North Dakota may expand Medicaid for mental health but some see other options

BISMARCK, N.D. (North Dakota Monitor) — North Dakota lawmakers are drafting a policy that would change the system in which some medical providers pay for their services when treating people’s mental health.

While leaders agree more mental health services are needed, especially for tribal citizens, not all agree on how best to achieve that goal.

At the behest of tribal officials who are struggling to keep up with the demand of people needing treatment, the Tribal and State Relations Committee is drafting a bill that would establish an “IMD waiver.”

An Institution for Mental Diseases, or IMD, is defined by federal regulation as a facility with more than 16 beds that focuses on providing services for people with mental illnesses and substance abuse disorders.

Without the IMD waiver, which is available in 37 other states but not North Dakota, facilities with more than 16 beds are not eligible for certain Medicaid reimbursements.

The policy will be discussed during the next Tribal and State Relations Committee meeting slated for Monday on the Turtle Mountain Reservation.

Jasten Schock, director of Bismarck-based Good Road Recovery Center, said that although the state has made significant progress in funding new ways to meet the demand for mental health care, particularly services to treat substance use disorder, the initiatives either “aren’t working” or they “aren’t enough.”

Good Road Recovery treats tribal citizens and does not turn away anyone seeking services, whether or not they have insurance — and a significant number of clients are not insured, according to the center’s chief operating officer, Paige Bell.

The facility is run by the Mandan, Hidatsa and Arikara Nation.

MHA Chair Mark Fox said in an October State and Tribal Relations Committee meeting that because North Dakota doesn’t have the waiver, the tribes are forced to send dozens of their members to other states for treatment.

According to the North Dakota Department of Health and Human Services, Medicaid members can receive payments through other mechanisms, like the state’s substance use disorder voucher, or through agreements available at Fargo-based mental health clinic Prairie St. John’s.

Substance use disorder vouchers use state funds to help people with limited financial resources afford treatment.

In the case of Good Road Recovery, employing the voucher is not a solution, according to Bell, because the facility’s unique status as an Indian Health Service allows it to receive other reimbursements that compensate for more costs than the voucher would.

But those reimbursements still aren’t enough to cover the demand for services, Bell said.

Can workforce initiatives be an alternative solution?
Some health care providers are against bringing the waiver to North Dakota.

Kurt Snyder, chief executive officer of Heartview Foundation, said reshaping the system would make the state overreliant on inpatient services when it comes to treating people who are experiencing mental health issues — particularly substance use disorder.

“I would be in more support of it (changing the system) if it came federally instead of doing a waiver. A waiver is a temporary thing,” Snyder said.

As an alternative, he pointed to community-based programs like the North Dakota Training Academy for Addiction Professionals, a publicly funded initiative established by the Heartview Foundation that trains and disperses addiction counselors across the state who help people in recovery.

The program’s overall aim is to reduce staffing shortages, which both Snyder and Schock maintain is a major barrier to treating people in rural communities.

Around 25 addiction counseling licenses are issued annually because of the program, according to Snyder, who also said North Dakota lawmakers should focus on using Medicaid dollars to increase and distribute the number of peer support specialists in the state instead of directing them toward establishing the IMD waiver.

“Because we’ve had such a lack of outpatient services, we’re in the deep end of the pool. By the time people get to the services, they’re already drowning,” Synder said.

The governor-appointed North Dakota Behavioral Health Planning Council has historically opposed bringing the waiver.

“Much of the discussion ultimately comes down to how limited resources are allocated and ensuring that community support remains the foundation of the system,” said Council Chair Tania Zerr, who emphasized the group is not advocating for a “one or the other” approach by opposing the waiver.

Sen. Tim Mathern, D-Fargo, is taking on the task of drafting IMD waiver legislation. He agreed with the need to make services more accessible in communities, but said he supports bringing the IMD waiver.

“The state’s approach should include more funding for both inpatient and outpatient settings,” he said. Mathern is the director of public policy at Prairie St. John’s.

The current costs of over-strained hospitals and law enforcement outweigh potential costs of implementing the waiver in North Dakota, he added. That dollar amount has not been determined.

Article written by Peyton Haug