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,
"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
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.
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.
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
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.