Recovery Parity: From Coverage to Integration

After a decades-long struggle, federal legislation now deems addiction treatment an essential health care benefit, mandating insurance coverage on par with other medical conditions. So why do advocates view this as only a first step toward achieving recovery parity? Listen in as host William C. Moyers talks with attorney Emily Piper about the biggest challenges and opportunities involved in efforts to fully integrate addiction treatment and recovery support within all aspects of health care.

0:00:13 William C. Moyers
Welcome to another interview in this series of Let's Talk Podcasts, brought to you by the Hazelden Betty Ford Foundation. I'm your host, William C. Moyers. In each podcast, I sit down with an expert to discuss the issues that are at the essence of Hazelden Betty Ford's mission. From prevention of substance use and cutting-edge research, to treatment, recovery support and advocacy. We are recording this podcast in the midst of the pandemic of coronavirus, and this requires us to take precautions here in the studio, which means our guest, Emily Piper and I are in separate rooms. But our focus is the same today. Parity for addiction treatment in private health insurance.

Emily Piper is the Executive Director of Government Relations for Hazelden Betty Ford. She is responsible for the organization's government affairs strategies focused on state and federal regulatory and public policy opportunities, as well as the expansion of Hazelden Betty Ford's mission through government contracts and public private partnerships. Thank goodness she is also an attorney with a ton of experience in big operations. She is the former Commissioner of Minnesota's Department of Human Services, and she's a full-time mom to two boys and three girls. That's hard to say Emily, that means that's five children.

0:01:35  Emily Piper
I got a lot of kids, William.

0:01:38 William C. Moyers
You got a lot of kids and you do a really, really good job of balancing it. Thanks for being with us today, Emily.

0:01:42  Emily Piper
Thank you for having me.

0:01:44  William C. Moyers
Yeah, you're in charge of all of our government affairs. Tell us, at Hazelden Betty Ford, what does that mean exactly from your perspective?

0:01:51  Emily Piper
Well, as a nationwide system of care, it's state government relations working with state governments, with local governments, as well as representing the organization and our patients, and people across the country who suffer from substance use disorders and their families before Congress. Making sure that lawmakers know our issues, know our people, and know about us and our work. Trying to make a change in our community and in our country.

0:02:16  William C. Moyers
And the key of that, of course, is to expand access to care, right?

0:02:20  Emily Piper
Absolutely. And access to prevention and access to recovery resources too.

0:02:25 William C. Moyers
And of course, for a long time at Hazelden Betty Ford, who were known as Hazelden, although we often worked with the Betty Ford Center, our big push was on getting insurance companies to end their discrimination, and to cover addiction like they would cover any other chronic illnesses. Can you talk a little bit about that history?

0:02:42 Emily Piper
Yeah, well, it wasn't too long ago that insurance wasn't required at all to cover any behavioral health, so mental health or substance use disorder treatment services. And so people, even though substance use is a really common disease condition, people didn't have insurance that covered the benefit for treatment services. And so our organization, along with many others, spent years and years in state legislatures and before Congress trying to make a difference to change that. And we have over time.

We have a long way to go, but states have parity laws saying you need to have equity in treatment coverage versus the rest of your health insurance. And Congress has taken several actions over the years to ensure that people have insurance that covers treatment for addiction.

0:03:33 William C. Moyers
And of course, as that manifests itself within our organization, parity has been critical to access of care for our patients, right?

0:03:42 Emily Piper
Yeah. I mean, the vast majority of us don't go to the doctor and try and pay cash to get our ears checked for an ear infection. And people rely on their insurance, and as a disease condition, it should be covered by health insurance. And slowly but surely we are getting that coverage for people who need it. Because, the vast majority of our patients, regardless of income or social status, socioeconomic status, they use their insurance to pay for their healthcare and they should be able to for their treatment.

0:04:12 William C. Moyers
And of course, at Hazelden Betty Ford about, I think it's 95% of our patients now are using their insurance to access our system. And that's a reflection on parity. Yes?

0:04:21 Emily Piper
Absolutely.

0:04:22 William C. Moyers
So where do we stand on parity? It's good news. What's the situation now?

0:04:30 Emily Piper
You know, I think historically parity's been thought of as insurance coverage. And we've made great gains for making sure people have insurance coverage, but that's really just the beginning of what parity looks like. Parity looks like equity in healthcare for people who have the chronic disease condition of substance use disorder. Just like mental health. And we have a long way to go in ensuring that that is the case for people and their real-life experience with healthcare and with treatment.

0:05:04 William C. Moyers
How do we get there then Emily?

0:05:06 Emily Piper
Well, I think we have to take a broad look and we have to have bigger conversations about what people need and what their experience should be versus what it is now. And that could include taking a different view of prevention and recovery as part of what parity is and what it should be. And I think there's openness in conversation, in understanding with lawmakers and public policy makers at all levels of government. But it takes a lot of explaining the science behind addiction. It takes a lot of understanding a person's personal experience, their family experience, and elevating those voices for people who make the decisions in our country to hear and understand. And so, that's a lot of the work that we do at Hazelden Betty Ford Foundation.

0:06:00 William C. Moyers
Also, the Affordable Care Act, some would call it Obamacare, that also addressed the disparity between coverage and what people needed for treatment. Is that right?

0:06:10 Emily Piper
Yeah. The ACA did a lot. It mandated that addiction treatment be an essential health benefit on people's health insurance plans. So new plans. Addiction care became an essential health benefit. And it expanded Medicaid to ensure that people who have government insurance as their main insurance carrier, that they have access to addiction treatment. And states that expanded Medicaid also, it really opened the door for a whole new group of people, adults without children, to get access to Medicaid and treatment services that are offered under Medicaid. And in states like Minnesota, about 25% of people who have Medicaid as their insurance, who are adults without children, so expansion population people get addiction and mental healthcare every single year.

So it's a huge benefit. Opened the door to a lot more people getting treatment when they need it.

0:07:07 William C. Moyers
So there's a risk then, to those people, particularly in any dismantling of the Affordable Care Act, right?

0:07:15 Emily Piper
Yeah. It's a tremendous risk and it's not just for people who have their insurance through Medicaid. It's, the essential health benefit of addiction care is at risk as well. And so, we heard a lot of mental health advocates, and advocates for people with substance use disorders speak out on these issues when the ACA was going to, when there was conversations about it being repealed, saying, hey, this is a huge issue for us. And we want to make sure that people continue to get the care that they need in behavioral health.

0:07:44 William C. Moyers
So we know that addiction is a bipartisan problem, and one that demands a bipartisan solution. What would you tell our viewers and our listeners today on this Let's Talk Podcast about what they can do to make sure their elected officials are aware of how important this issue is?

0:08:03 Emily Piper
Well, there's so much stigma attached to addiction. And the most impactful thing that I think people can do is talk to their legislators and their lawmakers, and tell their stories about how substance use disorders impacted them, their family, their community. Because virtually all of us have a story, and those are the most powerful ways to move and make a point about why something should be important to a lawmaker.

0:08:35 William C. Moyers
Particularly now, in this time of a pandemic, in this time of the social upheaval that's happening in this country, the economic challenges. Could you bring us up to speed on the impact that the pandemic has had on healthcare, and specifically what steps have been taken to address substance use and mental illness issues within the pandemic?

0:09:01 Emily Piper
Yeah. Well, it's been terrible for all of healthcare and you need to read the news once every week to just see all of the headlines of healthcare organizations being stretched to capacity, having budget issues that are impacting their ability to continue to deliver care and addiction treatment. And mental healthcare is no different. In fact, it has been something that has been brewing as an epidemic before the pandemic, and has been a challenge for lawmakers to get their arms around.

There has been action taken before Congress, some of it long overdue, like trying to align privacy rules more closely with the rest of healthcare. So we can integrate more our care with the rest of a person's healthcare as part of some of the pandemic proposals. And there has been some funding for substance use disorder that has passed, but far more needs to be done. And really, it has been crisis response funding only, versus real, long-term sticky investments in our treatment continuum.

So we're hoping that the focus will continue to grow, and that lawmakers will continue to see a bigger picture about what needs to be done in our field for all of the people that are suffering in our country.

0:10:24 William C. Moyers
I know this is going to sound a little bit inside baseball, but there'll be a lot of people who were watching this specifically because you are our guest and you have that expertise, and they're going to want to know about things like CFR 42. Could you just talk a little bit about that?

0:10:37 Emily Piper
Yeah. So 42 CFR Part 2 is the privacy rule that governs nonprofit substance use treatment providers, and as keepers of records for people with substance use disorder who come to us for treatment. And so if you're a for-profit provider who doesn't take government insurance, you don't have to comply with 42 CFR. We do because we're a nonprofit. And one of the issues we have is 42 CFR was created long before HIPAA was in place, and it was very much needed at the time it was created. But what it has had the effect of over time is walling us off from the ability to benefit from all of the innovations in healthcare. Like care coordination, doctors coordinating with each other. Having fully integrated electronic medical records. Being able to do e-prescribing, just because it's a really antiquated rule.

And so, we've been working for several years to try and align some of the requirements of 42 CFR with HIPAA so that we can do the things that we need to do to provide the best care for our patients. And so we were pleased in a congressional action recently that those changes were made, while still ensuring that there is additional privacy over our patients' records as it relates to law enforcement and other concerns. So we're very pleased. We're hoping that it will really help advance our patients' care and patients' care across the country to better align with their overall healthcare needs.

0:12:20 William C. Moyers
That privacy issue, as you know, is significant. We've been pretty good at it over the decades. But now we've all entered a new world of telehealth, and specifically virtual care. Do you have any concerns as the expert that you are, on how we, as in field, protect confidentiality and privacy in a virtual world?

0:12:44 Emily Piper
I do. I think, especially during the pandemic, because the federal government and state governments have lifted some of the privacy requirements for delivering virtual care. So you can deliver on platforms that aren't secure, that don't meet all of the privacy requirements of HIPAA for the period of the pandemic, and there's risk there. And we've heard about Zoom bombs, of people coming into Zoom meetings and things like that. And we want to make sure that we are trusted resources, that we're doing what we need to do to protect patients' privacy, as do all healthcare providers.

And so we're fortunate, frankly, that we have compliance solutions for telehealth ourselves. But it does concern me that not all operators do, and that people rely on them to be that, and perhaps they aren't good gatekeepers at this point during the pandemic.

0:13:42 William C. Moyers
One of the things that we've done in Hazelden Betty Ford is we've pivoted pretty quickly to virtual care with our Recovery Go platform. And that platform has allowed us to meet the needs of patients in seven states, I guess the seven states that we're licensed. But that means we still haven't been able to use our expertise, our clinical expertise, our technical expertise in some of the other states. Can you explain that just a little bit, of how that works and where we hope to go there?

0:14:09 Emily Piper
Yeah. Well, I think we hope to grow nationally over the next year or two to make sure that we can offer our virtual services in every state. The trick is, is that a lot of our work is state regulated. So our clinicians are state regulated, our facilities, our programs are state regulated. And so every state is different. So it takes time to figure out all of the operation's requirements of each state that might look a little different from one another to make sure that we're doing it right.

And so that's what we're doing now. We're working internally to go state by state to figure out what we need to do to follow all of the right rules and regulations, and stand up virtual services in more states as quickly as we possibly can.

0:14:57 William C. Moyers
We've got about a minute left. I just wanted to ask you, looking forward from this point on, I know you have a vast experience in healthcare. What do you see over the course of the next five years? Certainly knowing that this pandemic continues to defy all of our expectations. And here we are in June of 2020 recording this, and who knows where we'll be in three months or six months. But from your unique perspective, where do you see addiction treatment in the context of public policy and advocacy in this country in healthcare over the next five years?

0:15:28 Emily Piper
I see a focus on integration. Breaking down the barriers, like the privacy barriers we talked about earlier, to integrating our patients' treatment for substance use disorder with the rest of healthcare. And that can look like a lot of different things. It's better training doctors and our healthcare workforce, and what it means to care for someone with substance use disorder. It is investing in more research in brain diseases like dementia and addiction, just like we do cancer research.

It looks like ensuring that our patients have care coordination. It looks like some of the barriers around prescribing medications for people with addiction are broken down. And that really is how we get to true parity, is through integration and education and research.

0:16:24 William C. Moyers
True parity, that's our goal. And we'll get there with your leadership. Thank you, Emily Piper, the Executive Director of Government Relations for Hazelden Betty Ford. We appreciate you bringing your expertise to our podcast today. And thanks to all of you for tuning in. Be sure to keep coming back for more in our series of Let's Talk Podcasts. On behalf of our Executive Producer, Lisa Stangl, and all of us at Hazelden Betty Ford, please stay safe and stay healthy in these times as always.