Thursday, November 15, 2012

How Will the Election Affect Treatment for Addiction?

Here's a blog from a guest blogger, Ian McLoone, who is a student in the Integrated Behavioral Health Master's program at the University of Minnesota, as well as a Graduate Research Assistant at the new MN Center for Mental Health, which is focused on treatment for people with co-occurring mental and addictive disorders. Welcome Ian!


P.S. Anyone else want to volunteer? I'm open to blog submissions.

Why the Election Results Are Good News for Addicts and the People Who Treat Them

As Tuesday’s election results trickled in, addiction and mental health professionals throughout the country breathed a collective sigh of relief. President Obama’s re-election means that the Affordable Care Act - affectionately termed, “Obamacare” – is safe from the Romney/Ryan campaign promise of “total repeal” of the law (1). This means that President Obama will have the opportunity to oversee the implementation of his signature first-term accomplishment. What’s more, addiction research will see, at minimum, modest funding increases and the National Institutes of Health (NIH) will avoid the devastating cuts outlined in the Romney/Ryan 2013 budget proposal.

The ACA increases patient access to behavioral health services in several ways. By expanding Medicaid coverage to those at 138% of the federal poverty level, as well as the creation of state-run insurance exchanges, as many as 30 million new people will have access to health insurance (2). Health insurance providers will also be subject to several new provisions which are meant to improve the quality of the care they receive. For example, preventative care and interventions will be emphasized, and in many cases fully covered. The ACA has already awarded upwards of 100 million dollars for the implementation of an evidence-based prevention measure known as SBIRT – Screening, Brief Intervention and Referral to Treatment (3). Prevention efforts can improve outcomes for all people, but those with mental illness and substance use disorders are disproportionately affected with other health problems like diabetes, high blood pressure, asthma, heart disease and stroke (4). This, in addition to guaranteed coverage for patients with preexisting conditions, more coverage for prescription medications, and the carrying-forward of the 2009 “parity” law (which mandates that insurance companies cover treatment for mental health like they would any other condition), means those with addiction or mental illness, and those who treat them, will no longer need to question whether or not these services will be available in the years to come.

Mitt Romney, and his running mate, Paul Ryan, ran on a platform of significant cuts in government spending (“non-defense discretionary spending”), exemplified in Paul Ryan’s 2013 budget proposal. In addition to eliminating the ACA’s Medicaid expansion, their plan included provisions which would have resulted in 14 million more people losing their Medicaid insurance over the next 10 years – an estimated 31 million people, in total (5). While many have criticized Paul Ryan for the lack of specifics within his budget plan, the White House estimates of the impact on NIH-funded grants are sobering: 1,600 fewer grants in 2014 and 16,000 fewer over the next 10 years (6).

While we cannot yet say for certain exactly what the impacts of the ACA will be, we can expect some significant improvements in behavioral health coverage for all Americans. Expanded coverage means more patients seeing doctors, more clients with access to therapists and counselors, and more money to pay for drug and alcohol abuse treatments. Certain states have indicated an interest in “opting-out” of the Medicaid expansions, and their right to do so was recently upheld by the Supreme Court. Voters in these states will have to hold their lawmakers responsible for ensuring that they have the same access to healthcare that the rest of the country does. In the meantime, President Obama has an opportunity to do even more for the behavioral health community over the next four years. It will be important to remind him that we expect investments in addiction and mental health research. He has the chance to encourage innovations that could change the way we see addiction and its treatment throughout the 21st century.



  1. I doubt that the ACA will do much for the treatment of addiction. I was at a panel discussion of this very topic at the APA meeting in Hawaii a couple of years ago. I asked the panel: "What would prevent a managed care company from handing out some type of rating scale (like they do in Minnesota for depression right now) and calling that a chemical dependency assessment? The answer of course was nothing.

    I think people make a mistake when they think that expanded coverage will magically expand treatment for the mentally ill or the addicted. There is a clear pattern of discrimination over the past 25 years that would need to be reversed and there is not sign that will happen. In fact, I consider it a very bad sign that the SAMHSA web site is now touting the advantages of managed care. It is the first time that the government is explicitly backing managed care despite their behind the scenes backing for a long time.

    I have posted this example on this blog in the past as a case in point. If you are a middle aged man or woman with chest pain from probable esophagitis - it is not too difficult to get admitted to the CCU overnight and end up with a $20,000 - $30,000 expenditure for Cardiology services and consultations. On the other hand if you have an addiction and get sent to the ER, and entirely different set of scenarios is likely to unfold. The range may be being sent to a county detox facility for "social" or non-medical detox to being sent out of the ER with a bottle of benzodiazepines and told to detoxify yourself at home. There is rarely any acute care for addictions and that includes current members of managed care organizations.

    There are also institutional biases against people with mental illnesses or addictions. There has been some writing here about how some 12-step recovery seems to blame the person with the addiction. I would say that the odds of that happening are much lower than encountering institutional attitudes against those with addictions - frequently disguised in the form of cost containment. Remind me again of why a managed care company is sending anyone to a county detox facility?

    It takes more than a law that clearly favors big business to change these attitudes and the likelihood that Addiction Medicine is practiced at the same level as Internal Medicine or Cardiology in these systems. I will believe it when I actually see those resources move and I am not expecting that they will.

    1. I agree with your point, for the most part. Don't get me wrong - until we move away from managed care and toward a single-payer, universal health care system, we will always be doing a disservice to addiction and behavioral health patients.
      However, in a choice between better-than-the-status-quo and worse-than-the-status-quo, I take the former every time.


Comments are welcome.