Preventing addiction is the cheapest and most effective way to curb drug abuse in Vermont, health officials say, but they are struggling with the fact that insurance doesn't cover those costs.
Early screening - to catch drug dependence early -- and recovery services - to keep patients clean after treatment -- are also more cost-effective, but some insurers don't cover that, either.
Last week the state health officials who oversee the network of addiction prevention and recovery services explained that struggle to lawmakers.
Preventing drug addiction is more than drug-education classes, they said. People need healthy communities in which chemicals don't become an escape from life.
"Strong communities, strong families, strong schools, I mean, we have to have the infrastructure, and unfortunately a lot of our folks who get into trouble have disconnections from that," said Barbara Cimaglio, Deputy Health Commissioner for Alcohol and Drug Abuse Programs.
Cimaglio spoke before the Senate Health and Welfare Committee, which held two mornings of testimony, hearing from a litany of substance abuse professionals who gave reports and recommendations from the field.
The committee is trying to understand what types of addiction treatment exist, how they are related and whether the Legislature can do anything to help.
"As we're trying to address those big societal issues, there are no simple answers," Cimaglio said.
The average cost per person for drug prevention services was $9.28 last year, according to the Health Department. The monthly rate for the growing number of people receiving medication-assisted treatment in a hub is $500 per month for each patient.
Neither Medicaid, which covers low-income residents, nor Medicare, which covers senior citizens, covers prevention or recovery services, nor do third-party insurers.
"It doesn't fit into that traditional kind of fee for service," Cimaglio said.
Instead, the state uses a mix of state and federal grants to help teach people to stay away from drugs, Cimaglio said.
Last year, 230,000 Vermonters received "prevention messaging," Cimaglio said.
Screening people early and often for possible signs of substance abuse is also a proven way to catch addiction sooner and makes it easier to treat, health officials say.
Medicare and Medicaid, but not third-party insurers, cover early screening, according to the Department of Health.
The Health Department, meanwhile, is working on several programs to encourage health care providers to screen. Part of the challenge is just making it socially acceptable to talk about drugs and alcohol, officials say.
One in 10 Vermonters have been asked by their physician about alcohol use in the past year, according to Health Commissioner Harry Chen.
Nationally, 95 percent of people in need of treatment don't feel they need it, according to the National Survey on Drug Use and Health.
Cimaglio told the story of a diabetic man who had no idea the four of five drinks he had every night affected his diabetes.
Around Vermont, there is no difference in drug use from county to county, Cimaglio said. There are more people in Chittenden County, but the per capita rate is the same.
"The sad reality about addiction is that the majority of people that may need some help don't feel they need help," she said.
The relapse rate for addiction is around 30 percent, the same as for other chronic diseases.
Medicare also does not cover the treatment drug buprenorphine, administered in the seven hubs as well as the offices of about 125 doctors in the state who are licensed to prescribe it.
"As our population ages we're hearing (providers) say more and more that they have people coming in with Medicare and they're struggling with what that's going to mean," Cimaglio said.
Blue Cross Blue Shield of Vermont is in the process of working out contracts to cover hub services.
Addiction treatment services covered under Tricare, health insurance for veterans, is also restrictive, Cimaglio said.
Besides insurance coverage, there are other challenges to treating addiction in Vermont.
One is hiring. There is a shortage of substance abuse professionals, the Health Department says.
It is also difficult to link different levels of substance abuse services, Cimaglio said. Formerly disjointed types of treatment are now being integrated, which can be a challenge.
Officials also want to make sure patients have housing when they finish treatment and transportation to get to and from treatment.
Cimaglio last week said despite challenges the hub and spoke treatment system faces, it has had many successes and is the envy of many other states.
"It's important to remember how well we're doing," she said.
To measure that success, the state is developing a system to evaluate the results based on the outcome of patients treated in the addiction services network. The state expects to produce some sort of analysis by April 2015.