Decline In Public Substance Use Disorder Treatment Centers Most Serious In Counties With High Shares Of Black Residents
By Janet R. Cummings, Hefei Wen and Michelle Ko
Health Affairs, June 2016
Abstract
Previous research has associated declines in health care resources such as hospitals and trauma centers with communities’ racial composition. However, little is known about changes in the substance use disorder treatment infrastructure in recent years and the implications for black communities. We used data for the period 2002–10 from the National Survey of Substance Abuse Treatment Services to describe changes in the supply of public and private outpatient facilities for substance use disorder treatment, and to determine whether these trends had implications for the geographical availability of these facilities in counties with high percentages of black residents. During the study period the number of publicly owned facilities declined 17.2 percent, whereas the number of private for-profit facilities grew 19.1 percent. At baseline, counties with very high percentages of black residents (that is, more than one standard deviation above the mean) were more likely than counties with less than the mean percentage of black residents to be served by public facilities and were thus disproportionately affected by the overall decline in public facilities. Future research should examine the effect of expanding eligibility for Medicaid on the supply of substance use disorder treatment facilities across diverse communities.
From the Discussion
Between 2002 and 2010 there was a decline in the number of public and private nonprofit outpatient substance use treatment facilities, but considerable growth in the number of private for-profit facilities. Among counties with at least one public facility at baseline, nearly half experienced a net loss in the number of public facilities by 2010. Counties with a large percentage of black residents were disproportionately burdened by the decline in public facilities, and these losses were not offset by an increased likelihood of gains in private for-profit or nonprofit facilities.
An overall decline in the supply of public and private nonprofit facilities has important implications for vulnerable populations across all communities. Compared to private for-profit facilities, public and nonprofit facilities are less likely to turn clients away based on their ability to pay.
Although public facilities constituted only 15 percent of the sample at the beginning of the study period, the decline in this sector is especially notable because these facilities were the most likely, at baseline and follow-up, to provide services to people who could not pay. In addition, previous research has reported that public facilities serve a significantly higher percentage of clients who are unable to pay for services than private (for-profit and nonprofit) facilities do. Furthermore, public facilities are more likely than private ones to offer important services such as HIV testing and more likely than private for-profit facilities to offer comprehensive care, including physical examinations and mental health treatment. Future research is needed to better understand the implications of these declines for the accessibility of outpatient care among low-income populations and for the availability of specific types of services.
The decline of public facilities has important implications for counties with a high percentage of black residents in particular. Nearly half of the counties with a public facility at baseline experienced a net loss in this resource, and counties with higher percentages of black residents were overrepresented among these communities. Regression results indicated that there was no significant association between county percentage of black residents and the likelihood of losing a public facility after other county-level characteristics were adjusted for. Nevertheless, counties with very high or extremely high percentages of black residents were disproportionately affected by the overall downward trend in the public sector because they were more likely to be served by public facilities at baseline than counties with less than the mean percentage of black residents.
The net loss of public facilities in counties with very high or extremely high percentages of black residents was not offset by an increased likelihood of gains in private facilities. Instead, the latter counties were less likely to gain a private (for-profit or nonprofit) facility than counties with less than the mean percentage of black residents, after other county-level social and demographic characteristics were adjusted for in the analyses. Considered together, these results suggest that public facilities may help fill infrastructure gaps left by the private sector, and that losses of public providers may not necessarily result in new investments from the private sector. As a consequence of the general decline in the public sector, coupled with the similar or lower likelihood that counties with very high or extremely high percentages of black residents experienced a net gain in private facilities, the counties with higher percentages of black residents had a lower likelihood of having any outpatient facility by the end of the study period, compared to counties with less than the mean percentage of black residents.
As of March 14, 2016, thirty-one states had opted to participate in the Medicaid expansion. However, it is worth noting that the decline of public facilities was even more pronounced among states that are not participating in the expansion. In addition, more than four-fifths of counties with more than the mean percentage of black residents are located in states that have not expanded Medicaid.
Conclusion
This study provides the first empirical information about trends in the ownership mix of facilities for substance use disorder treatment since the beginning of the twenty-first century and the implications of these trends for counties with a high percentage of black residents. The general decline in the number of public facilities, coupled with a similar or reduced likelihood of gaining private facilities in these counties, resulted in an overall disparity between them and other counties in the geographic availability of treatment facilities by 2010. As national policies for substance use control continue to shift toward prevention and treatment and away from more punitive approaches, it will be essential to ensure that enough treatment facilities are available across diverse communities.
http://content.healthaffairs.org/content/35/6/1036.abstract
***
Nearly all ACA benchmark plans violate rules on addiction treatment coverage
By Steven Ross Johnson
Modern Healthcare, June 7, 2016
More than two-thirds of state benchmark plans violate federal requirements to cover treatment for addiction disorders.
The National Center on Addiction and Substance Abuse surveyed addiction treatment benefits offered among 2017 Essential Health Benefits benchmark plans and found none offered a comprehensive array of addiction treatment benefits.
The report cites benchmark plans, which determine the minimum level of benefits available to those covered in state exchange plans, frequently “excluded or not explicitly covered benefits” related to residential treatment and the use of methadone as therapy.
Calls for more comprehensive coverage of addiction treatment services have grown louder over the past few years as the number of drug overdose deaths have reached record levels. More than 28,000 people died in 2014 from overdoses involving opioid drugs, including heroin.
Last year, the federal government suggested including coverage of the full range of approved medication-assisted treatments as part of the essential health benefits to ensure more access to such therapies. But the proposal faced opposition from insurers and pharmacy benefit managers and was struck down.
http://www.modernhealthcare.com/article/20160607/NEWS/160609927
***
Comment:
By Don McCanne, M.D.
Outrageous! While the public drug abuse treatment centers decline in numbers, and the private, for-profit centers are proliferating, “the counties with higher percentages of black residents had a lower likelihood of having any outpatient facility by the end of the study period, compared to counties with less than the mean percentage of black residents” (Health Affairs). Further, more than two-thirds of private benchmark plans offered in the ACA exchanges “violate federal requirements to cover treatment for addiction disorders” (Modern Healthcare).
According to the Modern Healthcare article excerpted above, “Last year, the federal government suggested including coverage of the full range of approved medication-assisted treatments as part of the essential health benefits to ensure more access to such therapies. But the proposal faced opposition from insurers and pharmacy benefit managers and was struck down.”
Who is responsible for this egregious disregard of addiction treatment needs, coverage of which is required by the Affordable Care Act – omissions especially neglectful of our black brothers and sisters? The private, for-profit addiction treatment centers; the private, for-profit insurers; the private, for-profit pharmacy benefit managers; and the anti-government legislators who have underfunded public treatment centers, and who have turned the funding of health care over to private, for-profit intermediaries.
A well designed, publicly-funded and publicly-administered single payer system would separately budget capital expenditures, including those for facilities offering addiction services, with distribution based on needs rather than on for-profit business ventures, and the services would be paid for on an equitable basis, ensuring access and affordability for everyone. It should be about patients, not business stratagems.
