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The Effect of ObamaCare on Treatment

The Affordable Care Act has gotten a lot of attention since it was first introduced, but how does it change options for treating substance abuse? The Fix offers some practical information.

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Does it care for addicts? Shutterstock

By Marissa Rosado

04/21/14

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The course of events that add up to a substance abuse problem are often complicated and traumatic. The acknowledgment of the problem and the decision to enter a treatment program can be more difficult. And yet the most challenging part of this process, for many, is life after rehab: addiction resolution and continued sobriety.

Rehab can be like a cocoon. But once treatment has ended and the addict returns to society without the structure and support of the facility, he or she often relapses. For recovering addicts, the maintenance of their sobriety is a challenge that dominates their life. Will addicts be able to find continuing care from programs covered by their health insurance plans? With the landscape of health insurance options changing rapidly within the last year, what exactly can recovering addicts count on?

Previous healthcare reforms for the treatment of substance abuse

Alcoholics Anonymous was founded in the US in 1935, but it took the American Medical Association until 1952 to define and acknowledge alcoholism. Case in point: we are used to a government that falls short and lags behind the issues regarding substance abuse.

After mental health insurance coverage was protected with the enactment of 1996’s Mental Health Parity Act, it took another 12 years to get it amended to include the Addiction Equity Act (its name in total, the MHPAEA). The act placed annual or lifetime dollar limits on the cost of treatment for recovering substance abuse addicts. This was a landmark move not only because it recognized the importance of supporting recovering addicts under current insurance plans, but also because it also prevented insurance companies from taking advantage of insured parties. Care for recovering addicts was guaranteed, and it looked like it wouldn’t cost an arm and a leg. 

Thanks to this legislation, the cost of substance abuse treatment was no more than the coverage for medical/surgical treatments allotted for in health insurance plans. While this doesn’t necessarily mean the treatments are affordable (especially for many in recovery, money is tight), it does provide a safety net for those seeking help. Copays, coinsurance, and out-of-pocket maximums are the same for someone treating heroin addiction as they are for someone with persistent seasonal allergies.

However: the MHPAEA did not make treatment for substance abuse a mandatory point of coverage for insurance providers. It also did not require plans to offer copays or any financial help for specific treatment of substance abuse, such as rehab programs or addiction resolution. So here is this terrific landmark legislation with giant loopholes embedded in it. This left a gap that left many in recovery without help or care.

The Affordable Care Act

In 2010, President Obama signed the Affordable Care Act (“Obamacare” or “ACA”) into law. In late 2013 and continuing this year, the law has finally been put into practice. Millions (7.5 million, actually) of previously uninsured Americans now have health insurance. One of the tenets of the ACA is to increase the quality and affordability of health insurance. Another is to reduce the cost of healthcare for the government and insurable parties. So what does this mean for those seeking substance abuse treatment?

The good news

In a groundbreaking move, the ACA has declared the treatment of substance use disorders an essential health benefit. Where the MHPAEA fell short, the ACA is picking up the slack. Addiction recovery is now seen as a critical component to physical health. Now many more will have access to rehab programs. More in need of that treatment will receive it, which will decrease the number of abusers and, hopefully, the number of relapses.

The logic behind the ACA’s prioritization of treating substance abuse is simple dollars and cents: previously untreated addiction costs the tax payers billions of dollars accrued through privatized health care and law enforcement. Ideally, having addiction treatment covered will eventually save this country money and diminish the strain on law enforcement occupied with drug related crimes.

The methods of treating people with substance abuse under the ACA reflect a new approach. The law largely promotes the idea of preventative care. Previously, addicts were treated when they “hit bottom," when it was apparent to every outside perspective that the person needed help. Moving forward, the ACA will treat substance abuse the way it should be treated. This will include disease prevention. Think of all the campaigning to prevent obesity that’s sprung up in the last decade. Now think of that attention applied to preventing substance abuse. The ACA also promotes earlier intervention to prevent the addicted person from ever hitting bottom. The act also offers several treatment options when the insured party seeks care for their addiction.

An example of the advanced perspective of the ACA can be found in the way alcohol abuse is addressed. Screening and counseling for alcohol abuse is now considered preventative care, and under the ACA, preventative care must be fully covered. That means no deductible, co-pay or co-insurance for an insured party. People seeking care for alcohol abuse won’t be penalized or unnecessarily charged.

More good news: if someone has a history of substance abuse and is afraid of being disqualified from eligibility, there’s nothing to fear. Under the ACA, an applicant cannot be deemed ineligible for insurance based on a pre-existing condition. Under this law, substance abuse counts as a pre-existing condition; candidates cannot be rejected from the exchange based on previous drug abuse. Think of what this will mean to thousands battling drug and alcohol abuse: full health insurance, access to proper care, and a fresh start.

The bad news

The first on this list is a small strike, but worth mentioning. When applying for health insurance, candidates are asked about their tobacco use. It’s a simple question: “Do you use tobacco products?” If the answer yes, the ACA has allowed insurance companies to charge that applicant a higher premium. Another reason to quit smoking, sure, but that also seems oddly close to discrimination, especially considering the ACA’s seemingly open arms policy when it comes to a history of drug use.

The Affordable Care Act has mandated that all health insurance plans sold on American Health Insurance Exchanges must provide means for treating substance abuse. 

With some exceptions.

Small employer (businesses of 100 employees or less) plans put in place before March 23, 2010 don’t have to provide these benefits. Church-sponsored plans are also exempt. Even Medicare and Medicaid are excused from this mandate. These exemptions could leave many without the help they need.

And what about the demand for substance abuse treatment? Now that millions previously suffering from addiction are eligible for health insurance, they’re all going to need professionals to treat them. Just one problem: currently there aren’t enough professionals properly trained to treat recovering addicts. There is a gap between the number of prospective patients and the number of professionals ready to treat them. Many addicts need intervention and other preventative measures, which require specific training and certification. It’s disappointing that this is the case, because if one checked in on the process of implementing the ACA, there are months of news stories pointing to the roll out encountering some difficulty (to say the least). The system crashed multiple times due to the volume of applicants. How was this not noted and taken into consideration with regard to specialty treatment? This gap is going to provide a longer wait time for those in need, time that in some cases will mean the difference between life and death.

The worse news

When visiting the website for the ACA on whitehouse.gov, eventually it leads to pages underneath the Office of National Drug Control Policy.  On the subject of treatment, this is what the office has to say:

Treatment of substance use disorder consists of a range of clinical interventions that can include group and individual therapy, medication for detoxification, and stabilization. The ultimate goal of treatment is to assist individuals in achieving stable, long-term recovery, enabling them to become productive, contributing members of society and eliminating the substantial public health, public safety, and economic consequences associated with active addiction.

That’s odd. Did you read anything in there about covering rehab programs? There’s no mention of them. Does that mean rehab is a “Specialty Treatment," suggested by another link on the page? No. The specialty treatments mentioned are medicines approved to treat substance abuse in conjunction with behavioral therapy. 

The lack of literature on the availability of rehab coverage is concerning. For many, rehab is necessary to combat their addiction. The website also doesn’t mention whether or not the cost of care is adjusted if this is a patient’s second, third, fourth trip back to rehab. Relapsing is a hard reality of substance addiction; the possibility of it must be addressed under the ACA.

In regard to how the ACA will be supported, there is a two-pronged plan. One is High Intensity Drug Trafficking Areas (HIDTA), which pushes for all levels of government to coordinate efforts to bring down drug trafficking. Another suggests reform within the criminal justice system to break the cycle of drug use causing crime leading to further drug use.

What’s missing from this enforcement is the promise of care, not to mention the quality of that care.

The sad truth is that the ACA is primarily focused on substance abuse prevention. It falls seriously short in specifying how it will treat those active drug users seeking recovery.

Mistakes made before

The risk of sacrificing quality of treatment in order to treat the quantity of patients harkens back to the implementation of methadone clinics in the UK during the 20th century. In that situation, government-sanctioned substance abuse clinics were opened and offered medication and counseling to individuals addicted to heroin. In theory, the methadone provided a crutch to help the addict wean off, and counseling was there to support the process. The result of this plan was disappointing: the number of drug users in the UK jumped from 67,000 in the 1990s to 200,000 in the late 2000s. 

The biggest problem this government-implemented abuse treatment facility is facing is quality of care. One researcher of the institution, David Best, noted a patient going in and out of clinics for a year, receiving regular amounts of methadone, and little to no counseling. This sounds an awful lot like enabling. Sacrificing quality of care is a sure risk with the ACA. Additionally, how did no one within the system get on to the fact that this patient was taking a weaning-off dose for nearly a year? The answer is simple and unacceptable: the patient was not being tracked. There was no system in place to track patients from clinic to clinic, so one only wonders how many others were taking these same liberties. If the ACA fails to appropriately monitor those seeking substance abuse treatment, those in need may receive no help at all.

The mistakes made with the UK's methadone clinics echo the larger problems in the ACA. Loopholes left unchecked will be exploited and disrupt the quality of care. If the ACA doesn’t tie up the loose threads concerning rehab, relapse, and quality of care, those in recovery are still vulnerable.

Marissa Rosado is a regular contributor to The Fix. She last wrote about red flags for kids with potential addictions.

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