The Affordable Care Act (ACA) stands to increase access to mental health and addiction services for millions of Americans through expanded Medicaid coverage and other provisions, such as parity protections that require states to cover behavioral health services that are equivalent to physical health services. Newly published research, however, indicates that the ACA’s potential impact on substance use treatment will go unrealized without significant changes at the state level, including Medicaid expansion, resource reallocations, and institutional support for behavioral health treatment programs.
 
If all states expanded Medicaid, parity protections would extend to more than 62 million people, and as many as 4.8 million currently uninsured people with substance use disorders could become eligible for insurance. In states that have expanded the program, an estimated 30 percent of incarcerated people will be newly eligible to enroll in Medicaid. Since people who lack access to adequate health services for a serious mental illness and/or substance use disorder are significantly overrepresented in correctional facilities, enrolling justice-involved people in Medicaid—which integrates mental health and addiction services into primary care—upon release increases this population’s access to healthcare.
 
This not only yields significant cost savings, it reduces rates of illness and disease, mortality, ER use, and recidivism. Research also suggests that for formerly incarcerated people, facilitating access to healthcare is essential to improving other social determinants of health, like housing stability and employment outcomes. Though projected to grow through 2020, spending on behavioral health treatment will continue to lag behind other health spending, and most of the growth in funding for addiction treatment services will be driven by the ACA, particularly through Medicaid.
 
The potential of the ACA raises two important questions that states, which have the onus of implementing health reform, need to address. First, is expanding access to insurance coverage enough to increase the number of people making use of treatment services without a corresponding increase in the availability and accessibility of local quality services? Second, are states doing what they need to do to realize the ACA’s potential for addiction treatment and justice-involved individuals? Findings from a 2012 study on Massachusetts—a state that has paved the way in universal health insurance laws—offer a cautionary tale: increasing coverage alone is insufficient for increasing drug treatment services, as people with substance use issues require tailored outreach and service linkages.
 
The newly published research is featured in the current issue of leading health policy journal Health Affairs and explores how states’ “single state agencies” (SSAs)—the organizations charged with overseeing addiction treatment programs and allocating block grants—use their expertise and funding to improve addiction services. Researchers discovered that SSAs often facilitated collaboration between addiction treatment programs and other programs, including mental health and criminal justice related organizations. Few SSAs, however, helped with insurance enrollment, outreach to newly eligible people, advice for programs on how to become in-network for insurance providers, or technical assistance to help addiction treatment programs prepare for ACA implementation.
 
Additionally, ACA funds can allow for the reallocation of other resources currently used for drug treatment—such as Substance Abuse Prevention and Treatment block grant money—toward prevention and outreach efforts that can’t be funded by Medicaid. In states that expanded Medicaid or set up their own insurance exchanges, SSAs were much more likely to assist with enrollment and outreach services and to anticipate reallocating block grant funds. In states that did not expand Medicaid or set up their own exchanges, people with substance use disorders were less likely to receive insurance related assistance. This new information underscores the importance of state-based Medicaid expansion.
 
There is ample excitement about the potential of the ACA for improving behavioral health services. However, state agencies’ scarce consideration regarding the effort needed to prepare for its implementation could limit improved drug treatment and integrated care. Agencies must undergo a structural transformation, requiring significant investments in the community health workforce, information technology, policy changes, and technical assistance. For instance, jurisdictions can explore new technological tools like the Provider Availability Index (PAI), which measures the gap between the availability of behavioral health service providers and the demand for treatment, thus quantifying the imbalance between demands for care at a local level.
 
Understanding the logistics for improved care is the responsibility of individual states under the ACA. Expanding Medicaid is a necessary first step, but implementing reform through technical assistance and reallocations of block grants funds is vital for increasing not just access and coverage, but actual quality treatment.