The Affordable Care Act recognizes drug addiction and alcoholism as chronic diseases that must be covered by health insurance plans, and in so doing marks a major transformation of addiction care.
The biggest change is that 40 million people could enter substance abuse treatment, opening a huge market for addiction care.
“I don’t think there’s another illness that will be more affected by the Affordable Care Act,” said Dr. Thomas McLellan, former deputy director of the White House Office of National Drug Control Policy.
The ACA requires insurance companies to provide substance use treatment, and encourages medical providers to screen for problem drinking and drug use while allowing them to bill for doing it.
McLellan, who now serves as CEO of the Philadelphia-based Treatment Research Institute, said the designation of addiction as a chronic disease surprised everyone in the field.
“It [was] so marginalized that doctors didn’t think it was an illness.”
The reason for the change? McLellan said the tab for health care expenses due to addiction amounts to $120 billion a year, and cost saving is a major goal of the ACA.
Addicts and alcoholics are more likely to skip their medications or otherwise neglect their health and show up in ERs. They’re more likely to crash their cars or slip and fall, said Ken Bachrach, medical director at the Tarzana Treatment Center, one of the Southern California’s largest addiction care providers.
Albert Senella, who directs the treatment program, said he saw the link between physical well-being and substance abuse nearly 20 years ago and began offering primary care to both its substance abuse clients and the general public at four health clinics in the 1990s.
“My diabetes might impact my desire to get more loaded because of depression. Your blood pressure is out of control but you’re not taking your daily fix of heroin. It’s going to impact your state of mind and may be what triggers your relapse,” he said.
In a spare blue walled waiting area at the group’s Northridge clinic in the San Fernando Valley, patients—from the community and the center— doze, stare at a wall-mounted TV screen, or try to keep their kids contained while they wait to be called. One of the city’s last pay telephones stands at the back door because some patients have no other way to reach family and friends.
This clinic offers a full range of primary care services, while handing each patient a simple six-question survey to ferret out substance use issues.
The questionnaire is what the ACA calls Screening, Brief Intervention and Referral to Treatment, a tool that flags addicts or those at risk. It has been proven to save health care dollars and can help solve persistent health problems or prevent them — even in patients who aren’t considered addicts or alcoholics. In fact, McLellan said that non-addicts are likely to account for most of the cost-savings.
For example, daily marijuana use could account for a teenager’s uncontrolled asthma. Or a woman with a genetic susceptibility to breast cancer could unknowingly put herself at risk by drinking two cocktails a day.
Still, McLellan noted that physicians have been slow to discuss drugs and alcohol with their patients despite studies that show screening and doctor-patient conversation about substance use saves money and improves health.
Perhaps doctors felt there wasn’t much they could do if they discovered a problem, said Leonard Dootson, an RN at the Tarzana Treatment Center’s clinic. Now, as treatment becomes more readily available, that could change. But, Dootson, who is also a graduate of Tarzana’s treatment program, said that to effectively screen for substance abuse, medical professionals have to put aside their moralizing.
“The bottom line is having empathy. There’s often a lot of judgment. I’d call it bigotry. People want to project their own experiences onto the patient because it’s seen as a moral weakness. For people to see it as a real disease, it’s different.”
Some drug treatment professionals confront an even steeper learning curve than physicians because of the ways the Affordable Care Act is shaking up the field.
Drug treatment, especially in California, developed completely separately from the medical system, said Richard Rawson, a professor of psychiatry at UCLA and associate director of the university’s Integrated Substance Abuse Programs.
“It’s this weird mix of self-help, criminal justice, social work and a non-profit peer mentor collection of activities, none of which had anything to do with health care,” Ross said. “The system has not been able to decide if they [addicts] are sick people or bad people.”
Now, health care and drug treatment are coming together. The ACA calls for coordinated care in which physical, mental health and substance use professionals work as a team. Drug programs—many of which are small cash-strapped operations— will have to use electronic medical records and meet tougher Medicaid and private insurance standards.
The industry is already churning, said Senella, who is also president of the California Association of Alcohol and Drug Program Executives.
“There have been a number of mergers already because of the recognition that I’m not large enough to get these things done. I don’t have a continuum of care I can offer,” he said.
Pharmaceuticals, seen as taboo by some long time drug counselors, are already taking on a larger role in opiate or alcohol addiction treatment.
“It’s not okay to say I don’t believe in medication,” said Richard Rawson, a professor of psychiatry at UCLA and the associate director of the university’s Integrated Substance Abuse Programs. “It’s like not believing in penicillin.”
Medications to counter cocaine, methamphetamine and marijuana use have yet to be developed.
But, McLellan predicts pharmaceutical companies will market new drugs to meet the growing demand
At least at first, many in the 12-step movement and other treatment programs are likely to be skeptical of the increasing medicalization of treatment
Robert, who doesn’t want his last name used, is a 20-year Alcoholics Anonymous member, who attends meetings and sponsors many other alcoholics. He said that AA believes alcoholism and addiction have to be addressed spiritually and emotionally.
“We don’t oppose people getting medical treatment. In many cases, especially when people are detoxing, we recommend it. By the same token, we’re not of the mind there’s a quick fix.”
At the Riverside Recovery Center, a six-bed residential treatment center about 60 miles east of Los Angeles, administrator Jesse Green said he’s often leery of sending his clients to doctors.
“When you’re dealing with drug addicts, they’re going to say, ‘I have this [pain]. It works against us in a way.”
Riverside’s website emphasizes its philosophy of peer interaction, mutual self-help and changing the addict’s environment, known as the social model of drug treatment.
Green said he’d rather his clients not take methadone or similar drugs.
“It’s a catch-22 business. I have people come in and they get hooked on legal pharmaceuticals.”
“The tug-of-war is ancient between the social and medical model,” Senella said.
But it may end in a truce.
A group of physicians and drug care professionals are trying to bridge the gap by adopting a hybrid model that includes evidence-based treatment and medication.
“The weight of science is toward medication-assisted treatment,” said David Smith, an adjunct professor at the UCSF School of Nursing who teaches courses on addiction care, and the founder of the Haight Ashbury Clinic.
“The model is diabetes. If you can recover by diet and exercise, you don’t need medication. This is medical thinking brought to the addiction field.
Those drug treatment programs that don’t embrace the ACA-inspired changes aren’t likely to survive for long, predict Rawson and other observers.
“The train has left the station,” Smith said. “You can have critics but you can’t say the practice of medicine can’t be in the hands of physicians.”