Exclusive Commentary

Closing the Addiction Treatment Gap: A Priority for Health Care Reform, By Victor Capoccia, Open Society Institute, Dennis McCarty, Oregon Health & Science University, and Laura Schmidt, University of California, San Francisco

- Posted May 3, 2010


An unfortunate but persistent stereotype is that substance abuse is a “low-income” problem. It’s not. But what is a problem is the gap in successful intervention and treatment between low-income Americans and their wealthier counterparts. While health care reform will improve opportuntiies to close this gap, there is more to be done.

About 23 million individuals living in the United States meet diagnostic criteria for alcohol and drug use disorders each year—the same number of people in the US with another chronic disease: diabetes. Addiction affects women, men and adolescents from all socioeconomic levels.

But research shows that the impacts of addiction tend to be more visible within poorer communities with less access to health care and greater vulnerability to the consequences of alcohol and drug dependence.

Data from the 2008 National Household Survey on Drug Use and Health suggest that only about one-third (36 percent) of the individuals who received addiction treatment used private health insurance; the rest used savings (50 percent), Medicaid (25 percent), public assistance (22 percent), Medicare (18 percent), and family funds (17 percent). It is also noteworthy that inability to pay was the primary reason reported for not receiving treatment among individuals who felt they needed treatment. There is a strong reliance on public and personal funds for addiction treatment and access to care is more limited for low-income individuals.

The current addiction treatment gap is roughly 20 million people—90 percent of those in need of care, but who do not receive it. This gap represents the difference between the number who enter care – 2.3 million and the number who need care – 23 million. By comparison, only 24 percent of people with diabetes did not receive care last year.

The addiction treatment gap is greater for unemployed adults and young adults aged 18 to 25 years—women and men who have limited access to health insurance and publicly funded addiction treatment services. And the treatment gap is disproportionate for all ethnic minority groups except Asian-Americans.

The good news, however, is that recent federal legislation, changes in public understanding, and advances in treatment knowledge may together provide the opportunity to address and eliminate the disparities in access to addiction treatment.

Two pieces of federal health care reform legislation, the Patient Protection and Affordable Care Act (H.R. 3590) and the Reconciliation Act of 2010 (H.R. 4872), will provide health insurance for 32 million of the estimated 45 million uninsured people in the US through a combination of required, subsidized insurance and Medicaid expansion plans.

Explicit reference to mental health and addiction disorder core benefits coupled with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 suggest that federal health reforms may substantially enhance access to addiction treatment services.

To ensure success, treatment providers, consumers and advocates must participate in the development of federal regulations and state implementation plans and work to facilitate access to care. Persistent bias against providing treatment for alcohol and drug use disorders makes these benefits vulnerable to the politics that accompany implementation of health care reforms.

A 2009 poll provides promising data and indicates that Americans may be ahead of policymakers in their ability to grasp the complex nature of addiction and the value of addiction treatment. Seven of ten Americans (71 percent) considered alcohol and drug addition to be a serious problem and 77 percent supported efforts to make treatment more affordable and accessible

Our knowledge of the problem – and how to solve it – is also growing. We know more than ever about the nature of addiction, its identification and the interventions that can mitigate or eliminate the symptoms of addiction to alcohol and drugs. The current treatment benchmark for addiction disorders is embodied in a report from the healthcare nonprofit National Quality Forum which outlines the 11 science- and consensus-based treatment interventions relevant to the identification, assessment, intervention and continuing care components of treatment.

Taken together, these standards embrace a combination of public support, health insurance coverage, and knowledge of evidence-based treatment and offer a unique opportunity to reduce disparities in access to and quality of treatment for addiction disorders.

But continued efforts to close the treatment gap and dampen the impact of addiction on low-income communities should continue to be guided by sound research and practice. The Institute of Medicine – the health arm of the National Academy of Sciences – stipulates that quality addiction treatment is judged by the same standards applied to the general health care system—care should be safe, effective, timely, patient-centered, efficient and equitable.

Effective treatment requires greater and more consistent use of evidence-based behavioral and pharmacological therapies. Meeting the quality challenge and realizing the coverage and access opportunities requires major changes in the policy, structures, processes and technologies that govern the organization, financing and delivery of treatment for addiction disorders.

Policies that encourage greater integration of addiction treatment into primary care will facilitate increased access to addiction treatment services when needed. Integration between primary care and addiction specialty care can be reinforced through structural relationships that describe the flow of patient records and transfer of patients between settings—processes that track and report on transfers and results in each setting reinforce integration of records and patient care.

Finally, technology is key to communicating results and follow up to both patient and provider.

An organized voice of consumers and families advocating for full access to quality addiction treatment services can increase the potential for all communities to realize the promises of health care reform. We must demand the same level of access to care that individuals with other chronic health care conditions have already obtained.

Victor Capoccia is director of the Closing the Treatment Gap program at the Open Society Institute. Dennis McCarty is a professor at Oregon Health & Science University. Laura Schmidt is a professor at University of California, San Francisco.