ACA Increases Medicalized Treatment of Substance Use Disorders

The Affordable Care Act (ACA) appears to be having an impact on medicalizing treatment of substance use disorder (SUD), according to a study recently published in the Journal of Psychoactive Drugs. While organizational changes at treatment centers and shifts in treatment approaches were modest from 2010-2014, the increases in referrals from health care providers, the numbers of physicians and other medical staff at treatment centers, and the availability of a central medication, naltrexone, highlight a shift toward medicalized treatment of SUDs, consistent with the goals of the ACA, say the authors.

“There is a long way to go before we see SUD treatment fully integrated into mainstream medical care, and we have only just begun to examine the effects of the ACA on SUD treatment services” says study co-author Jana Pruett Covington, a research associate at the Georgia Health Policy Center.

The ACA offers strong support for medicalization of SUD treatment, including its mandate to bar exclusions for pre-existing conclusions, its equal reimbursements for behavior disorders and medical conditions, and its overall increase in the number of Americans with health insurance. Previous research estimates that about 3.6 million newly insured individuals under the ACA have SUD treatment needs.

Face-to-face interviews were conducted with the administrator and/or clinical director for a national sample of public treatment programs randomly sampled from the Substance Abuse and Mental Health Services Administration’s Substance Abuse Treatment Facility Locator. Detoxification-only programs and methadone-only programs were excluded. Interviews were conducted in two rounds—one that ended in January 2012 and one that ended in January 2014. The 200 programs that participated in both waves of interviews were included in analysis.

The researchers found an increase in the percentage of treatment referrals from non-primary care health care providers. Overall, there was a slight increase in the number of programs that received referrals from either primary care or other health care providers, up from 79 percent of programs in the first wave to 87 percent in the second wave.

While the number of programs that had no consistent access to a physician, either on contract or on staff remained sizable (38 percent), there was an increase in the number of full-time equivalent physicians for programs that did have a physician on staff, and an increase in counselors certified in treating alcohol and drug addiction. These trends show an important shift underway, the authors say, given the ACA reimbursement requirement for treatment services to be delivered by qualified professionals.

Additionally, there was significant growth in the availability of oral and injectable naltrexone and an increase on the emphasis of a medicalized treatment model, along with a decrease in support for the 12-step model. There was also a shift away from federal block grants and other public funding, consistent with the expected increase in insurance coverage of SUD treatment under the ACA.

The authors conclude by saying that while the changes were “modest,” nearly all changes were in direction that supports the thrust of the ACA.

“Since treatment of SUD has largely developed outside of the mainstream health care system, it has been mostly based on psychosocial interventions,” says study coauthor Lydia Aletaris, Ph.D., from the Owens Institute for Behavioral Research at the University of Georgia. “A smaller percentage of treatment programs have embraced medication-assisted treatment. As a result, it is unknown whether the push toward increased medicalization of SUD treatment will continue, particularly if the ACA is repealed.”

The study was supported by the National Institute on Drug Abuse through an award to the Owens Institute for Behavioral Research at the University of Georgia. In addition to Covington and Aletraris, Paul Roman, Ph.D., director of the Owens Institute, was a study co-author.