On Wednesday, the Illinois House overrode Bruce Rauner's amendatory veto of the Heroin Crisis Act; previously, the governor had cut a provision requiring Medicaid to pay for medication-based treatments. It might not be a massive defeat for the governor—his veto was not a cornerstone of his policy platform, and the override does not indicate a weakening of his political power—but the numbers were dramatic: 105 to 5, a near-unanimous agreement across the aisle.
Part of the debate leading to the House veto override was a recent report out of Roosevelt University that looked at both the heroin problem in the state (which has been getting worse) and the treatment opportunities that the state provides (which have been in decline).
The report surprised a lot of people—especially the lead author. The decline is so dramatic that lead author Kathleen Kane-Willis initially thought it was a data error. Kane-Willis and her colleagues found that, between 2007 and 2012, Illinois had the highest decline in state-funded treatment admissions in the country, a 52 percent decrease.
After the House vote, I spoke to Kane-Willis about the report, the vote, and how the bill fits into state and national trends of heroin abuse and treatment.
What was your reaction to the veto override?
It was pretty tearjerking—tears of joy. The advocates, and a lot of people who have been impacted by the crisis down there … To see that vote come in was a pretty heartfelt moment.
Your report seemed to have an effect on the outcome.
We've released many reports on heroin use, but when we were looking at the numbers most recently, we noticed the decline in treatment capacity; we really knew that it was an important report to get out as quickly as possible.
At first you thought it was a data error.
We really did think it was a data error. We'd been looking at these numbers for some time. I did a series with WBEZ called "Heroin LLC," and I'd gone in and analyzed the data, and was looking at race, and I'd noticed that the numbers were a little off. I knew that treatment had been cut extensively, just because of my role on the Illinois Advisory Council for Alcoholism and Drug Dependency; I'd heard the providers really complaining about this issue. So I knew that was the case, and when we looked at the data again, I was really surprised at how much it had dropped. I really did think it was a mistake. But then we looked at 2013—and we can't compare to all those states for 2013, but Illinois's numbers are in, and it's continued to decline.
And the decline has been going on for years.
Yes. And it's partially the result of the decline in funding, but it's also what we're going through right now with the budget crisis. Things are funded, they're not funded, they're funded again; the lack of surety in funding makes it really hard to deliver services. If the money is reinstated, it's not like you can go back and provide treatment to people.
So the treatment capacity is both a result of the cuts to treatment, and the the uncertainty of funding. And there's been a number of treatment centers that have closed or consolidated, because the state of Illinois is behind in paying its bills, not just this year, but a long time. When you're thinking about capacity, and you've got a smaller treatment center, they might not be able to float that for six months.
That's why, in some ways, the heroin-crisis bill was so important, to make sure the Medicaid funding was there, because the future of treatment for low-income folks is going to be more Medicaid-based in the future. That's where it's going to be. Ensuring that people have access to all forms of treatment, especially medication-assisted treatment, like methadone and buprenorphine, because that's what the future's going to look like. I don't know that we'll ever have the treatment capacity on the state-funded side, but on the Medicaid side, with the expansion, we hope that that can make up for some of the decrease in availability in state-funded treatment. This would provide treatment for a lot more people.
The truth is, on the funding side, is that Medicaid, especially the Medicaid expansion, is mostly picked up by the federal government until 2020. So I think the cost argument was wrong; it would save the state a lot of money. Because we pay for this in our emergency departments, our jails, our prisons, etc. So we're going to pay for it. It's cheaper to provide the care.
And there's an inflection point in 2014, when Medicaid funding for treatment surpasses state funding.
When you look at the proposed budget for 2016, the general revenue funding and Medicaid funding are lower than general revenue funding [alone] was in 2007. Treatment capacity and funding is decreasing.
General revenue funding in 2007 is $111 million; in 2016 proposed GRF is $43 million, and Medicaid is $75 million.
We released the report strategically because we thought it was really important; I hoped he wouldn't veto the legislation. We were really hoping the governor would sign the bill in its entirety; it's a very comprehensive fix to a broken and failed system.
The thing that surprised me in this latest report was when we looked at the areas across the state, and some of the metro areas had seen such large increases since we'd last looked at the data. When you're talking about places like Decatur, and Metro East, and Springfield, you just don't really imagine that they're experiencing the heroin problem there. But those places have been really hard hit.
Why do you think the increase is so great there? It seems like things around Chicago haven't changed as much.
I think if you were to characterize the problem around Chicago, it would be elevated—extremely high but stable. Actually, that's not true in the Chicago metropolitan area; it's high, but it has gone up, and it is increasing. It's the perception of places like Decatur. They hadn't ever seen this before. It's not that surprising, the increase in the Chicago metro area, but some of those increases downstate were very surprising.
Do you think the decline in treatment plays a role?
It's not helping, but I think it's a couple of different things. This is a national issue; it's expanding to places it hasn't been. But the prescription-drug opioid problem is intertwining with the heroin problem, and creating two separate epidemics that are existing at the same time. If you were going to look at downstate patterns of initiation, it's going to be more of a painkiller-to-heroin trajectory. In the Chicago metropolitan area, our pain-pill prescribing rates have always been kind of low, and the availability of heroin has always been very high.
Downstate, the prescribing patterns are different. If you're talking about the Metro East area [near St. Louis], which is contiguous with Missouri, their prescription pill problem in Missouri is very big. And those borders aren't solid walls. The downstate increase is a result of those intertwining crises, that intersection between the opioid pill problem and the heroin problem. For example, when people are cut off from doctor shopping, and opioid pain pills, it's cheaper to buy heroin. If there's a demand for it, the supply will come and meet the demand. And I think that's what we're seeing downstate.
What are the major things in the bill that you think are going to help?
It's a long, long bill. It enforces parity; it does so many good things. It allows for pharmacists to initiate a prescription for naloxone. Someone could walk into a pharmacy and get the antidote for an overdose—and that would be covered under Medicaid. That's really important, the coverage of the overdose-reversal drug under Medicaid. And being able to get it to these rural areas, for people to be able to access it at the pharmacy, that's really important. That's really important.
So someone who is a heroin addict, or someone who knows a heroin addict, could go in and get it?
Yes. One of the things we talk about with any opioid prescription is the co-prescribing of naloxone. When you think about the Medicaid population, people who are prescribed opioids for issues that are not addiction issues, people who are not addicted—there are still mistakes people make with this medication, and it's important to have people trained in naloxone. We believe it should be in everyone's medicine cabinet. This helps that effort.
To me the meat of the bill was the Medicaid provision. So when the governor applied the amendatory veto to that page of the bill, it was pretty heartbreaking.
The vote was pretty dramatic.
The people who have been impacted by heroin in this state are pretty well organized, I would say. When you're asking legislators who are being called by their constituents who are seeing it happen, who have hosted these forums, who are concerned about the problem—they know that it exists. I can't think of any legislator who would say "I know nothing of what you speak; it's not in my community." The representatives have been personally touched by this.
One legislator said she'd been to two funerals because of overdoses.
Yeah. The landscape has changed tremendously in terms of getting elected officials to understand what to do about it. It's required a lot of education; a lot of people have been working on that pretty hard. I think that's partly why the override was so overwhelming, nearly unanimous.
How do you think the bill could have been better?
I think it's relatively comprehensive, so it's hard for me to pick it apart in that kind of way. I would say education for doctors—that's incredibly important, because they don't get very much education in terms of addiction medicine. And the model that we're moving towards is that you have your health-care home, a primary doc that's going to coordinate your care. If the person who's seeing you doesn't understand your addiction, doesn't know how to screen for substance-abuse disorder, doesn't know how to have a conversation about that, I think that's a really vital piece.
The reality is that every provider is going to be in contact with someone with a substance-abuse problem in their career. Even if they're treating children—the family, the parents—it's going to arise, because it's a relatively common disorder.
One thing you mention in the report is the problem of time limits—how long people can be on medications. Was that addressed?
Yes. That's addressed in the bill; it's huge. That's in the part the governor applied the amendatory veto to. The reason that's so important is that the benefits for medication for addiction treatment aren't always realized in the first year. Some people need to be on medication for a longer period of time; some for shorter periods of time. Particularly in addiction science, the research shows that there's no one kind of treatment that's better than others. Things have to be individualized. But also, time in treatment matters. The length of treatment is the most robust outcome measure for success. Not that everyone has to be on these medications has to be on for a long time, but for people who do, you can't arbitrarily impose those limitations. Imagine if you had diabetes, and someone said "you can only have insulin for a year." We'd be pretty upset if it was any other condition.
You can't have a cookie-cutter system. There's no one way to do this. It depends on the individual. We want to have all the tools in the toolbox at the disposal of both the provider and the patient.