Insurance for Addiction: Dangers of the Rehab Machine

Assuming you’ve been present in this country for the last few years, I’m sure you’ve seen it on the news; and in the off chance you’ve been completely off the grid, allow me to fill you in—there’s a drug epidemic tearing through the lives of millions and growing steadily in number, quickly becoming one of the leading causes of premature death for young adults. The main offender as of late is opiate derived narcotics, namely, heroin.

We Need A Sustainable Solution for the Drug Epidemic

However, in the midst of all the inherent chaos following this seemingly inexplicable scourge, we still find ourselves drastically lagging on anything that resembles a viable solution. News outlets, politicians and medical professionals alike, have vocalized the problem tirelessly, but none seem to agree or even converse about possible antidotes for the situation at hand.

Unfortunately, if you find that you or someone you love is directly affected by problematic substance abuse or full blown addiction, you know that time is of the essence; and even beginning to navigate the limited “treatment” resources available can be daunting. So that said, I’d like to talk about the different options available in our current system, the parameters under which they are regulated, and even some of the possible risks involved in certain methodologies.

A Brief History of Insurance-Funded Treatment

Since the legislature passed during the Obama administration which required insurance companies to cover substance-related issues as a legitimate health issue, insurance funded treatment has become the primary modality utilized by those struggling with addiction. Prior to this, almost all aspects of supervised drug and alcohol mediation outside of acute hospital visits were funded privately by the individual seeking help.

The few exceptions to this were a handful of county and state funded programs with varying levels of effectiveness. However, the legitimization of substance abuse as a medical problem brought with it a massive influx of insurance based programs around the country, flooding the market with infinite options for those seeking to get treatment. 

Sounds great, right? 

Not so much.

 To understand some of the fundamental issues inherently built into the current system, you’d have to first look at the very nature of insurance. Despite the frothy commercials depicting joyous families overflowing with vitality, your health, at least in the capacity that you would expect, is of little importance to them. The industry is built on the calculated gamble that on any given day, more people will be paying for insurance that will not get utilized than people who require coverage. Any surplus can then be invested or traded for added profit, but the basis relies on that simple fact—customers pay more money than they require.

How Insurance Really Works

Insurance companies are filled to the brim with “analysts”, or individuals whose sole purpose is to figure out what liability a potential customer could pose or how worthy of coverage any given situation may be. Depending on the severity of a condition, the methods of treatment offered or any predisposed risks that the individual may have exhibited, the insurer works to negotiate the lowest price that they can pay out.

Of course, some treatments go without scrutiny whether or not they present a loss to the company as they have become recognized as the universal standard in treatment for whatever ailment may have prevented itself. These standards are recognized with irrefutable evidence posed by research within the medical community as well as regulatory stipulations placed on medical institutions in America. For the most part, these remain relatively stringent. 

How Does Addiction Work With Insurance?

Well, unlike cancer or pancreatitis, addiction is largely regarded as a criminal issue, both from a legislative standpoint as well as in the public eye. In fact, until recent years, the only proposed consequence for those suffering from addiction was of a legal nature. Only in the last couple decades or so have we seen things like drug court or other diversion programs start to come into play. Even with the slight shift in stigmatization, very little money is allocated towards effective research on addiction.

Truthfully, little is known on how to get people sober and even less on how to keep people sober. There is not much resembling a unified force to dictate the parameters of treatment, which leaves a lot of room for the insurance companies to wiggle. Beyond that, it has fostered a massive treatment industry with very little in the way of regulation. “Rehabilitation centers” have sprung up by the thousands making hollow promises in exchange for giant sums of money, usually paid out by insurance company.

Treating Addiction is not a By-The-Numbers Process

Now let me be absolutely clear, I am not saying that all insurance funded treatment centers are a hoax. There are plenty of reputable facilities which do great work. But following that logic, the problem should lie within the individual facility rather than the source of funding, correct?

Wrong again.

There is no singular way for an individual to find recovery. Given the behavioral nature of it, there will always be some level of subjectivity involved; but nearly anyone who has their wits about them in the field of addiction will tell you that for an individual to achieve and maintain any kind of long term sobriety, they will need to experience some significant change in either perception, lifestyle, social circumstance or behavioral pattern, usually aspects of all.

I’ll call that process “reformation”.

It should come as no surprise that such a drastic overhaul takes a healthy chunk of time and attention, assuming there is already some level of willingness for change.

Abstaining from Addiction is Not Recovery

Of course, when it comes to recovery from drugs and alcohol, there is one monumental obstacle to overcome prior to unraveling and recalibrating the mental or behavioral maladies—the physical addiction. In order to even begin to entertain change, the individual must first put some time between themselves and the last drink or drug to regain some semblance of physical health and mental clarity. Without this step, nothing is possible.

For the sake of argument, we’ll call this “cessation”. And this is where we find some of the major shortfalls that come with insurance-funded treatment. Remember when I said that the fundamental infrastructure of the insurance business revolves around paying out as little as possible?

Well, it‘s a whole lot cheaper to pay for an individual to be removed from a substance then to teach them to stay away from it.

How Insurance Covers Levels of Addiction Treatment

From a medical standpoint, there are varying levels of treatment that are deemed necessary depending on the situation of the addict or alcoholic. Traditionally, insurance will cover each level for certain amounts of time, gradually stepping down to less-intensive and ultimately cheaper forms of treatment.

The primary modality is acute detoxification, usually in a hospital setting. This ensures the safe cessation from the substance of choice in a medically-supervised facility. However, in states like California, this is getting harder and harder to receive coverage for. Depending on the severity, coverage will last anywhere between three and seven days.

As soon as it is determined that there is no imminent risk of medical emergency, insurance will drop down to “residential”. These are generally privately run businesses that offer 24 hour wake-staff, access to clinicians, group and individual therapy, and most importantly, insulation from drugs and alcohol. While many of these “treatment centers” offer quality services, there are no shortage of restrictive vacation homes masquerading as legitimate help, rising from the lackluster regulations that allow insurance funds to be exploited.

There is a whole subculture of business based around the exploitation of insurance coverage, but we won‘t get into that. Payouts for this level of treatment can last anywhere from seven to sixty days, but for the majority of plans, it’s usually on the shorter side. Very rarely is more than thirty days deemed necessary.

By this point, most of the physical symptoms have subsided and the individual is dropped down to the next level of treatment, PHP, or “Partial Hospitalization”. This means that for up to 7 hours a day, the individual will attend groups and therapy for anywhere from three to five days a week. In a short few weeks, coverage will be dropped to IOP, or “intensive outpatient”, and then finally to OP, or “outpatient”, before cutting off completely.

Low Levels of Structure Can Be Detrimental

Let’s assume that you’ve been granted 40 total days between residential and detox, and that’s being extremely generous. After just a relatively short time, you will be granted autonomy for large portions of the day, if not multiple days at a time. For anyone who has struggled with addiction or has watched someone afflicted with the disease, you know that this is a recipe for disaster. Within another month or so, the individual is granted absolute freedom and expected to figure out the rest on their own. As far as insurance is concerned, they’ve successfully fulfilled their obligation.

They’ve “ceased” the destructive behavior.

But sadly, 9 times out of 10, that doesn’t cut it. More often than not, the individual returns to the same environments from which they came, with only a rudimentary understanding of the tools which are integral to long term sobriety. Sometimes they may last months or weeks, but it is not uncommon to see relapse within only a few days.

So, if simple cessation can’t foster long term recovery, then who’s dealing with reformation??

Cessation vs. Reformation in Addiction Treatment

Quite a few places really, but most of them are long term. There’s a lot of debate around proper tactics for effecting transformative behavioral changes, but one fact is generally agreed upon—the longer an individual remains abstinent from drugs and alcohol, the better their chances of staying that way. Research has shown that far less than ⅓ of people who attempt to get sober will make it to a year on their own, while those who surpass one year hold closer to a 50 percent chance, statistically speaking.

As such, it only makes sense that providing structure and accountability during that vital first year is paramount to success. Barring anomalies, significant change doesn’t happen in 40 days. This fact is proving itself continually. If you have any experience with the “rehab machine”, you’ll know what I’m talking about. And what does this mean for addicts and alcoholics?

Relapse. Lots of relapse.

So long as we continue to treat the symptoms and remain willfully ignorant towards the problem, numbers will remain dismal. Unfortunately, the few facilities that are really attacking the issues at the roots are rarely covered by health insurance. They are private-pay, or occasionally run by the state, but these usually have waiting times spanning months. They are built on the concepts of long-term accountability and meaningful behavior change. They aim to recalibrate the values and perceptions of the addict. They are gradual. They emphasize transition and life skill. They do not simply remove the drug from the desire, but remove the desire for the drug. Without change there can be no recovery, and put quite simply, your insurance could give a damn whether or not the change occurs.

Follow-Through is the Key to Treatment

If you believe that merely removing the drugs and alcohol will suffice, then by all means, follow your heart. Go to rehab. They’re not evil, at least not always, they’re just not ENOUGH. But, on the other hand, if you’ve circled through the system for years or watched your loved one try tirelessly to achieve sobriety, admitting to treatment after treatment with dwindling hope, then maybe it’s time to admit that there’s something inherently wrong with the system. The issue is follow-through and usually there is none.

It’s a shame that quality treatment isn’t more readily available, but it is there if you know what to look for. Do not settle for an allotted amount of time. A 28-day rehab or 7-day detox is not a selling point. Neither is an on-staff chef or massage therapy. Those are distractions. Trivial comforts to compensate for little semblance of a viable solution. But ladies and gentlemen, recovery is uncomfortable. Beautiful. Gratifying. Transformative. Extremely uncomfortable.

In Conclusion

Without pain, there can be no growth. We’ve heard it a million times, but in this particular arena, no sentiment rings more true.

Do not walk blindly into such important territory. Arm yourself with the facts before pulling the trigger on proper treatment for you or your loved one. Ask the right questions—Do you prepare for the long term? Do you work to assimilate back into life? Is your program individualized? Do you have a high turn-around? What are your parameters for growth? What values do you instill? When all is said and done, where will this leave me?

If any of these answers seem fishy, they probably are. Cessation simply doesn’t cut it. Recovery is synonymous with growth and growth takes time. Time that the insurance companies just won’t grant you. So if you’re out to really change your life, maybe it’s time to look elsewhere.

Last Updated on February 22, 2024


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