Commentary: A Boon but No Silver Bullet: The ACA and Substance Abuse Treatment

The Patient Protection and Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act (MHPAEA) are tremendous steps toward ensuring that all individuals can access substance abuse treatment. But the laws are not silver bullets that will close the treatment gap or help every individual who needs treatment. Provider preparation and client outreach will ultimately determine how these laws truly affect behavioral health.

Known as “Obamacare,” the Congressional Budget Office estimates that the ACA will cover 25 million previously uninsured individuals by 2024.¹ Unfortunately, recent surveys find that the law’s provisions are poorly understood. Coupled with the individual mandate, the ACA will create insurance marketplaces and subsidize coverage purchased through those marketplaces for people earning 100 percent to 400 percent of the federal poverty level (FPL). In addition, states may expand their Medicaid programs to cover all adults earning up to 138 percent of the FPL — a population many already believed were covered.²  So far, about half the states have agreed to expand.³

By 2020, the ACA and MHPAEA will enhance behavioral health coverage for 62.5 million people.⁴ Together, the laws will allow 32.1 million individuals to access substance abuse benefits for the first time and expand coverage for 30.4 million individuals with existing behavioral health benefits. The ACA ensures that newly covered individuals will receive substance abuse benefits through Essential Health Benefits, which affect newly eligible Medicaid enrollees and most individual and small group plans. However, not all low-income Americans are eligible for ACA assistance.

An estimated 4.8 million uninsured individuals in 25 states fall into the ACA “coverage gap.”⁵ Because the law cannot provide marketplace subsidies for individuals earning less than the FPL, the poorest residents in states that do not expand Medicaid will remain ineligible for Medicaid and federal subsidies. These individuals are simply beyond ACA’s reach. Yet the coverage gap is not the only challenge.

Though the ACA dramatically expands behavioral health coverage, the mere existence of the ACA may do little for most substance users with unmet need. In 2012, 89 percent of the 23.1 million persons that needed treatment for substance use did not receive treatment at a specialty facility.⁶  Perhaps this is because 95 percent of those with an unmet treatment need do not feel they need treatment.⁷ The field must help individuals learn about their options, enroll in coverage, acknowledge their needs, and utilize needed services. No easy task under the best of circumstances.

The ACA will also thrust many providers from simpler payment schemes into the complicated worlds of Medicaid and private insurance. Providers must ensure that they can work with the new payers and financing mechanisms while aggressively pursuing outreach goals. Provider preparation and client outreach are the first steps, but the field must ultimately help individuals acknowledge and act on their need for treatment. The ACA cannot do that.

John Carnevale, President of Carnevale Associates, and Raanan Kagan, Managing Director of Health Policy Research at Carnevale Associates

For more information on the Affordable Care Act, please visit:

Shaping Substance Abuse Treatment: http://carnevaleassociates.com/aca (April 2013)
Opportunities & Challenges for Behavioral Health Providers: http://carnevaleassociates.com/acaprovider (January 2014)

¹http://www.cbo.gov/sites/default/files/cbofiles/attachments/45010-Outlook2014_Feb.pdf
²http://kaiserfamilyfoundation.files.wordpress.com/2011/04/8061-021.pdf
³http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/
⁴http://aspe.hhs.gov/health/reports/2013/mental/rb_mental.pdf
⁵http://kaiserfamilyfoundation.files.wordpress.com/2013/10/8505-the-coverage-gap-uninsured-poor-adults8.pdf
⁶http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/NationalFindings/NSDUHresults2012.htm
⁷Ibid.