Commentary: Hope is on the Horizon: Leveraging the Promise of the Affordable Care and Parity Acts

Research has clearly shown that adolescence is the at-risk period for developing a substance use disorder – yet the state of substance abuse prevention, early intervention and treatment for adolescents and young adults is woefully inadequate. The current focus on reducing problematic use among adolescents with a diagnosable disorder is often too little, too late. This coupled with inequitable insurance coverage and under- or non-funded prevention and early intervention programs contribute to the fact that more than 90% of adults with addiction developed the problem between the ages of 12 to 20 years. This infrastructure is contributing to this growing population of young adults suffering from escalating, and often fatal, substance use disorders. This is a system that clearly needs to be fixed.

But hope is on the horizon. Like never before in our history, the possibility to make systemic changes needed to improve prevention and care of substance use disorders during adolescence is real.

If properly implemented, the Affordable Care Act (ACA), together with Mental Health Parity and Addiction Equity Acts (Parity Act), should put an end to the chronic underfunding and lack of equitable coverage for substance use disorder prevention, early intervention, treatment and continuing care in this country. New laws entitle patients to a full range of prevention and early intervention services for substance use disorders on par with those provided for other chronic illnesses. In other words, there is now a mandate and incentive for providers and payers to address substance use disorders earlier in their trajectory.

Thanks to a $1.35 million grant from the Conrad N. Hilton Foundation, the Treatment Research Institute, along with the Legal Action Center and Truven Health, is working to rigorously assess how the implementation of the ACA and Parity Act are impacting adolescent substance use. We will determine what services are and are not being offered – and in what settings. We will identify barriers (real and perceived) that are reported to preventing services from being offered so that solutions, guidance, and support can be enacted. The ACA and Parity Act make it a requirement to provide a continuum of care for substance use disorders, but the regulations do not provide funds for enforcement of either the ACA or Parity Act; thus there is little assurance that these services will be provided appropriately on the ground. This project aims to discover if that is happening – and if it is not – to find out why, and then develop solutions to address obstacles.

We will be documenting and analyzing the status of the ACA and Parity Act implementation by focusing on insurance coverage and access to substance use screening, as well as early or brief intervention services (SBI) by providers in a variety of settings. We hope to learn things like how frequently services are offered, under what conditions and what socio-demographic characteristic of the adolescents are services, and shed light on the scope of providers that do and do not deliver such services, as well as some of the hurdles they may be facing.

Adolescents can sometimes be reluctant to share what they may feel is stigmatizing information with their primary care doctors or other health care provider for fear that it will be disclosed to parents and others. What the adolescent and/or the provider may not realize is the confidentially obligations that exist in this type of setting. We would like to learn how current and potential SBI providers in different settings view confidentially regulations and help them overcome misunderstandings and misgivings to deliver preventive care.

Throughout the course of this project, we will inform and educate purchasers, payers and other stakeholders of the services now mandated by law, and document the current state of prevention/early intervention coverage, barriers to expanding services and strategies for improvement. We will create tools and resources to inform families, clinicians and advocates.

Although our focus will be on the interactions of insurance and health service delivery, it is important to note that prevention and intervention conversations, actions and services can take place outside of the healthcare environment; in schools and in any other natural setting in which adolescents gather. Parents, school-based health counselors and nurses, teachers, police officers, community workers, doctors and neighbors can all play a role influencing adolescent behavior and understanding of drug or alcohol use. If we are to be successful at achieving better outcomes during adolescence, we must find ways to offer prevention and early intervention services in all of these settings. Prevention works best when it is approached as a coordinated community effort.

Scientific advances have shown that adolescent substance use can be prevented, abuse can be identified and reduced and dependence can be effectively treated. The new ACA and Parity legislations truly provide the opportunity to improve the incorporation of evidence-based prevention services into adolescent care, and to make sure that insurers provide the proper coverage and benefits. There is great potential to dramatically expand coverage for, and access to, life-saving services for adolescents. But we all must do our part to ensure that this promise becomes a reality. There is much work to be done – but never before has the potential been greater to change the way that we approach substance use prevention in this country. Hope is on the horizon.

Mady Chalk, PhD, MSW, Director, Policy Center, Treatment Research Institute