A Broken Promise: Why the ACA May Not Improve Access to Effective Addiction Treatment
Lack of health insurance coverage for addiction treatment is a dangerous reality for many individuals across the nation. The Affordable Care Act (ACA) was expected to significantly reduce this barrier by providing insurance coverage to millions of previously uninsured people, mandating coverage of addiction benefits by designating them Essential Health Benefits (EHB), and by requiring parity (equal coverage) among addiction benefits and medical/surgical benefits. However, our recent review of the 2017 EHB benchmark plans, which establish the minimum level of coverage for the ACA plans sold in each state, reveals that the ACA’s promise of greatly expanding access to addiction treatment through health insurance coverage is not being met. This represents a serious threat to the health of people suffering from addiction and the well-being of their families.
What does this mean for patients?
Patients benefit most when addiction treatment is tailored to their specific needs and treatment can only be appropriately tailored when different levels of care are available. Ideally, insurance plans should cover a full array of effective services including: emergency care, inpatient (hospital) services, outpatient (office visits) services, intermediate services (residential treatment, intensive outpatient and day/partial hospitalization) and all medications approved by the U.S. Food and Drug Administration (FDA) to treat addiction.
Residential treatment is frequently excluded or not explicitly covered by the 2017 EHB benchmark plans. This exclusion means patients have to either seek treatment in an inpatient hospital setting where unnecessary care may be provided, or in an outpatient setting, where their needs may not be adequately addressed. This results in poor outcomes for the patient and unnecessary costs for the health plan.
Further, our report found that plans are not covering a scope of benefits for addiction that is comparable to the covered benefits for medical conditions because the plans that exclude residential treatment for addiction cover what is considered a parallel level of care for other medical conditions, for example skilled nursing facility care. To illustrate, let’s assume that a patient with diabetes needs to have a foot amputation. The patient’s health plan would pay for the surgery and inpatient hospital stay. If the patient is not well enough to return home after surgery, the plan would pay for the patient to continue recovery in a skilled nursing facility. Now assume that this same patient has another chronic life-threatening disease (opioid addiction) and has recently experienced an overdose. The patient’s plan would pay for the treatment of the overdose in the hospital, but once the patient regains consciousness and is stable, the only option – because of the patient’s insurance coverage – is to send the patient home to receive outpatient treatment. This can happen even if the patient requires a more intense level of care, because the plan excludes residential treatment.
Another frequently excluded or not explicitly covered benefit for this patient would be the FDA-approved drugs to treat opioid addiction (including methadone, buprenorphine or Suboxone, and naltrexone or Vivitrol). The lack of comprehensive coverage of these drugs used in medication-assisted treatment is alarming given the widespread calls for increased access to these life-saving drugs to combat the devastating effects of the current opioid crisis. Only three state EHB benchmark insurance plans explicitly cover methadone, which has been the gold standard for the treatment of opioid addiction for the past 50 years. Additionally, methadone, Suboxone, and Vivitrol are not interchangeable (patients may improve with one medication but not another, just like in other medical conditions) and these medicines vary in their accessibility in different parts of the country. To ensure proper treatment, patients must have access to all of these medications so they can take the one that is most effective for them.
Finally, the level of benefit detail in plan documents is woefully inadequate. The documents that we reviewed are documents that insurance plans give to members. They should provide thorough, comprehensive and easily understood benefit information so that members are able to quickly understand what their plan covers when seeking addiction treatment. Patients and their families should not have to waste time and energy trying to figure out what benefits are covered by their plan when seeking life-saving care.
How can this be fixed?
We hope and strongly recommend that the 2017 EHB benchmark plans are revised to provide comprehensive coverage of the benefits that are critical to treat and manage addiction. Providing inadequate benefits is costly for health plans, as it leads to worse outcomes for patients and repeat episodes of treatment, thereby increasing costs. Strong oversight, enforcement and additional guidance and technical assistance are needed to ensure compliance with the ACA’s requirements for the coverage of addiction benefits. If these steps are taken, it will help to close the treatment gap by increasing access to addiction treatment, support the continuum of care necessary to manage a chronic illness, improve the health of patients and their families, and decrease costs for the health plans in the long run.
Lindsey Vuolo, JD, MPH
Lindsey is an Associate Director of Health Law and
Policy at Center on Addiction