From Promise to Reality: Substance Use Disorders and the ACA

In February 2013, the HHS Office of the Assistant Secretary for Planning and Evaluation issued a press release extolling the virtues of the Affordable Care Act’s expansion of substance use disorder benefits. HHS found it hard to hide its excitement, touting that the ACA beginning in 2014 would foster “one of the largest expansions of … substance use disorder coverage in a generation.” According to HHS, the ACA would extend coverage for substance use treatment to 62 million U.S. residents.

That enthusiasm is understandable. Although substance use is one of the more under-acknowledged public health issues in the U.S., it’s getting harder and harder to ignore the scope of the situation.

For example, according to the National Survey on Drug Use and Health, in 2011 more than 19 million U.S. residents — or 7.5% of the population ages 12 and older — needed treatment for a substance use disorder or alcohol misuse problem but did not receive it. Further, illicit drug use costs the U.S. approximately $161 billion annually, more than diabetes and nearly as much as cancer. That’s not even counting misuse of prescription opioids, which itself has become an epidemic, with the number of overdose deaths now greater than deaths from heroin and cocaine combined.

How the ACA Extends Treatment Coverage

The ACA builds on Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, which requires group health plans and insurers that offer mental health and substance use treatment benefits to provide coverage that is comparable to coverage for general medicine and surgical care. In essence, insurers must cover substance use treatment the same way they cover diabetes treatment, for example.

The ACA goes further, requiring all small group and individual market plans created after March 23, 2010, to include coverage of mental health and substance use treatments as one of the 10 categories of essential health benefits. In addition, the law requires states to include substance use treatments in their Medicaid benefits.

The ACA also requires that substance use screening and referrals are available without any additional consumer cost-sharing, as part of the law’s preventive services provision.

Barriers to Care

Expanding coverage might not be enough to address the problem of substance use. Just as there are concerns about whether there will be enough primary care providers amid the ACA’s coverage expansion, experts also are worried about a shortage of treatment options for people with substance use disorders.

According to the Substance Abuse and Mental Health Services Administration, only about 11% of the more than 23 million U.S. residents who needed treatment for alcohol misuse or substance use disorders in 2012 received it. “We don’t have enough capacity right now,” Becky Vaughn, executive director of State Associations of Addiction Services, told Kaiser Health News.

Further, a recent New York Times article notes than an obscure federal Medicaid rule enacted about 50 years ago could prevent many people with drug or alcohol addictions from accessing necessary treatment under the ACA. Under the 1965 rule, known as the Institutions for Mental Disease exclusion, Medicaid covers community-based programs for residential addiction treatment only if they have 16 beds or fewer.

Coverage First, Access Next

Despite those challenges, experts who spoke with California Healthline are confident that the ACA will be a game-changer when it comes to access to substance use treatment.

A. Thomas McLellan, former deputy director of the Office of National Drug Control Policy and current CEO of the Treatment Research Institute, said he is “more confident than ever” that the ACA will help the U.S. achieve the substance use treatment “that we need and expect.” 

Keith Humphreys, a professor of mental health policy at Stanford University and a senior research career scientist at the VA Health Services Research Center in Palo Alto, also expressed confidence that the ACA would be a major boon to substance use treatment. He said that substance use treatment is one of the biggest areas of “underinvestment” in public health and that such treatment garners a massive return on investment. For example, according to data compiled by the National Association of State Mental Health Program Directors, cost-benefit analyses of substance use treatment have found returns on investment of between $4 and $7 for every dollar spent.

Humphreys added that the “market-based system” in the U.S. guarantees that access to substance use treatment will come. “We give people the insurance, which creates demand” for providers, he said, adding, “Over time, the system will adapt” to meet the needs of people with substance use disorders.

McLellan noted that TRI has been in touch with about 15 of the largest investment groups, including Wells Fargo and Goldman Sachs, and they all have said they expect to invest at least $100 million each into the substance use treatment field.

As for the Medicaid rule on treatment, Humphreys said it is “no big deal,” noting that the rule was meant to “stop warehousing” of patients and that 90% of substance use treatment is outpatient and therefore not affected by the rule. McLellan said the residential treatment described in the Times article is “old-style thinking” in terms of substance use treatment, describing such treatment as just one aspect of “the care continuum.” He added, “What the ACA is all about is managing care outside of residential” treatment centers.

Both Humphreys and McLellan noted that it might take time for the number of necessary providers to catch up with the demand for care. Humphreys said, “We just put a lot of demand on the fire. We’re not going to be able to keep up at first.” However, McLellan said that people in the field “understand that and will respond.”

Around the nation

Here’s a quick look at what else is making news on the road to reform.

Access =/= savings. A frequently repeated axiom in support of the ACA is that improving access to preventive care will reduce the need for more-costly care. However, Aaron Carroll, a professor of pediatrics at Indiana University, writes in the New York Times‘ “The Upshot” that a “growing body of evidence” refutes that notion.

The Carolina disconnect. In North Carolina, state residents “came out in droves” to sign up for coverage under the ACA. However, Sen. Kay Hagan (D-N.C.), who supported the law, still is at risk of losing her re-election campaign this year, which demonstrates the “disconnect” over the law in the state, according to Politico.

Not damning for Democrats. A pair of Marist University/NBC News polls show that Democratic Senate candidates in Colorado and Michigan have increased their leads in the races. BloombergView columnist Jonathan Bernstein notes that although the data indicate that the ACA is polling badly in each state, it doesn’t necessarily rub off on the Democratic candidates. However, the Washington Post‘s “The Fix” the data should both “reassure” and “terrify” Democrats. 

Related Topics

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