Updates

Updates

Editor’s Note: As Congress prepares to vote on a replacement for the Affordable Care Act (ACA), we at PGDF thought it worth examining the important ways the ACA has affected treatment availability for substance use disorder.

In 2014, Dr. A. Thomas McLellan and Abigail Mason Woodworth of the Treatment Research Institute published a landmark article discussing at length how the Affordable Care Act (ACA) and Mental Health Parity and Addiction Equity Act (Parity Act) were designed to improve access, choice and quality of care for all.  Together, these pieces of legislation mandated that health insurers cover addiction and mental health services on par with services provided for general healthcare, with equal standards of care, and under the same insurance financing conditions.

Historically, addictions have not been treated or insured like other illnesses and most addiction treatment was not covered at all by insurance. When private insurance coverage was available (only about 12% of the time) it applied only to severe addiction and did not cover milder forms of substance use disorders, which are more prevalent.

One of the key provisions of the ACA is that health insurance plans and healthcare systems cover 10 “essential health benefits” – including substance use disorders (SUD).  The ACA recognizes that covering the following “essential services” positively impacts public health and cost savings:  ambulatory patient care; emergency care; hospitalization; maternity and newborn care; prescription drugs; rehabilitative services and devices; laboratory services; preventive and wellness services; chronic disease management; pediatric services – and mental health and substance use disorder services.

McLellan and Woodworth discuss how the ACA dramatically changes healthcare in America, and how substance abuse disorders are the illness most heavily affected:

  • More people covered: it is estimated that about 12% more of the 23-25 million adults who meet criteria for substance use disorders will be eligible for addiction treatment coverage under the expansion of Medicaid benefits. Also, the even larger portion of patients who do not meet the diagnostic threshold but also struggle with substance use issues will be covered by health insurance.
  • New settings and care providers: The large increase in the number of people who now have access to treatment means that the group of people involved in identifying, screening and treating those with SUD’s will need to broaden. More primary care doctors and other healthcare workers will need to be trained in screening and referral.  Earlier referral to treatment can mean better outcomes.
  • Reimbursement for new types and components of care: Since SUD’s are recognized as a chronic illness and the full spectrum of SUD’s is now covered under the ACA, they should be treated like other diseases, including coverage for evidence-based treatments and tests, and chronic disease management.

The changes brought about by the ACA bring both challenges and opportunities. Health care providers will need new training, and exact specifications for which therapies, medications, and interventions will be covered will need to be decided.  The changes that stem from the ACA will drive the market to offer evidence-based treatments and create an opportunity to refine traditional addiction care to now implement best practices of traditional medical care.

An important aspect of The ACA and the Parity Act is that they were designed to end the separate and unequal treatment of substance use disorders, in effect, destigmatizing it. McLellan and Woodworth point out that while some doubt true integration will ever happen, they believe there is good evidence that it will. They note that over $120 billion is wasted by not addressing and treating harmful substance use within general medicine, which creates an incentive to properly identify and address issues related to SUD’s and treat it as a mainstream disease.  Also, integration has happened before, with such diseases as breast cancer, depression, tuberculosis and AIDS. They note that the re-organization of care has created larger, more coordinated teams who recognize the importance of comprehensive treatment, who can better manage complex behavioral health issues such as SUD’s.

With over 50 million people with SUD’s now eligible for services, potentially involving 500,000 primary care physicians, McLellan and Woodworth cite the most compelling cause for integration could be the new and powerful market forces, “This is the kind of patient and provider market that could inspire creation of new screening tools, medications, therapies, monitoring systems, and other clinical management services. Again, these unprecedented markets provide important incentives for greater access, innovation and quality – all proven drivers of consumer demand. These forces are simply too powerful, and the clinical needs are simply too great for things to continue as they have for the past 40 years.”