There is much to celebrate about the enactment of the Comprehensive Addiction And Recovery Act (CARA), including promising provisions related to treatment and recovery. However, the impact of the new law in terms of its ability to fill the so called treatment gap is severely limited by the minimal level of funding for many of these promising new programs and initiatives to expand evidence-based treatment. Without appropriations, CARA is a powerful statement but not necessarily an actionable plan.
The treatment gap refers to the more than 1.2 million people who meet the diagnostic criteria for an opioid use disorder (OUD) but do not receive treatment. According to the 2014 National Survey on Drug Use and Health, about 2.27 million individuals met diagnostic criteria for an OUD, yet fewer than half, about 1 million people, received methadone, buprenorphine, or extended-release naltrexone-based medication-assisted treatment (MAT) at any given time in 2014.
What are the reasons for this vexing gap between need and receipt of care? The predominant reasons include: inability to afford treatment and lack of readiness to seek treatment. For persons suffering with illicit drug use disorders, 39 percent reported that they had no health insurance coverage and could not afford the cost of treatment. Twenty-nine percent reported that they were not ready to stop using substances. Other commonly cited barriers to receiving treatment include the stigma of addiction in the work place and the community, the lack of availability of providers, and the belief that they do not have a problem that needs care.
Policies expanding access to treatment for OUD will not attract everyone who needs care into treatment but they can go a long way to address financial barriers, provider availability, and information barriers. President Obama’s 2017 budget proposal called for $920 million over two years to support states’ efforts to reduce barriers to care for people with OUD who want to obtain care or can be persuaded to seek care through outreach efforts.
This first segment of the treatment group that are the target for these funds might be termed the addressable treatment gap, which I estimate to be around 450,000 people. I arrive at this estimate by taking the 39 percent that report affordability as a reason for not obtaining care and adjust it downward by the presence of other reasons for not obtaining care, like stigma. More specifically we can think of the addressable treatment gap as the people with an opioid use disorder who want to receive care but cannot afford it or do not have providers of MAT available, and those that through outreach efforts can be persuaded to seek treatment.
At the time of the release of the President’s budget, the Administration’s opioid initiative in 2016 made a “down payment” on shrinking the treatment gap by spending by nearly $70 million on treatment for OUD. That can be expected to reduce the treatment gap by roughly 30,000 people leaving the addressable treatment gap at about 420,000. CARA authorizes a variety of activities that aim to further shrink the addressable treatment gap but does not provide funds to support those activities.
How could additional money be used? Until the recent changes in coverage for substance use disorder coverage associated with the Mental Health Parity and Addiction Equity Act (MHPAEA) and the Affordable Care Act (ACA) substance use treatment was disproportionately funded by federal block grants and state governments. One consequence is that as we expand coverage for consumers who need OUD treatment, our capacity to deliver it lags behind. For that reason, money needs to be spent on expanding treatment capacity in the health system especially where the opioid epidemic has hit hard and resources are limited.
In addition, there remain sections of the country that have not fully availed themselves of the coverage expansions offered by the ACA; in these places low-income, uninsured people need help paying for care. Finally, even among some insured populations there remain limitations on the scope of covered services for OUD and assistance for people in those circumstances is needed to bring people into evidence-based treatment.
The President’s proposal of $920 million in funding over two years amounts to $2,190 per person in the addressable treatment gap. That figure represents an important and realistic initial investment in shrinking the addressable treatment gap. Because the initial funding aims to build capacity and awareness that creates a platform for additional efforts to close the entire treatment gap, and because the epidemic continues to grow and evolve in ways that include new substances and new populations, a sustained longer-term investment in treatment will surely be required.
If we intend to keep the promise of CARA to really provide comprehensive recovery to people with opioid use disorders, then Congress will have to step up to the plate and fully fund its provisions.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/2cR846f
No comments:
Post a Comment