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Addiction treatment is included in the minimum benefits packages in all three major national healthcare reform bills now being considered by Congress, and each also includes equal coverage of addiction-related services as outlined in the 2008 Wellstone parity bill.
Carol McDaid of Capital Decisions, who lobbies on behalf of addiction treatment and prevention organizations,said that of the five “big buckets” that advocates for addiction services need to fill in the healthcare reform debate, at least these two are being treated favorably by lawmakers, while work still needs to be done on three others — prevention, workforce development, and electronic health records.
“We're thrilled [addiction treatment is] in at this point,” said Victor Capoccia, Ph.D., director of the Closing the Addiction Treatment Gap (CATG) program, which this week issued a white paper stating that covering addiction treatment services under healthcare reform could make a major contribution to cutting health costs.
Compared to the last big health reform battle on Capital Hill — Hillary Clinton's ill-fated stab at universal coverage in 1993-94 — “we're in much better shape as a field in terms of advocacy,” said McDaid.
That's due in part to the fact that the field waged a recent and successful battle for inclusion in and passage of the parity law, so the arguments in favor of addiction treatment coverage are still fresh in policymakers' minds, noted McDaid.
Also, federal agencies like the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Office of National Drug Control Policy have been far more engaged in collaborating with the field under the Obama administration, and cooperation between the addiction and mental-health communities has matured and coalesced around the Coalition for Whole Health, said McDaid.
For example, SAMHSA recently issued a consensus statement calling for addiction and mental health services to be included in healthcare reform and outlining a series of core principles for reform, while the Coalition for Whole Health has drafted legislative language reflecting the field's priorities.
CATG, funded by the Open Society Institute, helped organize a July 17 briefing for Washington, D.C., policymakers on the case for addiction treatment in health reform. The hearing, which was attended by more than 230 people, will be followed by a series of regional policy panels during the Congressional summer recess, according to Capoccia. The group also sponsored a survey released in June showing that a solid majority of American support inclusion of addiction treatment in national healthcare reform, and plans a more detailed followup survey later this summer.
Progress on Prevention
Addiction-field advocates have made some progress towards ensuring that alcohol and other drug prevention services are included in the preventive-health provisions of the healthcare reform legislation. The bills will also cover screening and brief intervention for problem drinking as a covered preventive service. “This is enormously important, because research has shown that widespread screening can lead to significant reductions in alcohol related medical expenses,” said David Rosenbloom, president and CEO of the National Center on Addiction and Substance Abuse (CASA) at Columbia University.
However, “There are certainly gaps in how coverage will be included” for prevention services, cautioned Capoccia.
Advocates also are working to ensure that addiction-treatment professionals can share in the workforce-development programs envisioned under the various bills, such as forgiveness for educational loans and increased slots for medical residents. “It could become a real issue if we get parity and have a big increase in patients with no providers to serve them,” pointed out McDaid.
Finally, field leaders are pressing lawmakers to ensure that addiction-treatment providers can tap into assistance to develop and enhance electronic health records to improve coordination and efficiency, while at the same time recognizing the special confidentiality issues inherent in addiction treatment, McDaid said.
Currently, the addiction field “comes out better in the House Tri-Committee bill,” said McDaid, although she stressed that the measures are “good across the board.” None of the bills deal with the specifics of healthcare benefits, which would be spelled out after passage by special committees established under the reform act.
A 'Secret Weapon' to Cut Healthcare Costs
Capoccia goes beyond arguing for simple inclusion, arguing that expanding addiction treatment for the estimated 20 million American who need it could be a “secret weapon” for cutting overall healthcare costs in the U.S. “When you treat people, their use of general medical services and associated costs both decrease,” he said. “Even if you only help one-fifth, 25 percent of them, it begins to translate into lost of money on an annual basis — to say nothing of the fact that people with an illness should get treatment, period.”
CASA's Rosenbloom urged lawmakers to consider raising the federal tax on alcohol as part of health-reform legislation. “It will raise a lot of the money needed to pay for reform and also lower future medical care costs,” he said. “When the price of alcohol goes up, problematic drinking by young people and the small number of very heavy drinkers goes down.” Rosenbloom said research shows that governments currently spend $7 dealing with the consequences of excessive alcohol use for every dollar they collect in alcohol taxes.
McDaid — who would like to convince lawmakers to get the Congressional Budget Office to score addiction treatment services and conduct a cost-benefit analysis of inclusion in health reform — said she's not surprised that the public and members of Congress are reacting sharply to the cost of healthcare reform now that specifics are emerging. She expects that the debate will stretch out much further than the summer.
“I still believe we will get something done, though I think Congress may be in until Christmas Eve,” she said. “The question is how significant will it be — will it be incremental or a whole-system reform?”
McDaid is less concerned about Congress backtracking on providing coverage for addiction treatment services. “I think many of the victories we have had will be sustained” in whatever reform bill passes, she said.
What Comes After Reform?
For the addiction field, the hard work will hardly be starting if and when the ink dries on a healthcare reform bill. While lawmakers may be willing to finally deny the myth that addiction treatment is too expensive and accept that it saves money in the long run — and Washington's recent embrace of drug courts suggests they are — the field still faces tremendous challenges in terms of accountability and lack of integration with the mainstream healthcare system.
Capoccia said that there is good outcome data to support certain types of treatment, such as medication-assisted programs and those using motivational enhancement and interviewing techniques. Standards developed by the National Quality Forum have been adopted by some states to guide purchasing decisions.
But many programs still lack credible outcome data, and Capoccia predicted that programs that lack accountability and quality standards will be “winnowed out” within five years of healthcare reform passing. “Accountability is written all over healthcare reform,” he said.
Capoccia added that healthcare reform is likely to force addiction treatment providers to become more sophisticated and comprehensive in the services they offer to the patients they “own” — namely, those with severe or persistent addiction or mental-health problems. “If we own them, we'll have to provide or link to general medical care, too,” he said.
Currently, however, “Our field is woefully unprepared to make the changes necessary to operate in a healthcare-reform environment,” said Capoccia.