Substance Abuse and Health Care: What Might Be or Could Have Been

For the past year, health care reform has dominated the headlines and monopolized the time of Congress and the White House.  Not since 9/11 has all of Washington been singularly focused on one issue.

While the legislation going to conference between the House and Senate is over 1,900 pages, there are parts that apply to substance abuse treatment and prevention.  In some cases, the House and Senate provisions are fairly close. Yet in others, it remains to be seen which version will prevail when the final bill is introduced.

In Washington, the substance abuse and mental health advocacy communities came together under one banner to push for these provisions.  Led by the Legal Action Center, the Coalition contains over 30 organizations.  Represented are organizations representing treatment centers, prevention, consumer’s rights, health professionals, and a slew of other interests.

First and foremost, both bills require that substance use disorders, as well as mental health disorders, be part of the minimum benefits package.  The senate version, though, exempts large employers from this provision. “In my view, the largest victory is the inclusion of coverage of substance use disorder services as part of the essential benefit package,” said Rob Morrison, Executive Director of the National Association of State Alcohol and Drug Abuse Directors (NASADAD.)  “ This represents a giant opportunity to increase access to addiction treatment services and demonstrates that the work of the Coalition for Whole Health did a fantastic job to make this happen. “

Perhaps one of the most important provisions is how those newly enrolled in Medicaid will be classified when it comes to substance abuse treatment.  While the Senate version of the bill expands coverage to those at 133% of the poverty level, new enrollees would be placed in a plan that includes addiction and mental health treatment services.  Childless adults would be eligible for this plan.  The House version, however, allows for enrollment for those up to 150% of the poverty level.  Those newly enrolled would be provided addiction and mental health services, at a state’s option, according to a respective state’s plan.  The House version would also prohibit enrollment of childless adults, unless the state can demonstrate that the plan has the capacity to meet the health, mental health, and substance use disorder needs of the individual.

Workforce development is also part of the proposed legislation.  The House version is very simple, as it authorizes workforce development grants for providers of mental health and substance use services.   $60 million is authorized for the program, and the report accompanying the legislation specifies training for addiction physicians.

The Senate version of the bill is more detailed in this area.  Perhaps most importantly, it would qualify individuals practicing pediatric counseling for a loan repayment program.  It also authorizes grants to higher education institutions for substance abuse and mental health professionals.   Priority will be given to those schools where training focuses on the needs of vulnerable populations, as well as those where applicants display a familiarity with evidence based methods.  Unfortunately, the senate only provides for $35 million for this program, with $8 million going to social work and $12 million going to graduate psychology.  $10 million would go to mental health and substance abuse.

In the fall of 2008, the behavioral health advocacy community saw over a decade of work pay off when the Paul Wellstone & Pete Domenici Mental Health Parity Act was signed into law.  Both the Senate and House versions of health care reform requires individual, small group, and large group insurance plans to comply with the regulations set forth in Wellstone-Domenici.

“One of the most crucial components of the healthcare reform legislation now being debated is the concept of parity. The bill includes the principles contained in the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, the federal law passed last year which prohibits unequal treatment limits and financial requirements for mental health and substance use treatment,” said Linda Rosenberg, executive director of the National Council for Community Behavioral Healthcare.   “The parity provisions are essential given that mental health and substance use treatment have traditionally been subject to blatantly discriminatory limits on coverage that restrict access to effective and, at times, lifesaving therapies.”

Screening and prevention is another part of the bill where the Senate version is far different than the House.  The House provides $30 million for new SBIRT grant programs.  The Senate’s effort is more fragmented. Substance use prevention is included in a section authorizing community health team grants supporting medical homes.  Substance use disorders services are also required to be provided at school based community health centers.  It would also allow state or local health departments which receive grant funds through a public health grant program administered by the CDC to enter into contracts with substance use and mental health providers.

Finally, there is the matter of including the federal agencies that work in mental health and substance abuse in relevant working groups and studies.  The House version adds SAMHSA to the list of agencies to be consulted for the development of a national prevention and wellness program.  The senate version includes SAMHSA as an agency to be included in the “Interagency Working Group on Health Care Quality.”  It also directs states to consult with SAMHSA when addressing Medicaid coverage of mental health and substance abuse prevention and treatment.

If and when the health care reform package does become law, there is still more work to be done.  All of the programs and changes it provides for must be implemented.  Also, these new or modified programs must be funded, which means a whole new round of advocacy at the appropriations level. “The work has only just begun,” said Morrison.  “As the saying goes, the devil is in the details.  Or in this case, the devil is in the details – and the implementation.”

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