Is Substance Abuse Treated Adequately in Reform Bills?

Substance abuse screening and treatment may get short shrift under health care reform, based on the provisions of leading legislative proposals, according to some treatment advocates.

As health care reform leaders in Congress prepare for a final push to enact a sweeping overhaul of the nation's health care system, advocates worry that substance abuse may be left behind in some critical areas.

All three of the major health reform plans working their way through Congress include features to increase access to substance abuse care, including the inclusion of addiction treatment under provisions requiring insurers to provide coverage at parity with general health care. Some of the measures also include general mental health and substance abuse care in the basic package required for policies included in planned insurance exchanges, or marketplaces.

“All of the bills and concept papers say mental health and substance abuse coverage will be part of basic benefit packages,” said Charles Ingoglia, vice president of public policy of the National Council for Community Behavioral Health, at a July briefing on health care sponsored by the Alliance for Health Reform. The nonpartisan, nonprofit alliance advocates for universal coverage and cost-effective care.

That's good news for the estimated 23 million Americans who, according to a 2007 national survey conducted for the Substance Abuse and Mental Health Services Administration, are addicted to alcohol or drugs. The expansion of services is important because only 1 in 10 people with an addiction now gets treatment.

However, some mental health advocates are concerned that the legislative health reforms under consideration have comparatively little focus on substance abuse services.

“There are a number of places [in the legislation] where mental health professionals are addressed, but there isn't a comparable definition or description or support for addictions recovery,” said Eric Goplerud, Ph.D., a research professor in the Department of Health Policy at George Washington University, at the alliance's forum. “They talk about mental health but they very rarely talk about substance abuse.”

Areas where there is no mention of substance abuse in the reform bills include provisions that support the use of “medical homes,” fund training of health care professionals, and expand children's health programs. The lack of specific mention of addiction care in those and other areas likely will mean support for such care will not be included, he said.

The omission of substance abuse care is significant, Goplerud said, because his research has consistently found substance abuse treatment faces more“ discriminatory coverage” by health insurers than any other area, including general mental health coverage.

“It's not surprising that we have an underfunded, overworked, inaccessible, substance use treatment system, because it has not been part of [previous efforts at] health reform,” Goplerud said.

Hope May Rest With Regulators

Advocates of substance abuse care hope that it eventually will be included in health reform programs by regulators who implement provisions of the final bill; however, the absence of specific and consistent mention of substance abuse care in the text of the bills makes that less likely.

One area in which addiction prevention, treatment, and screening are not mentioned is in the reform bills' provisions to support school-based health programs. That omission comes despite research that has found high levels of substance use among youth. For example, about 15 percent of adolescents screened positive for substance abuse in a 2007 Harvard study published in the New England Journal of Medicine.

Another area of the legislation that has drawn criticism from substance use treatment advocates is that the bills largely fail to provide development support to professionals who specialize in such care. Although several provisions provide training-assistance grants and tuition support for professionals in mental health, addiction professionals are not specifically included. Although some advocates hope that regulators will include these professionals when they issue guidelines implementing the various workforce support measures, the lack of their inclusion in the legislative language lessens the chances of that happening.

Amendment Adds Prevention

Addiction treatment has received support in other areas of the reform legislation, including an amendment to the House health reform bill, titled America's Affordable Health Choices Act of 2009 (HR 3200). It explicitly added substance abuse to the bill's prevention-related section. The bill also would cover screening and brief interventions for “problem drinking,” among preventive services.

The same bill also added substance abuse treatment programs to the 340B Drug Pricing Program. That program requires drug manufacturers to provide discounted medications to qualifying facilities, which currently include public hospitals. Such a change has long been sought by substance use treatment advocates, and its inclusion in a reform bill “is a very major and important success,” Goplerud said.

In addition, “Addiction treatment has an unforeseen benefit of making health reform more affordable,” said Victor Capoccia, director of the Closing the Addiction Treatment Gap initiative at the Open Society Institute (OSI), a liberal reform advocacy group. “When addictions go untreated, a person's medical care is fragmented, inefficient, and ultimately more costly.”

Strong substance use treatment provisions could produce billions in annual health care savings, according to a white paper issued in July by the OSI. Expanded addiction treatment saves money through reduced hospital costs, according to the paper, because 1 of 14 hospital stays is addiction related. The paper also cited research showing that patients who received addiction treatment reduced their other medical costs by 26 percent.

The OSI released a national survey in June that showed that addiction treatment would be a popular feature of health reform, with a solid majority of Americans supporting its inclusion. Almost three-quarters of 1,001 adults polled supported inclusion of alcohol and other drug treatment in national health care reform to make such care more affordable, while 68 percent of survey participants supported increasing federal and state funding for preventing and treating addiction.

The OSI paper is posted at<www.soros.org/initiatives/treatmentgap/articles_publications/publications/paper1_20090714>. The OSI poll is posted at</www.soros.org/initiatives/treatmentgap/research/poll_20090616>.▪