Expansion of insurance coverage for substance use disorders (SUDs) under the Affordable Care Act (ACA) and Mental Health Parity and Addiction Equity Act (MHPAEA) may offer opportunity to improve access to care and reduce the societal costs related to SUDs. However, policymakers and providers are concerned that the current SUD treatment system does not have the capacity to adequately meet the potential increase in demand.
In September 2014, the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services (HHS), contracted with Mathematica Policy Research to conduct this project to assess: (1) current demand for SUD treatment; (2) how demand will change as more people obtain SUD treatment coverage; (3) the current state of provider capacity in the SUD treatment field; and (4) the degree to which SUD treatment providers are prepared to be more integrated with the broader health care system. This report summarizes the findings from the first phase of this study, which encompassed interviews with experts from two provider credentialing organizations and a national provider organization representative as well as a review of the available literature and data on SUD prevalence, treatment, and workforce capacity.
Current Demand for Substance Use Disorders Treatment
Demand for SUD treatment is defined by the rate of SUDs in the population and the extent to which those with an SUD seek treatment. The prevalence rate for SUDs is slightly lower in recent years relative to earlier in the last decade. This decline occurred for both illicit drug and alcohol disorders. Based on HHS Substance Abuse and Mental Health Services Administration (SAMHSA) analysis (SAMHSA 2015a) of the National Survey of Drug Use and Health (NSDUH), the proportion of individuals 12 years and older who met diagnostic criteria for an SUD1 in the past year (Figure ES.1) remained relatively constant from 2002-2010 (ranging from 8.8 percent to 9.4 percent), and then decreased in 2011 through 2013 (ranging from 8.0 percent to 8.5 percent). Although there was a slight decline in the current prevalence of SUDs between 2002-2010 and 2011-2013, accounting for population growth, the actual number of individuals meeting criteria for an SUD in the past 12 months was unchanged (Figure ES.2).
|FIGURE ES.1. Proportion of Individuals Age 12 and Older with Abuse of or Dependence on Alcohol or Illicit Drugs in the Past Year, NSDUH 2002-2013|
|SOURCE: Estimates obtained from SAMHSA 2015a, Table 7.40B.|
Trends for some specific substances differed from the overall trends for SUDs over the last decade. The number of individuals with cocaine-related disorders decreased from 1.5 million to 1.7 million from 2002-2007 to 0.9 million in 2014. In contrast, the number of individuals with heroin-related disorders increased from a level of 189,000-324,000 from 2002-2008 to 586,000 individuals in 2014. The number of individuals with disorders related to pain relievers ranged from 1.4 million to 1.5 million between 2002-2005. This increased to 1.9 million by 2014 (SAMHSA 2015e).
|FIGURE ES.2. Number of Individuals Age 12 and Older with Abuse of or Dependence on Alcohol or Illicit Drugs in the Past Year, NSDUH 2002-2013|
|SOURCE: Estimates obtained from SAMHSA 2015a, Table 7.40A.|
In parallel with trends in the overall number of individuals with SUDs, according to the NSDUH survey the number of individuals receiving any SUD treatment in the past year remained constant between 2004 and 2014 at about 4 million individuals, or 18 percent (Figure ES.3).2 About 60 percent of these individuals (2.3-2.6 million individuals per year) or 11 percent received treatment in a specialty setting defined as any of the following types of facilities: hospitals (inpatient only), drug or alcohol rehabilitation facilities (inpatient or outpatient), or mental health centers.3 Similar to the NSDUH, the National Survey of Substance Abuse Treatment Services (N-SSATS) collects information on the number of individuals in care at specialty SUD treatment facilities. However, the NSDUH measures the number of individuals with any receipt of treatment in the past year, while the N-SSATS measures the number of clients in treatment on a single day in each year (the last working day in March of each survey year). From 2004-2007, there were about 1.1 million clients in treatment at the time of the N-SSATS survey (Figure ES.3). This rose to 1.2 million from 2008-2013.
|FIGURE ES.3. Number of Individuals Receiving Treatment, 2004-2014|
|SOURCE: Estimates for N-SSATS 2005, 2007, 2009, 2011, and 2013 were obtained from SAMHSA 2014a, Table 3.2; Estimates for N-SSATS 2008, 2010, and 2012 were obtained from SAMHSA 2013a, Table 3.2; Estimates for N-SSATS 2002, 2004, and 2006 were obtained from SAMHSA 2007, Table 3.2a. NSDUH estimates for 2004-2014 were obtained from SAMHSA 2005, SAMHSA 2006b, SAMHSA 2007b, SAMHSA 2008, SAMHSA 2009, SAMHSA 2010, SAMHSA 2011a, SAMHSA 2012a, SAMHSA 2013b, SAMHSA 2014b, SAMHSA 2015e, respectively.
NOTE: In the NSDUH survey specialty treatment is defined as treatment received at hospitals (inpatient only), drug or alcohol rehabilitation facilities (inpatient or outpatient), or mental health centers. In this report we refer to all clients receiving treatment at facilities responding to N-SSATS as receiving specialty treatment. N-SSATS is a census of all known, public and private, facilities with substance abuse treatment programs. It excludes those programs located in jails or prisons, serving only incarcerated clients, and solo practitioners (unless a state substance abuse agency specifically requests to include them). N-SSATS 2014 did not collect data on clients in treatment.
There is a substantial gap between the number of people with an SUD and the number of individuals who receive any treatment in a given year (SAMHSA 2014b). In 2013, an estimated 22.7 million United States residents had an SUD in the past year (21.6 million) or received specialty treatment for an SUD in the past year although did not meet criteria for a current disorder (1.1 million). Only 18 percent (4.1 million) of these individuals received any treatment including self-help or emergency care and only 11 percent (2.5 million) received treatment at a specialty facility (Figure ES.3). According to a review by Foster (2014), this rate of treatment receipt is substantially lower than that for common health conditions such as hypertension (77 percent), diabetes (73 percent) and major depression (71 percent). However, some researchers have noted that standard diagnostic criteria for SUDs may inflate estimates of treatment need and thereby estimates of unmet need. They have proposed alternative concepts which narrow the definition of need. For example, Wakefield and Schmitz (2015) have proposed narrowing the diagnostic criteria for SUDs to require dysfunction and harm (Wakefield and Schmitz 2015). Others have suggested treatment need may be defined in relationship to the individual's own perception of need or based on a disability associated with the SUD (Mechanic 2003).
In fact, according to SAMHSA analysis of response to the NSDUH for 2013 (SAMHSA 2014b), 95.5 percent of individuals who met the criteria for an SUD, but who did not receive specialty treatment, did not believe they needed treatment. The remaining 4.5 percent who felt they needed treatment may provide a better estimate of unmet demand and of the set of individuals who might be responsive to increased coverage for SUDs available under the ACA. To obtain specialty SUD treatment for all the individuals in this population who felt they needed, but who did not receive treatment (Figure ES.4), the number of individuals receiving specialty treatment per year would need to rise from 2.5 million to 3.4 million (a 36 percent increase). SAMHSA analysis (2014b) further divided this set of individuals who felt they needed treatment, but did not receive treatment into two groups: (1) those who reported making an effort to receive treatment (34.8 percent or 316,000 persons in 2013); and (2) those who reported making no effort to obtain treatment (65.2 percent or 592,000 persons in 2013).
Those who reported seeking treatment but who failed to receive it reported many obstacles to obtaining care (multiple obstacles could be reported by the same respondent):
- 37.3 percent reported having no health coverage and could not afford cost of treatment.
- 24.5 percent reported not being ready to stop using drugs or alcohol.
- 9.0 percent did not know where to go for treatment.
- 8.2 percent had health coverage but it did not cover treatment or did not cover cost.
- 8.0 percent reported it was inconvenient or they lacked transportation.
|FIGURE ES.4. Number of Individuals Who Received Specialty Treatment or Who Felt They Needed It but did not Receive Treatment, NSDUH 2004-2013|
|SOURCE: NSDUH estimates for 2004-2013 were obtained from SAMHSA 2005, SAMHSA 2006, SAMHSA 2007b, SAMHSA 2008, SAMHSA 2009, SAMHSA 2010, SAMHSA 2011a, SAMHSA 2012a, SAMHSA 2013b, SAMHSA 2014b, respectively.
NOTE: Treatment receipt is reported within the last 12 months.
Individuals who did not seek treatment reported many of the same barriers (SAMHSA 2014b). Health insurance coverage expansion may address some of these reported obstacles, but other obstacles will remain.
Trends and Policies Affecting Future Demand for Care
Although trends in SUD prevalence and treatment receipt have been relatively constant for the last decade, we assessed the extent to which we expect a substantial shift in these trends between 2014 and 2020. Overall, the implementation of the ACA is likely to be the largest force increasing demand, but other factors may also contribute to demand increases. The factors that may influence demand include the following:
Affordable Care Act. The ACA is expected to affect demand for SUD treatment through a number of mechanisms: (1) reducing in the number of uninsured; (2) enhancing SUD treatment coverage for insured individuals; (3) promoting integration of primary care and behavioral health care; (4) changing Medicaid coverage of SUD treatment services; and (5) changing perceptions about SUD treatment.
Projections from the Congressional Budget Office (CBO 2014) indicate 26 million individuals will gain insurance coverage as a result of the ACA by 2020. This includes an increase of 13 million individuals on Medicaid. Based on analysis of NSDUH 2008-2011 Mark et al. (2015a) estimate about 14 percent of the newly insured (3.6 million individuals) will have SUD treatment needs. Although many uninsured individuals (2 percent annually) received specialty treatment prior to ACA implementation, the rate of treatment receipt was higher (3 percent) among individuals who were Medicaid insured despite lower disorder prevalence (12 percent for Medicaid insured versus 14 percent uninsured). Thus, the rate of SUD treatment use might increase for individuals who transition from being uninsured to having Medicaid coverage. In contrast, evidence that transitioning from being uninsured to privately insured will increase SUD treatment use is limited. While the recent literature provides some evidence that inability to afford treatment is a barrier to treatment use, the available research indicates that people with treatment needs who lack insurance access SUD treatment at greater or the same rates as individuals who have private insurance (Wu and Ringwalt 2005; Schmidt and Weisner 2005; Mojtabai 2005; Bouchery et al. 2012). However, it should be noted that SUD treatment benefits provided through Medicaid expansion and marketplace plans may be more generous than traditional Medicaid or private insurance coverage represented in the literature reviewed for this study due to provisions of the ACA identifying SUD treatment as an essential benefit.
Mental Health Parity and Addictions Equity Act. Under the 2008 MHPAEA, large group employers who offer SUD treatment benefits could no longer offer more limited coverage for SUD treatment than for medical/surgical care. The MHPAEA identifies limitations on frequency of treatment, copayments, coinsurance, and deductibles as possible plan limitations that must be in parity (Frank et al. 2014). We reviewed the findings in the literature on implementation of state and federal parity provisions generally. The provisions of the initiatives reviewed varied. Providers may respond to parity requirements by implementing a care management program such as a capitated behavioral health program with a narrow network or a hospital diversion program. Such efforts may reduce expenditures for SUD treatment. Thus, the findings from identified studies were mixed. For example, one study found a decrease in SUD treatment use when care management approaches and parity were implemented simultaneously (Rosenbach et al. 2003). Another study found a 15 percent increase in treatment use when impacts focused on only facilities accepting private insurance (Wen et al. 2013).
Changing Care Norms. Thought leaders in the SUD treatment field identified increased recognition of SUDs as a valid health condition as a key trend likely to affect the field over the next five years (Ryan et al. 2012). Potential changes in perceptions of the acceptability of SUD treatment and integration of SUD treatment into mental health and primary care settings have the potential to influence trends in demand. However, historically, only 6 percent of referrals to SUD treatment come from the general medical sector (CASA 2012) and implementing care integration and new models of care, including Screening, Brief Intervention, and Referral to Treatment requires substantial upfront investments. Thus, the influence of changing attitudes and new approaches to care could be slow to impact the actual number of people seeking or referred to services.
Opioid Use Epidemic. Over the last decade there have been significant increases in disorders associated with pain relievers and heroin. The number of individuals using treatment for these disorders increased in parallel. Health professionals and federal, state, and local officials are developing and implementing initiatives targeted at reducing opioid use, abuse, overdose and related-deaths, including a Department of Health and Human Services (HHS) Opioid Initiative (HHS 2015e). There is some evidence that these efforts are working, as there have been increases in the supply of physicians waivered to prescribe buprenorphine for opioid dependence, particularly in states that expanded Medicaid (Knudsen, Lofwall, Havens and Walsh 2015), as well as numbers of individuals receiving buprenorphine treatment (SAMHSA 2014a). This early evidence suggests that the upward trend in demand for opioid disorder treatment is likely to continue through 2020.
Trends in Government Spending. The Federal Government will increase spending on SUD treatment in association with ACA coverage expansions. In other areas of of SUD treatment and activities to reduce use, the Federal Government through the HHS Opioid Initiative is working to increase funding to expand access to medication-assisted treatment (MAT) for opioid use disorders. . Substance Abuse Treatment Block Grant spending will remain constant and the additional targeted investments in SUD treatment programs identified in this study are small relative to overall SUD treatment spending nationally. Data on state and local SUD treatment expenditures are not systematically collected. Estimates from the SAMHSA Spending Estimates Initiative, the most recent observed estimates of state and local spending, indicate that state and local spending as a share of all SUD treatment spending nationally declined from 34 percent in 2004 to 31 percent in 2009 (SAMHSA 2013c). State Medicaid programs have the potential to play an important role in transforming the SUD treatment system and the HHS Centers for Medicare and Medicaid Services (CMS) is taking an active role encouraging states to make reforms. However, this transformation will not be immediate.
Current Supply of Substance Use Disorders Providers
There are no current data available on the size of the SUD workforce. Data on specialty SUD treatment facility staffing will be collected as part of the 2016 N-SSATS survey and analyzed in the second phase of the current study in late 2017. The most recent reliable data on the size of the SUD workforce are almost 20 years old. These data were collected as part of the Alcohol and Drug Services Study in 1996. These data indicate about 88,000 counselors, almost 50,000 medical professionals, and 65,000 other staff, for a total of about 200,000 staff members, comprised the workforce at the time of the study (SAMHSA 2003).
Our review of the available evidence on the capacity of the SUD workforce prior to ACA implementation suggests that the SUD treatment workforce was strained to effectively meet the existing level of treatment demand. A significant number of facilities reported operating at or above capacity (SAMHSA 2014a). Low wages made hiring and retaining qualified staff a challenge, and clinical directors and representatives of certification organizations expressed concerns about adequacy of training (Ryan et al. 2012). Also, a review of the services provided to clients indicated that current practice was often inconsistent with the scientific findings on evidence-based treatment (National Center on Addiction and Substance Abuse at Columbia University [CASA] 2012). Finally, many facilities may not accept or be included in the insurance networks associated with coverage obtained under the ACA.
Trends and Policies Affecting the Future Supply of Substance Use Disorders Providers
The Bureau of Labor Statistics (BLS), which develops employment statistics that include projections for employment by occupation, provides no specific category just for SUD treatment professionals. However, two categories encompass a substantial proportion of the SUD treatment workforce: (1) substance abuse and behavioral disorder counselors; and (2) mental health and substance abuse social workers. The share of these categories represented by SUD treatment versus mental health professionals is unknown. BLS projects employment in these categories to grow at a faster rate than the average for all occupations (BLS 2015a, 2015b) because addiction and mental health counseling services will be increasingly covered by insurance policies, and health insurance coverage expansion will increase demand for health care services in general (BLS 2015a). BLS also notes that drug offenders are increasingly being sent to treatment rather than jail, thereby increasing treatment program use (BLS 2015a, 2015b).
These BLS projected growth rates diverge from past employment trends in these occupations. Nationally, employment of substance abuse and behavioral disorder counselors declined 3 percent between 2008 and 2011. However, in the most recent two years observed, 2011-2013, employment growth ranged from 4 percent to 5 percent per year. Likewise, employment of mental health and substance abuse social workers declined 16 percent between 2008 and 2012. Then, between 2012 and 2013, employment of these professionals grew by 1 percent (BLS 2015c).
Overall the evidence for assessing change in the size of the SUD workforce is limited, but it suggests, at most, a small increase in the workforce in the last few years. If substantial additional funding becomes available through ACA insurance coverage or other federal or state sources, facilities may seek to expand hiring; however the existing level of training program output is unlikely to meet demand, and clinical directors already report having difficulty hiring candidates with appropriate training and experience (Ryan et al. 2012).
Comparison of Trends in Demand and Supply
Although trends in SUD prevalence and treatment receipt have been relatively constant for the last decade, the ACA could result in a substantial increase in the number of SUD treatment users. Additional increases related to the impact of MHPAEA, changing perspectives about the importance of SUDs as a health condition, the opioid epidemic, and activities associated with care integration could further increase demand.
In contrast, on the supply side, we find a workforce that is challenged to meet the existing demand prior to ACA implementation. Although there is no available data on trends in training program output, our interviews with experts suggest, at most, a small increase in training programs in recent years. Meanwhile, credentialing experts and clinical directors (Ryan et al. 2012) expressed concern about training adequacy, specifically noting that more highly educated workers, most of whom graduate from programs that are not specifically focused on addiction, may not have necessary addiction-specific training and experience. Overall, the best available evidence suggests that the supply side does not have sufficient capacity to address a potential short-run increase in demand.
Gaps in Current Knowledge
Overall, the literature available to assess whether the treatment system has the capacity to meet changes in demand associated with increased insurance coverage is quite limited:
Current Demand for SUD Treatment Services. The methods used in the literature on barriers to treatment and the relationship between insurance coverage and treatment do not provide sufficient information to assess how treatment use will change when insurance coverage is provided or other barriers to treatment are removed.
Trends and Policies Impacting Demand Over the Next Decade. The literature on how recent changes may impact demand is limited by lack of information on how individuals will respond to the policy changes and trends.
Previous Efforts to Estimate the Size and Composition of the Workforce. The most recent data on the size and professional composition of the workforce is from the late 1990s. Thus, these data do not address recent trends in staffing. These data are also at the national level and do not allow for detailed analysis of factors that may influence staffing patterns.
Recruiting and Developing the Workforce. There is limited information about the pipeline for SUD treatment professionals. Although there is much concern from experts in the field about inadequate training, there is limited information on training program content and typical career paths. Although the literature includes many suggested approaches for increasing the supply of SUD professionals, there was no information documenting the potential impact of implementing the suggested strategies.