Impact of the Patient Protection and Affordable Care Act on Substance Use, Treatment, and Coverage: A National and Local Perspective Douglas A. Hoopsick - MPA Project Proposal Laurie A. Buonanno, PhD - Project Advisor Introduction & Purpose Statement Methodology & Data Analysis Discussion Prescription drug abuse and addiction, primarily nonmedical use of prescription opioids, has become an epidemic in the United States, second only to cannabis (Yu, 2012) and three times that of cocaine (Manchikanti, 2007). In the United States, the death rate due to drug overdose doubled from 1998 to 2008 and has steadily continued to rise (Yu, 2012). Locally, the number of deaths in Erie County due to opioid overdose tripled from 2012 to 2017 (103 vs. 316), representing a significant public health issue at the national and local levels (Zremski, 2018). Lack of access to treatment has often been cited as a precipitating factor in these deaths, and public policy efforts have aimed to address this issue. However, the impact of such policies on substance use and access to treatment have not been well-studied. This project will examine the role of the Patient Protection and Affordable Care Act (ACA) in addressing substance use and access to treatment in the United States, as well as its effect on the efforts of local behavioral health organizations that treat this population. This study will add to our understanding of the effects of the ACA on substance use, treatment, and health care coverage. Given the current opioid epidemic and public focus on this issue, the findings of this study will be timely and help to identify potential gaps in current policy efforts to address this problem. Although the ACA contained some provisions that had the potential to affect those with substance use disorders, it is not clear if the downstream effects of the ACA have translated into fewer people having substance use disorders, more people receiving treatment for substance use, or more people having coverage for substance use treatment. By using an embedded mixed methods design that begins by examining nationally representative data and then following up with in-depth interviews from local behavioral health stakeholders, the findings of this study will give national and local perspective to a complex issue. Study Design. This project utilized an embedded mixed methods design by using secondary quantitative data analysis in the first stage followed by the collection and analysis of qualitative data in the second stage to support the quantitative findings (Creswell, Plano Clark, Gutmann, & Hanson, 2003). In the first stage of the study, data were obtained from the National Survey on Drug Use and Health. In the second stage of the study, qualitative data was collected from two behavioral health organizations in Western New York. Sample Selection. Since 1990, the National Survey on Drug Use and Health (SAMHSA, 2014) has been administered each year to collect nationally representative data on substance use and mental health problems among individuals aged 12 years and older. To ensure a nationally representative sample, the National Survey on Drug Use and Health uses a complex multi-stage sampling technique. Data Analysis. Descriptive statistics were used to characterize and describe the study sample that was analyzed for the first stage of this embedded mixed methods study. Figure 1 illustrates the different payers reported by those who received treatment in the last 12 months by year. The second stage of this study included interviews of stakeholders from two non-profit organizations that serve individuals with substance use disorders: Horizon Health Services and Niagara Falls Memorial Medical Center. Horizon Health Services provides outpatient and overnight rehab, while Niagara Falls Memorial Medical Center serves individuals with substance use disorders in the emergency room, overnight hospital stays, in affiliated outpatient clinics, and through case management services. Key themes identified: Changes in the Delivery of Care Post-ACA: The ACA has influenced the way that care is delivered, including the creation of intensive case management programs to better coordinate care as well as higher standards for evidence-based care. Changes to Care Access Post-ACA: The ACA has allowed more individuals with commercial insurance to seek substance use treatment and case management services better link people with comprehensive services. Challenges as a Result of the ACA: The ACA has required organizations to make significant clinical and operational changes that require substantial time, effort, and personnel. Suggestions for Regulatory Change: Policies affecting substance use prevention, stigma, and social determinant of health are recommended. Implications, Recommendations & Future Research Figure 1. Implications. The results of this study demonstrated that the ACA has had positive impacts, both nationally and locally, on access to behavioral health care. However, findings also demonstrate that there are opportunities for policy improvement. National quantitative data indicate that there haven’t been any improvements in the proportion of individuals seeking treatment, and results from the qualitative interviews suggest that stigma may be to blame. Findings from this project may help to inform area in need of additional funding, such as anti-stigma campaigns. Limitations. The first stage of this study was limited by several factors. First, all data were self-reported, making them subject to bias. Second, this was a secondary data analysis. This means that we were unable to ask specific questions related to this project, and were limited to the questions and definitions contained in the original survey. The second stage of this study was limited in that only two representatives were interviewed, so their perspectives may not necessarily reflect those of other organizations in the Western New York region. Future Research. The ACA has many complex provisions related to behavioral health and this also overlapped the time of the mounting opioid epidemic. Primary research is needed to tease apart these complicated issues to determine what effect the ACA may have had on individuals seeking substance use treatment. Literature Review Societal Effects of Substance Use. Substance use disorders have a significant impact both economically and socially. Nationally, an estimated $215 billion has been spent on direct healthcare costs due to the opioid crisis since 2001 (Allen, 2018). New York State ranks 3rd nationally in annual healthcare costs associated with the epidemic at over $1.2 billion per year (Matrix Global Advisors, 2015). Although the economic costs of treatment are staggering, the social costs are even greater (Meara & Frank, 2005). Of the total expenditures related to opioid abuse and dependence, lost earnings from premature death make up 46% (Birnbaum et al., 2011). Importance of Non-Profits. There are varying types of substance use treatment facilities, but non-profits make up the greatest proportion at 51% (SAMHSA, 2014). Those with substance use disorders tend to be particularly vulnerable; among all inpatient hospitalizations in the United States for substance use, nearly 14% were uninsured, which is more than twice that of all other types of inpatient stays (Heslin et al., 2006).   Using Public Policy to Address Substance Use. On March 23, 2010, President Obama signed the ACA into law, which defines “essential benefits” all insurance plans must cover, including substance abuse coverage with no lifetime limits (U.S. Centers for Medicare & Medicaid Services, 2018). Primary Research Hypothesis: There will be a significant difference in the distribution of treatment payer types (commercial insurance, Medicare, Medicaid, other public assistance, own savings, family member(s), courts, military health care, employer) among those who received treatment between 2010 and 2014. Chi-Square tests of independence was used to test for differences between 2010 and 2014 in the distribution of demographic and clinical characteristics of individuals that were surveyed. Table 1 shows results examining differences in types of payers between 2010 and 2014. The increase in use of commercial insurance to treat drug addiction post-ACA is statistically significant (p<.05). Table 1.   2010 (pre-ACA) N = 476 2014 (post-ACA) N = 396 Chi-Square Value Significance n % Commercial Insurance 165 34.66% 172 43.43% X2 = 5.73 p < 0.05 Medicare 118 24.79% 94 23.74% X2 = 0.22 NS Medicaid 125 26.26% 111 28.03% Other Public Assistance 104 21.85% 85 21.46% X2 = 0.13 Own Savings 211 44.33% 179 45.20% X2 = 0.01 Family Member(s) 164 34.45% 131 33.08% X2 = 0.50 Courts 68 14.29% 39 9.85% X2 = 4.33 Military Health Care 21 4.41% 18 4.55% X2 = 0.00 Employer 13 2.73% 19 4.80% X2 = 2.45 References Birnbaum, H. G., White, A. G., Schiller, M., Waldman, T., Cleveland, J. M., & Roland, C. L. (2011). Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain Medicine, 12(4), 657-667. Creswell, J., Plano Clark, V., Gutmann, M., & Hanson, W. (2003). Advances in mixed methods research designs. In T. A & T. C (Eds.), Handbook of mixed methods in social and behavioral research (pp. 209–240). Thousand Oaks, CA: SAGE. Heslin, K. C., Elixhauser, A., & Steiner, C. A. (2006). Hospitalizations involving mental and substance use disorders among adults, 2012: Manchikanti, L. (2007). National drug control policy and prescription drug abuse: Facts and fallacies. Pain Physician, 10(3), 399-424. Matrix Global Advisors. (2015). Health Care Costs from Opioid Abuse: A State-by-State Analysis, a report prepared for Partnership for Drug-Free Kids. Retrieved from https://drugfree.org/wp-content/uploads/2015/04/Matrix_OpioidAbuse_040415.pdf Meara, E., & Frank, R. G. (2005). Spending on substance abuse treatment: how much is enough? Addiction, 100(9), 1240-1248. SAMHSA. (2014). National survey of substance abuse treatment services (N-SSATS): 2013. U.S. Centers for Medicare & Medicaid Services. (2018). Mental Health & Substance Abuse Coverage. Yu, H. (2012). The prescription drug abuse epidemic. Clin Lab Med, 32(3), 361-377. Zremski, J. (2018, January 10, 2018). Opioid death toll rises in Erie County as Schumer pushes for boost in aid. Results demonstrate that there was a significant increase between 2010 and 2014 in the proportion of individuals who identified having commercial insurance cover their substance use treatment.