SEATTLE — When Washingtonians addicted to drugs seek long-term care, they arrive at treatment facilities knowing that, on top of therapy and medication, they’ll also get food, a bed to sleep in and a roof over their heads.
What they might not know: The meals, beds, chairs, shower facilities, pest control, building repairs and wages for cooks, janitors and groundskeepers aren’t covered by public insurance.
As Washington continues to grapple with deadly fentanyl overdoses and high rates of addiction, operators of the state’s addiction treatment centers say they’re drowning under the weight of overhead costs.
To cover each publicly insured patient’s basic necessities, operators are reimbursed just $14.20 a day. Some counties may offer additional room and board funds: King County, for instance, offers its providers an extra $14 per day, officials said.
“I don’t eat for $14 a day. Plus the cook to cook it, the gas for the stove,” said Kristen Prentice, program director at Renacer Youth Treatment Center, a South Seattle treatment facility. To make ends meet, facilities say they stretch all the dollars they do receive, such as clinical reimbursement payments from commercial and public insurers, grants and donations. “We function on passion and love. That sounds froufrou as all get out … (but) we don’t have the luxury to just pay for something to fix it.”
Now, even in the midst of an extraordinarily tight budget year, a small bipartisan group of Washington lawmakers wants more state dollars to cover addiction patients’ basic needs.
“I was shocked,” to learn the daily rate, said state Sen. Judy Warnick, a Moses Lake Republican. Warnick said she “would certainly support a (budget) proviso,” but didn’t immediately have a dollar number in mind.
In general, there’s long been a mismatch between what care costs and what substance use and mental health treatment providers are paid. Insurance reimbursement rates have historically fallen far below the actual costs of care, a reality that’s kept many behavioral health professionals’ salaries low and providers’ buildings in disrepair. Many facilities have shuttered altogether.
Addiction treatment operators have for years lobbied state officials, with some success, to raise public Medicaid insurance rates; Medicaid is a public health insurance program paid for by a mix of federal and state dollars that reimburses providers for clinical services and medical employee salaries.
But federal Medicaid rules forbid states from using these dollars to pay for so-called “room and board” — or, in practical terms, every other cost associated with feeding and housing people during their round-the-clock addiction care. The federal ban is in line with long-standing federal policies designed to discourage states from warehousing patients in institutions, and instead provide treatment in their communities.
To help fill in the gap, the state has set aside a tiny pot of dollars — $14.20 per day per patient — to cover cost-of-living expenses.
At least a handful of states are investing magnitudes more than Washington on patients’ basic needs. Maryland reimburses at least $45.84 per day, for example. Montana’s daily rate is at least $135.30.
Last year, a group of operators requested Washington lawmakers study the average daily room and board costs across facilities statewide to better estimate how much state funding is needed to make providers whole. “It was not funded. So we don’t have that information,” said Scott Munson, executive director at Sundown M Ranch, a Yakima addiction treatment center that serves adults and youth.
The last time Munson analyzed room and board costs on his own, he estimated daily living costs at $120-$150 per patient at Sundown. “And of course that’s all gone up and it continues to go up,” he said, citing inflation in food prices and staff wages.
A few years ago, the state’s Health Care Authority estimated average daily room and board costs at about $70 per patient, and requested a modest state budget increase — from $11.64 to $28.87 per day. In their budget request, state documents show, officials at HCA raised red flags about a raft of budget pressures on the horizon: increased pandemic-related demand for mental health and substance use treatment, inflation and a state-sponsored plan to transition certain patients from state-run psychiatric hospitals into community-run facilities.
But former Gov. Jay Inslee left that request out of his proposed budget, said state Rep. Nicole Macri, a Seattle Democrat. In 2023, Macri helped secure a small increase that raised rates by a fraction of HCA’s proposal, from $11.64 to $14.20.
The Association of Alcoholism and Addiction Programs of Washington State wants to see rates jump to at least $84 per patient per day, said Amanda Jahshan, a lobbyist for the association.
“This is literally the only thing they will be asking for this year … The system will break if you’re not funding all of the parts,” Jahshan said. “So this is something that’s kind of been left behind, and we want to catch it up.”
It’s easier than ever to get access to outpatient treatment: More and more physicians are prescribing gold-standard treatments like buprenorphine — a lifesaving opioid use disorder medication — in clinics and through telehealth. And the overdose reversal medication Narcan, which doesn’t require a prescription, has become widely available.
But residential facilities are still a vital corner of the addiction treatment landscape, Macri said, for people who are unhoused, have complex mental health conditions or are at a high risk of overdosing without supervised care.
There’s a financial imperative to raise the rate now, Jahshan said. Washington’s Department of Commerce has awarded more than $41 million in construction grants to bring new or upgraded inpatient substance use disorder facilities online over the next few years, state records show. Those investments, she said, “Can be really tricky when the rates aren’t right because those providers will be in the same pickle that all the current providers are in right now.”
Some lawmakers eager to see higher rates say that, realistically, the state’s projected budget shortfall of $10 billion to $12 billion over the next four years might make increases a tough sell.
“(The rate is) not high enough, there’s no doubt,” said state Rep. Tom Dent, a Moses Lake Republican, who plans to move a budget proviso to raise rates. “By the same token, I’m supportive of what they want to do there but I’m not sure this is going to be the year that we’ll be able to do that.”
Citing the state’s budget woes, HCA officials didn’t make a room-and-board budget request this year.
“We were given pretty clear direction, given the known budget shortfall, to only submit things that were necessary for requirements or functioning of the agency,” said Dr. Charissa Fotinos, Medicaid and Behavioral Health Medical Director at HCA.
