including HIV care, substance abuse treatment, and mental health services (Gourevitch, 1996).

Variations in reimbursement rates, eligibility requirements, and funded services lead to differences between states (as to the Medicaid covered substance abuse services offered and for whom). As C. Lubinski’s paper (unpublished) details, geography plays an important role in access to substance abuse treatment for people with HIV as demonstrated by differences in eligibility and covered services between the states she examined: Florida, Georgia, Illinois, New York, and Texas. For example, to qualify as medically needy an individual must spend her/his income down to 27 percent of the federal poverty level in Florida, 31 percent in Georgia, 42 percent in Illinois, and 87 percent in New York. Texas does not offer coverage under this category. Medicaid does not reimburse inpatient substance abuse treatment services in Georgia, outpatient treatment in Texas, and residential treatment in any of the five states. In all five states, Medicaid reimburses for clinic visits, day treatment, evaluation and testing, individual and family therapy, group therapy, and detoxification services. However, the scope and duration of these services differs considerably among states.

Lacking System Capacity

According to SAMSHA, there are an estimated 13 million substance abusers in the United States, 10 million of whom do not receive any treatment for their substance use (SAMSHA, 2000). The substance use treatment shortage is especially acute for people in prisons and jails, where only 15 percent of inmates receive treatment but where 30 percent of inmates in federal prisons and 70 percent in state prisons need such treatment (Schneider Institute for Health Policy, 2001). Close to half of existing treatment slots are filled by people referred through the criminal justice system, which is the largest single source of referrals to substance abuse treatment (SAMSHA, 2002c). Significantly, very few people are referred to treatment either through their health or mental health provider (9.4 percent), or through a welfare or social service agency (7.2 percent) (SAMSHA, 2000).

Because substance abuse treatment systems vary greatly from state to state, the gap between treatment availability and the need for treatment also varies. While waiting lists and treatment shortage are common, the dearth of services is particularly acute in rural and non-metropolitan areas where people may have to travel long distances for substance abuse treatment (SAMSHA, 2000; Whetten-Goldstein et al., 2001). The hours of treatment, as well as supportive services such as transportation, may be severely limited. The availability of methadone maintenance, widely considered an effective treatment for opiate addiction, varies considerably as does the availability of low threshold harm reduction services.

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