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Essential Coverage for Often Neglected Health Needs

posted on Tue, Jan 3 2012 2:06 pm by Corey Davis

Substance Abuse Disorder

Substance use disorder (SUD) includes not only the disease often referred to as “addiction” but also the conditions of substance abuse and substance dependence. Left untreated, SUD can lead to a number of serious public health problems. As a recent blog post noted, drug overdose is now the second leading cause of injury death in the United States. Excessive alcohol use is responsible for almost 80,000 deaths and many more injuries every year. Because of poor access to sterile syringes, injection drug use acts as a vector for transmission of HIV, hepatitis and other bloodborne diseases. In addition to these and other health concerns, untreated SUD can lead to lower quality of life, decreased productivity and other problems at work and home.

Addiction, a prominent SUD, has been misunderstood in popular culture. According to Nora D. Volkow, Director of National Institute on Drug Abuse, “when science began to study addictive behavior in the 1930s, people addicted to drugs were thought to be morally flawed and lacking in willpower. Those views shaped society's responses to drug abuse, treating it as a moral failing rather than a health problem, which led to an emphasis on punitive rather than preventative and therapeutic actions.” Current research findings demonstrate that some SUDs, like addiction, are diseases of the brain and need to be treated much like heart disease or cancer.

The good news is that there are now high-quality, evidence-based treatments for substance use disorders. Unfortunately, many people who would benefit from treatment are not able to access it because they cannot afford to pay out of pocket, cannot afford health insurance or have health insurance that doesn’t cover the required treatment.

The Affordable Care Act (ACA) should help to improve access to treatment for substance use disorders in three main ways.

First, beginning in 2014, the Act will require many health insurance plans to cover certain “essential health benefits (EHBs).” These essential health benefits must be included in health insurance plans offered through health care exchanges, state-sponsored basic health programs and plans available to people enrolled under the expanded Medicaid coverage rules. Among these essential benefits is coverage for mental health and SUDs, including behavioral health treatment.

Second, the ACA extends a federal law, the Mental Health Parity and Addiction Equity Act (MHPAEA), that requires that SUD services, when provided, be provided at parity with medical and surgical benefits to most people who will gain insurance under the Act. The MHPAEA prohibits most plans from charging higher deductibles or copayments for SUD services than those charged for medical/surgical services. It also prohibits them from limiting the number or frequency of provider visits for SUD except to the extent that those limits are also imposed on substantially all medical and surgical benefits, and it requires that plans that provide out-of-network medical/surgical benefits also provide out-of-network SUD treatment. The MHPAEA, however, does not require plans that do not currently provide SUD treatment to begin doing so.

Finally, the ACA prohibits group health plans and issuers offering group or individual health insurance coverage from denying coverage to people over the age of 18 because of pre-existing conditions, and it prohibits individual and small group policies from charging higher rates because of an enrollee’s health status.  Because many SUDs are chronic disorders characterized by occasional relapses, many people with these conditions are currently barred from accessing care by pre-existing condition exclusions. Together, these changes should help many people with previous or current substance use conditions access treatment. The Department of Health and Human Services recently announced that it intends to give states a great deal of flexibility in determining which services, including SUD services, qualify as essential health benefits. Since increased access to treatment is likely to improve the health of people with SUDs, reduce health care costs and improve quality of life for people with SUDs and the public, it is important that a wide variety of SUD services be deemed “essential” so that that most health plans will be required to cover them at parity with other health services. Read more about substance use disorder and the ACA here.

This information was developed by Corey Davis, staff attorney, for the Network for Public Health Law – Southeastern Region at National Health Law Program.

The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document does not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state.


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