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The CBHSQ Report. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2013-.
Background: With the implementation of the Patient Protection and Affordable Care Act, also known as the Affordable Care Act, some uninsured, low-income individuals whose treatment would have been covered by the Substance Abuse Block Grant (SABG) are likely to now be covered by Medicaid. Method: The Treatment Episode Data Set (TEDS) data were used in this report. TEDS is a national data system of admissions to publicly-funded substance use treatment facilities reported to SAMHSA by state substance abuse agencies. Results: The 58.3 percent who were uninsured and either unemployed or not in the labor force will likely be covered by public funds, which could include SABG funding, as well as Medicaid for those newly enrolled under the Affordable Care Act. It is unlikely that Medicaid can absorb the entire 58.3 percent who were uninsured and either unemployed or not in the labor force. Conclusion: Despite the expected increase in Medicaid enrollment, the SABG will continue to be important in paying for specialty substance use treatment for uninsured, low-income individuals.
The Substance Abuse and Mental Health Services Administration (SAMHSA) administers two types of block grants, the Community Mental Health Block Grants (MHBGs) and the Substance Abuse Block Grants (SABGs). They serve as a "safety net," which has been defined in the health care literature,1,2 for individuals without health insurance or other resources who seek specialty mental health or substance use treatment and prevention services. Block grant funds are allocated to the states, the District of Columbia, and territories according to a congressionally mandated formula.3 These block grants predominantly pay for outpatient services and, to a much lesser extent, residential services and inpatient substance abuse detoxification.4 Almost all of these jurisdictions use the block grant funds to pay for services at specialty mental health and substance use facilities and programs.5
The two SAMHSA block grants equaled $3.1 billion for fiscal year 2014; this funding accounted for about 9 percent of the total mental health public financing and about 16 percent of the total substance abuse public health financing in the United States.6 SAMHSA block grant funds are commingled with other public funds, as well as with Medicaid, health care insurance, and private payments.7
With the implementation of the Patient Protection and Affordable Care Act, also known as the Affordable Care Act, some uninsured, low-income individuals whose treatment would have been covered by the SAMHSA block grants are likely to now be covered by Medicaid.8 This report examines this potential shift from public funds to Medicaid coverage for substance use treatment and its impact on certain vulnerable populations (i.e., those who were uninsured and either unemployed or not in the labor force, those who were homeless, and those who were incarcerated).
The Treatment Episode Data Set (TEDS) is a national data system of admissions to publicly funded substance abuse treatment facilities reported to SAMHSA by state substance abuse agencies. TEDS data do not include all admissions to substance abuse treatment. TEDS includes admissions to facilities that are licensed or certified by a state substance abuse agency to provide substance abuse treatment; therefore, those admissions represent the public burden. Because TEDS is an admissions-based system, it does not represent individuals. Thus, an individual admitted to treatment twice within a calendar year would be counted as two admissions. Because TEDS is a census and involves actual counts rather than estimates, statistical significance and confidence intervals do not apply. The differences between subgroups mentioned in the text of this report have Cohen's h effect sizes ≥ 0.20, indicating that the differences between subgroups are considered meaningful.
TEDS data for 2014, when the Affordable Care Act was fully implemented, are not yet available. The latest data available are for 2012; as the type of health insurance coverage and employment status changes very little from year to year in TEDS, the situation in 2014 can be expected to be represented by that in 2012. TEDS data for 2012 were received through October 17, 2013. In 2012, the total number of TEDS admissions aged 12 or older was about 1.7 million.
TEDS collects data on the employment and health insurance status9 for admissions to substance abuse treatment facilities. The Affordable Care Act expands Medicaid coverage to adults below 138 percent of the Federal Poverty Levels (FPL) (i.e., $15,856 for an individual or $26,951 for a family of 3 in 2013); however, a June 2012 Supreme Court decision allowed states to opt out of Medicaid expansion.10 Adults who live in states that have opted to expand Medicaid and who are uninsured and whose income falls below the FPL may be able to enroll in Medicaid.11 Based on recent studies of enrollment under the Affordable Care Act, this report assumes that those who have no coverage and who are unemployed or not in the labor force will likely meet income eligibility criteria for Medicaid.12
In 2012, the majority of substance abuse treatment admissions aged 18 to 64 (72.9 percent) with known insurance status were either unemployed or not in the labor force. Of these admissions, 58.3 percent did not have health insurance, 25.7 percent had Medicaid coverage, and 16.1 percent had some other type of health insurance (Figure 1). The 58.3 percent who were uninsured and unemployed or not in the labor force would likely be covered by public funds, which could include SABG funding, as well as Medicaid for those newly enrolled under the Affordable Care Act. It is unlikely that Medicaid—which prior to full implementation covered 25.7 percent of those who were unemployed or not in the labor force— can absorb the entire 58.3 percent who were uninsured and unemployed or not in the labor force.
Health insurance coverage among substance abuse treatment admissions aged 18 to 64 who were unemployed or not in the labor force: TEDS 2012
Two vulnerable populations, the homeless and institutional inmates, are likely to continue to depend on public funding to cover the costs of substance abuse treatment. Although these two groups were small in comparison with the total admissions in 2012, 65.6 percent of homeless admissions13 aged 18 to 64 and 84.9 percent of admissions in the same age group who were inmates of an institution14 had no health care insurance. By contrast, only 24.2 percent of homeless admissions aged 18 to 64 and 6.2 percent of institutional inmates had Medicaid. Medicaid does not cover those in the criminal justice system, whereas the SABG provides funding to treat those referred from the criminal justice system. Enrollment in Medicaid can be difficult for the homeless. Thus, public funding will continue to be important for these two vulnerable populations.
Under the Affordable Care Act, some of the treatment that has been covered by the SABG is likely to be covered by the expansion of Medicaid. Despite the expected increase in Medicaid enrollment, the SABG will still be important in paying for specialty substance abuse treatment for uninsured, low-income individuals.
The expansion of Medicaid under the Affordable Care Act is designed to enroll those without health insurance whose family incomes are, in general, less than 138 percent of the FPL.15 In 2012, 58.3 percent of substance abuse treatment admissions aged 18 to 64 who were unemployed or not in the labor force were without health insurance. Those without health insurance are eligible to enroll in Medicaid or, if their income is greater than 138 percent of the FPL, the health insurance exchanges. Many of these newly eligible are likely to be single adults living without children.16 If individuals newly enrolled in Medicaid receive specialty substance abuse treatment, their providers are likely to be reimbursed by Medicaid.
The Affordable Care Act may bring in newly enrolled Medicaid patients to substance abuse treatment facilities who otherwise would have been funded from public funds such as the SABG. Still, these facilities treating newly enrolled Medicaid patients may need to use the SABG and other governmental, non-Medicaid funds for more comprehensive treatment or for ancillary services not covered by Medicaid or other private health insurance. Certain social services that supplement substance abuse treatment are not covered by Medicaid. For example, although Medicaid may cover services provided in supportive housing settings, it is precluded from covering direct housing costs. Medicaid may cover employment supports and educational supports (often through waivers or state plan amendments under Section 1915 of the Social Security Act), but states will likely use the SABG and other public funding to support such ancillary services.16
A significant number of individuals who are coming out of jails or prisons will be eligible for Medicaid for the first time as a result of the Affordable Care Act. Importantly, of the 2.3 million inmates in U.S. prisons in 2010, 1.5 million (65 percent) met the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) medical criteria for alcohol or other drug abuse or addiction.16 Some states have begun to enroll the formerly incarcerated in Medicaid in order to provide specialty substance abuse treatment.16 Likewise, some states have begun outreach to enroll homeless substance users in need of treatment in Medicaid.17 Not all eligible individuals will enroll in Medicaid, however—only about two-thirds of those who are eligible ultimately enroll18—so treatment facilities will likely depend on the SABG funding. Two vulnerable populations, the incarcerated and the homeless, are either ineligible or unlikely to enroll in Medicaid but will still need substance abuse treatment. For these reasons, the SABG will still be important as safety-net funding for specialty substance use treatment.19,20
Albert Woodward, Ph.D., M.B.A. The Substance Abuse Prevention and Treatment Block Grant is Still Important Even with the Expansion of Medicaid. The CBHSQ Report: January 7, 2016. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Rockville, MD. [PubMed: 27054226]
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Panel on Formula Allocations, Committee on National Statistics, National Research Council. (2001). The SAMHSA block grants. In T. B. Jabine, T. A. Louis, & A. L. Schirm (Eds.), Choosing the right formula: Initial report (pp. 23–30). Washington, DC: National Affordable Care Academy Press.
The law does not allow the jurisdictions to pay for inpatient hospital services, with certain exceptions that occur infrequently, as stated in 45 CFR §96.135(a)(1)(c) and §96.135(a)(2).
Levit K. R., Stranges E., Coffey R. M., Kassed C., Mark T. L., Buck J. A., Vandivort-Warren R. (2013). Current and future funding sources for specialty mental health and substance abuse treatment providers. Psychiatric Services, 64(6), 512–519.10.1176/appi.ps.201200298 [PubMed: 23450375] [CrossRef]
Center for Behavioral Health Services and Quality. (2013). Table 124. In Behavioral health, United States, 2012 (HHS Publication No. SMA 13–4797). Rockville, MD: Substance Abuse and Mental Health Services Administration. [PubMed: 24354029]
Cowell A., McCarty D., Woodward A. (2003). Impact of federal substance abuse block grants on state substance abuse spending: Literature and data review. Journal of Mental Health Policy and Economics, 6(4), 173–179. [PubMed: 14713724]
Goldman H. H., Karakus M. C. (2014). Do not turn out the lights on the public mental health system when the ACA is fully implemented. Journal of Behavioral Health Services & Research, 41(4), 429–433.10.1007/s11414-014-9394-y [PubMed: 24807644] [CrossRef]
Health Insurance Status is a Supplemental Data Set item, which is reported at the state's option. Health Insurance Status in TEDS is defined as the client's health insurance at treatment admission (if any). The insurance may or may not cover alcohol or drug treatment.
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Collins, S. R., Doty, M. M., & Garber, T. (2010). Realizing health reform's potential: Adults ages 50-64 and the Affordable Care Act of 2010 (The Commonwealth Fund Issue Brief). Retrieved from http://www
Fronstin, P. (2012, September). Sources of health insurance and characteristics of the uninsured: Analysis of the March 2012 Current Population Survey (Issue Brief No. 376). Washington, D.C.: Employee Benefit Research Institute. [PubMed: 23155929]
Living Arrangements is a Supplemental Data Set item, which is reported at the state's option. Living Arrangements in TEDS specifies whether the client is homeless, living with parents, in a supervised setting, or living on his or her own.
Detailed Not in Labor Force is a Supplemental Data Set item, which is reported at the state's option. Detailed Not in Labor Force in TEDS gives more detailed information about those clients who are coded as "Not in labor force" in the TEDS Minimum Data Set item Employment Status (whether the client is disabled, a homemaker, an inmate of an institution, retired, a student, or other).
Hill S. C., Abdus S., Hudson J. L., Selden T. M. (2014). Adults in the income range for the Affordable Care Act's Medicaid expansion are healthier than pre-ACA enrollees. Health Affairs, 33(4), 691-699. doi: 10.1377/hlthaff.2013.0743 [PubMed: 24670269] [CrossRef]
Boozang, P., Bachrach, D., & Detty, A. (2014, May). Coverage and delivery of adult substance abuse services in Medicaid managed care (Technical Assistance Brief No. 2). Washington, DC: Medicaid Managed Care Information Resource Center, Centers for Medicare and Medicaid Services.
Tsai J., Rosenheck R. A., Culhane D. P., Artiga S. (2013). Medicaid expansion: Chronically homeless adults will need targeted enrollment and access to a broad range of services. Health Affairs, 32(9), 1552–1559. 10.1377/hlthaff.2013.0228 [PubMed: 24019359] [CrossRef]
Krueger A. B., Kuziemko I. (2013). The demand for health insurance among uninsured Americans: Results of a survey experiment and implications for policy. Journal of Health Economics, 32(5), 780–793. doi: .10.1016/j.jhealeco.2012.09.005 [PubMed: 23787372] [CrossRef]
Cummings L., Hooker J., Siegel B. (2012). Editorial: The safety net after health reform: Needed more than ever. Journal for Healthcare Quality, 34(2), 11. 10.1111/j.1945-1474.2011.00200.x [PubMed: 23552198] [CrossRef]
Davis H. Jr. The impact of the Patient Protection and Affordable Care Act on the national safety net. Journal of Emergency Nursing, 39(4), 360–361. 10.1016/j.jen.2013.05.002 [PubMed: 23829987] [CrossRef]
All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS.
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