Treatment for substance use disorder: opportunities and challenges under the affordable care act.
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ABSTRACT:
SUBMITTER: Tai B
PROVIDER: S-EPMC4827339 | biostudies-literature | 2013
REPOSITORIES: biostudies-literature
Publications
Treatment for substance use disorder: opportunities and challenges under the affordable care act.
Social work in public health 20130101 3-4
Addiction is a chronic brain disease with consequences that remain problematic years after discontinuation of use. Despite this, treatment models focus on acute interventions and are carved out from the main health care system. The Patient Protection and Affordable Care Act (2010) brings the opportunity to change the way substance use disorder (SUD) is treated in the United States. The treatment of SUD must adapt to a chronic care model offered in an integrated care system that screens for at-ri ...[more]
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Project description:We examine the effect of Medicaid expansion under the Affordable Care Act (ACA) on substance use disorder (SUD) treatment utilization and financing. We combine data on admissions to specialty facilities and Medicaid-reimbursed prescriptions for medications commonly used to treat SUDs in nonspecialty outpatient settings with an event-study design. Several findings emerge from our study. First, among patients receiving specialty care, Medicaid coverage and payments increased. Second, the share of patients who were uninsured and who had treatment paid for by state and local government payments declined. Third, private insurance coverage and payments increased. Fourth, expansion also increased prescriptions for SUD medications reimbursed by Medicaid. Fifth, we find suggestive evidence that admissions to specialty treatment may have increased one or more years post-expansion. However, this finding is sensitive to specification and we observe differential pretrends between the treatment and comparison groups. Thus, our finding for admissions should be interpreted with caution.
| S-EPMC7071834 | biostudies-literature
Project description:BACKGROUND:The Affordable Care Act (ACA) offered an unprecedented opportunity to expand insurance coverage to patients with substance use disorders (SUDs). We explored the expectations of key stakeholders for the ACA's impact on SUD care, and examined how clinical characteristics of newly enrolled patients with SUD in a large healthcare delivery system differed pre- and post- ACA implementation. METHODS:In this mixed-methods study, qualitative interviews were conducted with health system leaders to identify themes regarding how the health system prepared for the ACA. Electronic health record data were used to examine demographics, as well as specific SUD, psychiatric, and medical diagnoses in cohorts of pre-ACA (2012, n?=?6066) vs. post-ACA (2014, n?=?7099) newly enrolled patients with SUD. Descriptive statistics and logistic regression models were employed to compare pre-ACA and post-ACA measures. RESULTS:Interviewees felt much uncertainty, but anticipated having to care for more SUD patients, who might have greater severity. Quantitative findings affirmed these expectations, with post-ACA SUD patients having higher rates of cannabis and amphetamine use disorders, and more psychiatric and medical conditions, compared to their pre-ACA counterparts. The post-ACA SUD cohort also had more Medicaid patients and greater enrollment in high-deductible plans. CONCLUSIONS:Post-ACA, SUD patients had more comorbidities as well as and more financial barriers to care. As federal healthcare policy continues to evolve, with potentially more restrictive coverage criteria, it is essential to continue examining how health systems adapt to changing health policy and its impact on SUD care.
| S-EPMC6703160 | biostudies-literature
Project description:ObjectiveThe study examined whether the use of opioid agonist therapy (OAT) for treatment of opioid use disorder in specialty substance use treatment settings increased following Medicaid expansion.MethodsAdministrative data on 943,430 admissions from the Treatment Episodes Data Set-Admissions (2010-2016) were used to examine the association between Medicaid expansion and the use of OAT and to assess whether this association was mediated by increased proportion of admissions with Medicaid in expansion states.ResultsFrom 2010-2013 to 2014-2016, OAT use among patients with opioid use disorder increased in both expansion (39.1% and 50.2%, respectively) and nonexpansion (39.9% and 40.5%, respectively) states. The effect of Medicaid expansion on OAT use was mainly mediated through a larger proportion of admissions with Medicaid in expansion states.ConclusionsAs the nation grapples with the opioid epidemic, expanding Medicaid coverage has the potential to promote greater access to evidence-based treatment.
| S-EPMC6602831 | biostudies-literature
Project description:The dependent coverage expansion under the Affordable Care Act (ACA) required health insurance policies that cover dependents to offer coverage for policyholder' children up to age 26. It has been well documented that the provision successfully reduced the uninsured rate among the young adults. However, less is known about whether dependent coverage crowded out other insurance types and whether young adults used dependent coverage as a fill-in-the-gap short-term option. Using data from the Survey of Income and Program Participation 2008 Panel, the paper assesses dependent coverage uptake and duration before and after the ACA provision among young adults aged 19-26 versus those aged 27-30. Regressions for additional coverage outcomes were also performed to estimate the crowd-out rate. It was found that the ACA provision had a significant positive impact on dependent coverage uptake and duration. The estimated crowd-out rate ranges from 27 to 42%, depending on the definition. Most dependent coverage enrollees used the coverage for 1 or 2?years. Differences in dependent coverage uptake and duration remained among racial groups. Less healthy individuals were also less likely to make use of dependent coverage.
| S-EPMC5797739 | biostudies-literature
Project description:PurposeHealth insurance coverage affects a patient's ability to access optimal care, the percentage of insured patients on a clinic's panel has an impact on the clinic's ability to provide needed health care services, and there are racial and ethnic disparities in coverage in the United States. Thus, we aimed to assess changes in insurance coverage at community health center (CHC) visits after the Patient Protection and Affordable Care Act (ACA) Medicaid expansion by race and ethnicity.MethodsWe undertook a retrospective, observational study of visit payment type for CHC patients aged 19 to 64 years. We used electronic health record data from 10 states that expanded Medicaid and 6 states that did not, 359 CHCs, and 870,319 patients with more than 4 million visits. Our analyses included difference-in-difference (DD) and difference-in-difference-in-difference (DDD) estimates via generalized estimating equation models. The primary outcome was health insurance type at each visit (Medicaid-insured, uninsured, or privately insured).ResultsAfter the ACA was implemented, uninsured visit rates decreased for all racial and ethnic groups. Hispanic patients experienced the greatest increases in Medicaid-insured visit rates after ACA implementation in expansion states (rate ratio [RR] = 1.77; 95% CI, 1.56-2.02) and the largest gains in privately insured visit rates in nonexpansion states (RR = 3.63; 95% CI, 2.73-4.83). In expansion states, non-Hispanic white patients had twice the magnitude of decrease in uninsured visits compared with Hispanic patients (DD = 2.03; 95% CI, 1.53-2.70), and this relative change was more than 2 times greater in expansion states compared with nonexpansion states (DDD = 2.06; 95% CI, 1.52-2.78).ConclusionThe lower rates of uninsured visits for all racial and ethnic groups after ACA implementation suggest progress in expanding coverage to CHC patients; this progress, however, was not uniform when comparing expansion with nonexpansion states and among all racial and ethnic minority subgroups. These findings suggest the need for continued and more equitable insurance expansion efforts to eliminate health insurance disparities.
| S-EPMC5593726 | biostudies-literature
Project description:OBJECTIVES:To explore whether the Affordable Care Act (ACA) enactment is associated with changes in the proportion of discharge against medical advice (DAMA) among hospitalizations due to substance use disorders (SUDs). METHODS:Data were drawn from the 2012-2015 National Inpatient Samples. The sample comprised hospitalizations with a principal diagnosis of SUD (i.e., SUD-involved hospitalization) for patients aged 18-64 years (unweighted N?=?287,629). Interrupted time series analyses were conducted to evaluate the effect of the ACA on monthly proportions of DAMA among SUD-involved hospitalizations. RESULTS:Overall, approximately 11% of SUD-involved hospitalizations were DAMA. DAMA was most frequently found among hospitalizations for primary opioid use disorder (pre-ACA: 16.4%; post-ACA: 17.2%). Despite the increase in the Medicaid coverage after ACA enactment, there was no significant change in the proportion of DAMA before and after ACA periods across various demographic groups and clinical conditions. Time series analyses also indicated no significant trend effect on the proportion of DAMA during the pre- and post-ACA months. CONCLUSIONS:As many as 1 in 10 SUD-involved hospitalizations were considered as DAMA. Concerted efforts are needed to enhance insurance benefits for SUDs and patients' knowledge of SUD treatment benefits in order to increase SUD treatment engagement and completion and to reduce DAMA, especially for substance-using patients with Medicaid or opioid use disorder.
| S-EPMC6508559 | biostudies-literature
Project description:BackgroundPractitioners expected the Affordable Care Act (ACA) to increase availability of health services and access to treatment for Americans with substance use disorders (SUDs). Yet research has not examined the associations among ACA enrollment mechanisms, deductibles, and the use of SUD treatment and other healthcare services. Understanding these relationships can inform future healthcare policy.MethodsWe conducted a longitudinal analysis of patients with SUDs newly enrolled in the Kaiser Permanente Northern California health system in 2014 (N = 6957). Analyses examined the likelihood of service utilization (primary care, specialty SUD treatment, psychiatry, inpatient, and emergency department [ED]) over three years after SUD diagnosis, and associations with enrollment mechanisms (ACA Exchange vs. other), deductibles (none, $1-$999 [low] and ≥$1000 [high]), membership duration, psychiatric comorbidity, and demographic characteristics. We also evaluated whether the enrollment mechanism moderated the associations between deductible limits and utilization likelihood.ResultsService utilization was highest in the 6 months after SUD diagnosis, decreased in the following 6 months, and remained stable in years 2-3. Relative to patients with no deductible, those with a high deductible had lower odds of using all health services except SUD treatment; associations with primary care and psychiatry were strongly negative among Exchange enrollees. Among non-Exchange enrollees, patients with deductibles were more likely than those without deductibles to receive SUD treatment. Exchange enrollment compared to other mechanisms was associated with less ED use. Psychiatric comorbidity was associated with greater use of all services. Nonwhite patients were less likely to initiate SUD and psychiatry treatment.ConclusionsHigher deductibles generally were associated with use of fewer health services, especially in combination with enrollment through the Exchange. The role of insurance factors, psychiatric comorbidity and race/ethnicity in health services for people with SUDs are important to consider as health policy evolves.
| S-EPMC7519171 | biostudies-literature
Project description:ImportanceMedicaid expansion is associated with increased access to health services, increased quality of medical care delivered, and reduced mortality, but little is known about its association with use of long-term care.ObjectiveTo examine the association of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) with long-term care use among newly eligible low-income adults and among older adults whose eligibility did not change.Design, setting, and participantsThis difference-in-difference cohort study used data from the Health and Retirement Study, a nationally representative longitudinal survey of persons 50 years or older. Long-term care use from 2008 to 2012 was compared with use from 2014 to 2016 among low-income adults aged 50 to 64 years without Medicare coverage residing in states in which Medicaid coverage expanded in 2014 and those living in states without expansion. Low-income adults who were covered by Medicare and were ineligible for expanded Medicaid were also included in the analysis. Data were analyzed from January 15, 2018, to December 31, 2019.ExposuresResidence in a state with Medicaid expansion in 2014.Main outcomes and measuresAny home health care use or any nursing home use in 2014 or 2016. All estimates are weighted to account for the Health and Retirement Study sampling design.ResultsAmong the 891 individuals likely eligible for expanded Medicaid, the mean (SD) age was 55.2 (3.1) years; 534 (53.4%) were women, 482 (49.5%) were married, and 661 (45.9%) were White non-Hispanic. Before the ACA-funded Medicaid expansion, 0.4% (95% CI, -0.3% to 1.1%) in expansion states and 1.0% (95% CI, -0.1% to 2.2%) in nonexpansion states used nursing homes, and 1.9% (95% CI, 0.4%-3.4%) in expansion states and 7.1% (95% CI, 4.7%-9.5%) in nonexpansion states used any formal home care. The ACA-funded Medicaid expansion was associated with an increase of 4.4 percentage points (95% CI, 2.8-6.1 percentage points) in the probability of any long-term care use among low-income, middle-aged adults, with increases in home health use (3.8 percentage points; 95% CI, 2.0-5.6 percentage points) and in any nursing home use (2.1 percentage points; 95% CI, 0.9-3.3 percentage points).Conclusions and relevanceIn this study, ACA-funded Medicaid expansion was associated with an increase in any long-term care use among newly eligible low-income, middle-aged adults, suggesting that the population covered by the Medicaid expansion may have had unmet long-term care needs before expansion.
| S-EPMC7530637 | biostudies-literature
Project description:The Centers for Disease Control and Prevention (CDC) estimates that 156,300 (95% CI 144,100-165,900) Americans living with HIV in 2012 were unaware of their infection. To increase knowledge of HIV status, CDC guidelines seek to make HIV screening a routine part of medical care. This paper examines how routinely California primary care providers test for HIV and how providers' knowledge of California's streamlined testing requirements, use of sexual histories, and having an electronic medical record prompt for HIV testing, relate to test offers.We surveyed all ten California health plans offered under health reform's Insurance Exchange (response rate = 50%) and 322 primary care providers to those plans (response rate = 19%) to assess use of HIV screening and risk assessments.Only 31.7% of 60 responding providers reported offering HIV tests to all or most new enrollees and only 8.8% offered an HIV test of blood samples all or most of the time despite the California law requiring that providers offer HIV testing of blood samples in primary care settings. Twenty-eight of the 60 providers (46.6%) were unaware that California had reduced barriers to HIV screening by eliminating the requirement for written informed consent and pre-test counseling. HIV screening of new enrollees all or most of the time was reported by 53.1% of the well-informed providers, but only 7.1% of the less informed providers, a difference of 46 percentage points (95% CI: 21.0%-66.5%). Providers who routinely obtained sexual histories were 29 percentage points (95% CI: 0.2%-54.9%) more likely to screen for HIV all or most of the time than those who did not ask sexual histories.Changing HIV screening requirements is important, but not sufficient to make HIV testing a routine part of medical care. Provider education to increase knowledge about the changed HIV testing requirements could positively impact testing rates.
| S-EPMC4587809 | biostudies-literature
Project description:The Affordable Care Act (ACA) was expected to benefit patients with substance use disorders, including opioid use disorders (OUDs). This study examined buprenorphine use and health services utilization by patients with OUDs pre- and post-ACA in a large health care system. Using electronic health record data, we examined demographic and clinical characteristics (substance use, psychiatric and medical conditions) of two patient cohorts using buprenorphine: those newly enrolled in 2012 ("pre-ACA," N = 204) and in 2014 ("post-ACA," N = 258). Logistic and negative binomial regressions were used to model persistent buprenorphine use, and to examine whether persistent use was related to health services utilization. Buprenorphine patients were largely similar pre- and post-ACA, although more post-ACA patients had a marijuana use disorder (p < .01). Post-ACA patients were more likely to have high-deductible benefit plans (p < .01). Use of psychiatry services was lower post-ACA (IRR: 0.56, p < .01), and high-deductible plans were also related to lower use of psychiatry services (IRR: 0.30, p < .01). The relationship between marijuana use disorder and prescription opioid use is complex, and deserves further study, particularly with increasingly widespread marijuana legalization. Access to psychiatry services may be more challenging for buprenorphine patients post-ACA, especially for patients with deductible plans.
| S-EPMC5555852 | biostudies-other