to see the value of a psychiatrist in supervising the treatment of these patients, and I assumed a much greater role.

There is no doubt that if this law had not passed, this treatment program would not have employed a physician. This law had a profound impact on the lives of the patients I treated, and on the quality of the treatment they received.

Many of the patients coming to us had lost their jobs as a result of their addictions. If indigent, these patients were eligible to receive Medicaid, if they were disabled as a result of their addiction. Although success was not assured, at least the patient had a chance at recovery through access to treatment. Many of the patients we treated did recover from their addiction, completed school, got jobs, and got on with their lives.

When I moved to Maryland in 1996, I began treating patients with addictions in a variety of public and private clinics. I soon discovered that the picture here was different. In 1994, the rules on Medicaid eligibility changed, so those patients who are addicted to alcohol or drugs are not eligible for Medicaid, even if the addiction is severe enough to be disabling. This contrasts addiction with every other medical disorder; other disorders, if severe enough to be disabling, entitle the indigent to receive Medicaid. The effect of this exclusion on Maryland residents with addictions is profound. Although early in the history of an addiction, many patients still work, as the disorder progresses they often lose their jobs and their health insurance, making it difficult to find affordable treatment. There is a patchwork of very poorly funded public treatment programs, which target selected populations. If patients belong to one of these groups, and a new grant program opens, they can get treatment in a reasonable period of time. Otherwise, they can wait years. Patients can get into these programs only if they belong to one of the following populations: those who have AIDS, those who have been hospitalized for drug-related medical problems, those who use intravenous drugs, and those who are pregnant. It is sad and ironic that many of these patients ultimately develop illnesses as a result of their drug addictions, which then render them eligible to receive Medicaid. A patient of mine, for example, had five hospitalizations for endocarditis from injecting heroin, and as a result developed severe congestive heart failure. She could then qualify for Medicaid and was able to enroll in a methadone program. She stopped using heroin, but it was too late. She died of heart failure shortly afterwards.

As a member of the MPS Legislative Committee, I have been speaking with public officials and leaders of non-profit groups about this problem. Many were unaware of this particular exclusion. Others were aware of it, but focused on the few who might abuse the system, i.e. by feigning drug addiction in order to get Medicaid, rather than thinking about the many Marylanders who suffer with drug addiction and have no access to treatment. These fears of abuse of the Medicaid system are overblown. In 1997, Maryland received a waiver from the Federal Government; it now requires all Medicaid recipients to enroll in one of the several managed care organizations in order to receive medical care. These managed care organizations have built-in barriers controlling access to care. For example, they have primary care “gatekeepers” in order to reduce fraud and abuse, and they further review treatments in order to control costs. A Medicaid card in 1999 is a part of a regulated system; it is not the unrestricted card it was in 1994 when this exclusion was enacted.

A State Task force, chaired by Lieutenant Governor Townsend, has been studying this matter for well over a year. I have urged the task force members to recommend legislation eliminating this exclusion. We must increase access to treatment for Marylanders who are disabled due to drug addiction. Only then can we hope to allow them to return to productive roles in society.