Tess Dana for Montana Free Press
In the early hours of Jan. 31, 2015, Jason McNees found himself driving a stolen Silverado the wrong way down Fourth Avenue in Billings, high on opioids and meth, in a mental fog.
“I didn’t even process what I was doing until I was across town, in this stolen vehicle,” McNees said. “Then I’m like, ‘Oh, I could get in a whole lot of trouble for this. I could go to prison.’”
It was McNees’s lowest point, and his story could’ve ended there, defined by drugs and addiction. He has a family history of chemical dependence. McNees said his mother first gave him meth when he was 16. She died of an overdose in 2008.
Instead, McNees opted to use Medicaid expansion health-care coverage to take control of his dependency. He’s now off Medicaid and helping people who struggle with the problems that plagued him only a few years ago.
“I guess I’d be one of those successful graduation stories that senators and everybody like to hear so much about,” McNees said.
Montana’s expansion program is set to expire this summer. Lawmakers are currently scrambling to find a way to extend the program in a way that satisfies both the Republican-led Legislature and the state’s Democratic governor.
Amidst the fray, another bill has emerged that would secure the future of peer support, a type of therapy led by people who have been down the same road as McNees. Peer support specialists use their experiences to connect with people suffering from addiction and mental illness. Senate Bill 30, sponsored by Sen. Jen Gross, D-Billings, would fund peer support by allowing clinics to bill the services to Medicaid.
“I think the idea of peer-to-peer mentoring of any kind really speaks for itself,” Gross said. “We are more likely to relate, understand and be more open to someone who has a shared experience.”
But formidable barriers stand in the way of SB 30. The bill hinges heavily on renewed Medicaid expansion coverage in Montana, but uncertainty hangs over whether that program will continue.
Coping with pain
If it weren’t for Medicaid expansion, McNees said, “I would’ve went right back to using drugs.”
Still, his road to recovery wasn’t easy.
McNees said his addiction to opioids began while attending college in Great Falls in the early 2000s. One day, while working at an auto-detailing shop, he felt a pain in his right side that dropped him to his knees. After multiple trips to surgeons, urologists and oncologists, he was diagnosed with schwannomatosis, a rare chronic condition that causes benign tumors to grow on his nerves. Doctors prescribed him opiates to cope with the pain.
After college, McNees chased the oil boom to North Dakota. He ended up with a new doctor who put him on a more powerful drug, OxyContin, and, McNees said, steadily increased the dose. At the height of his use, McNees said, he was taking 350 milligrams of OxyContin a day.
In hindsight, McNees called it irresponsible.
“Heavy doses of opioids like that are for end-of-life and cancer patients. I don’t think they should be used on someone who’s a high-functioning young adult,” McNees said. “That’s clearly going to end in addiction.”
Eventually the doctor stopped prescribing the opioids. McNees had used the drugs to manage chronic pain for nearly 15 years, and suddenly had no way to get them.
“I turned to meth to detox,” McNees said. “There weren’t any other options available at that point, and I was really sick.”
He moved back to Montana in 2014. Sometimes he stayed with his sister-in-law. Sometimes he was homeless.
It was during this rough patch that McNees stole the truck in Billings. McNees said he’d gone to the city to meet up with a friend, but the friend stood him up. It was a cold winter night, and McNees said he was high and disoriented with nowhere to take shelter.
Once McNees realized what he’d done, he said, he tried to return the stolen Silverado to where he’d taken it.
“I went the wrong way down a one-way street and got pulled over,” he said. “The rest is history.”
News reports from the time document a high-speed police chase as well. McNees was arrested later that morning. He spent two years in jail.
“That was difficult, but I’m also grateful for that whole process,” McNees said. “[It] led me to where I am today.”
The route to recovery
State lawmakers approved Medicaid expansion through the HELP Act in 2015. Expansion provides health-care coverage to individuals and families making less than 138 percent of the federal poverty level. About 96,000 state residents are currently enrolled in the program.
By 2017, McNees had moved to the Boyd Andrew Community Services pre-release center in Helena, where he prepared to re-enter the world after incarceration. Counselors encouraged him to sign up for coverage under Montana’s Medicaid expansion.
Medicaid marked a turning point in his life. It was the first time McNees ever had health insurance.
“My first inclination as an addict was to go back to what I’ve always known,” McNees said. “I went to [the doctor] and basically asked for opioids, like, ‘can I have this prescription?’ And he writes whatever prescription I ask for.”
But McNees stopped himself from getting the prescription filled. He recognized patterns in his behavior.
“I could see myself in this downward spiral,” McNees said. “I could identify the things that have been in my past and what life is going to be in my future if I choose to go back down this route, because that’s where it’s always led. Addiction ends in incarceration.”
He opted instead to use his Medicaid coverage to take control of his dependency.
Treatment for opioid addiction isn’t cheap. The initial doctor’s visit can run $300, and medications cost hundreds of dollars each month. Medicaid covered all of those costs. It also covered some of the counseling McNees sought at the Leo Pocha Memorial Clinic at the Helena Indian Alliance.
McNees said it was his seventh time getting help. This time, it worked.
“I excelled really quickly in my recovery. I think a lot of the reason was I was able to be accountable to myself,” he said. “Also, I was being treated more humanely, more like a human. I didn’t feel like I had to be dishonest about my past.”
Traditional addiction counseling didn’t work for McNees.
“I was always told, ‘This is what you’re going to do, this how you’re going to do it, this is the only way it works. If you don’t like it, there’s the door,’” McNees said.
Experts say that’s where alternative, non-clinical assistance programs like peer support can help.
“Our peer support specialist has a credibility that I as a professional, regardless of how many degrees or how many years, simply can’t bring,” said Earl Sutherland, a licensed psychologist who oversees peer support at the Big Horn Valley Health Center, during a hearing about SB 30.
Those with mental health and substance use disorders are more likely to continue treatment when they can connect with someone who intimately understands their struggles, Sutherland said.
Peer support specialists are supervised by a psychologist, social worker, or licensed therapist. The benefit of working with peers instead of medical professionals lies in the peers’ real-world experience. They also cost less than seeing a doctor.
The state of Montana began certifying peer support specialists in 2017. When Gross first presented her bill in January, she said the state counted 22 licensed specialists, although not everyone offering peer support has or needs a license.
Peer support services are currently funded through a mix of grants, volunteer work, administrative funds, and other revenue, according to health professionals and clinic directors who spoke in favor of SB 30. Those funds can be sporadic, and there’s no guarantee they’ll be available in the long term.
“As a certified peer support specialist, you’ve come out on the other side. You’re in recovery and you’ve gotten to the point where you’re ready to reach down and help somebody up,” said Joel Peden, with Montana Centers for Independent Living, during a hearing. “That’s what these positions do, but like everything else in the world, it takes funding.”
If SB 30 passes, peer support would be billable to Medicaid, creating some stability for the services and the peer counselors who fill those roles.
“This bill matters for so many reasons. It’s no secret that we have huge problems with substance abuse and mental illness,” Gross said. “Our jails are overcrowded. Services have been cut to the bone, into the bone. Peer support service can make a huge difference.”
Representatives from tribal nations, rural clinics, and urban treatment centers have voiced support for SB 30, as have lobbyists with the National Alliance on Mental Illness, the ACLU of Montana, and Disability Rights Montana.
The only voice to testify against the bill comes from the governor’s office.
“Montanans really expect us to have a balanced budget, one that doesn’t spend more than it brings in,” Gov. Steve Bullock said during a meeting with the press Wednesday.
When Gross first presented her bill at the start of the legislative session, the Governor’s Office of Budget and Planning issued a fiscal note. It estimates the latest draft of SB 30 would cost the state more than $1 million a year, assuming Medicaid expansion continues.
The state health department estimates 5,018 adults would be eligible for peer support under SB 30, and 61 percent of those people will sign up for the service by 2021.
Gross disagrees with those calculations. Only state-certified specialists would receive Medicaid payments under her proposal. She doubts there will be enough specialists to meet the department’s estimated demand, at least in the beginning.
“I don’t think it’s realistic,” Gross said of the health department estimates. “I think it takes time for these services to ramp up, to get individuals licensed, and also for the target population to become aware that this is a service available to them.”
The budget office’s fiscal note also doesn’t take into account the amount of money the state would save, Gross said.
Gross points to studies that found benefits to peer support services, like a 2006 evaluation in Georgia that found peer support services cost the state $997 per patient each year, compared to $6,491 annually for day treatment.
While the governor and his budget director both said they supports the policy goals behind SB 30, the problem lies with the cost. If Medicaid covers peer support services, the federal government will pick up most of the tab. But the state would still be on the hook for a portion — at least 10 percent of the costs by 2020 if Montana renews Medicaid expansion, and up to 35 percent for traditional Medicaid recipients.
“We’ve got to make sure we’re funding whatever services are provided,” Bullock said. “I have a lot of respect for Sen. Gross. We’ll take a close look at [SB 30] if it gets here, but we’ve also got to figure out how to pay for all of this.”
It appears Gross may have found a solution.
The Senate passed an amendment to the state budget April 4, allocating $2.5 million for the biennium from state medical marijuana tax revenues to SB 30’s peer support services.
Both SB 30 and the revised budget now await approval in the House.
Meanwhile, the question of Medicaid expansion’s future looms large. The program will sunset in June unless the Legislature agrees on a way to extend it. The expansion bill with the most promise of becoming law, House Bill 658, adds adds additional work and eligibility requirements. It was tabled in a Senate committee Friday, only for the chamber to revive the bill hours later.
“I would say [SB 30] is inextricably tied to Medicaid expansion,” Gross said. “It is literally nothing but a guessing game as to what this is actually going to cost while we have the moving target that is Medicaid expansion.”
After getting clean, McNees became a trained and state-certified peer support specialist. He works at the Helena Indian Alliance in the very clinic that guided him on his recovery path.
He approached the clinic about starting a peer support program after receiving treatment there for a year and a half. He now has his own office with walls painted cobalt blue. He sees between four and six clients a day, with an average caseload of 50 people. His clients include both men and women as young as 19 and as old as 74.
The Helena Indian Alliance pays for McNees’s position with a federal grant from the Substance Abuse and Mental Health Services Administration, but those funds are set to run out this year.
Although McNees now has a stable job that allowed him to move off Medicaid, the state’s expansion program remains integral to many of the people he helps. It could secure his employment future, too, if SB 30 becomes law.
“Probably 98 percent of the people I serve are on Medicaid, and the majority are on Medicaid expansion,” he said.
While the Helena Indian Alliance remains neutral on whether Medicaid expansion should continue, McNees supports the program if Montana lawmakers can find a way to fund it. He also supports HB 30. He’s appeared at the Capitol to voice his support twice since the bill was introduced.
“I think it’s a big part of my passion, the advocacy,” he said. “To reduce the stigma that goes along with opioid addiction and medically assisted treatment, the stigma that’s attached to being a Medicaid recipient, all those kinds of things.”