Substance Abuse Treatment Before the Affordable Care Act: Trends in Social and Economic Characteristics of Facilities and Admissions, 2006 to 2011

In Brief
  • The percentage of substance abuse treatment admissions reporting unemployment at treatment entry increased from 33.2 percent in 2006 to 41.6 percent in 2011; during this time, over one-third of facilities offered employment counseling or training services.
  • Between 2006 and 2011, about 6 in 10 admissions reported having no health insurance coverage at treatment entry.
  • Over 6 in 10 facilities offered sliding fee scales to clients who could not afford to pay for treatment between 2006 and 2011.
  • About half of admissions aged 22 or older expected to pay for their treatment using Medicaid, Medicare, or other government payment between 2006 and 2011; over half of the substance abuse treatment facilities accepted Medicaid between 2006 (52 percent) and 2011 (57 percent).

Economic factors can hinder access to treatment for individuals with substance use disorders. For example, recent data show that among persons who needed treatment and made an effort to obtain it, the most often reported reason for not receiving treatment was lack of health coverage and inability to afford the cost of treatment (38.2 percent).1 Additionally, high unemployment rates have been associated with declines in the number of clients entering substance abuse treatment.2 Other studies have linked economic hardship and unemployment with increased binge drinking, alcohol-involved driving, alcohol abuse and/or dependence,3 and marijuana initiation.4

These findings are notable in light of the recent U.S. economic recession and the implementation of the Patient Protection and Affordable Care Act, both of which have implications for those with substance use disorders. From December 2007 to June 2009, the United States was in an economic recession, with an unemployment rate that peaked at 10 percent in October 2009.5,6 It has been estimated that about 9 million Americans lost their health insurance due to unemployment during the 2007 to 2009 recession.7,8

The Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (together referred to as the Affordable Care Act) heralded the beginning of important reforms to the health care system, many of which are now being implemented.9,10 Through insurance subsidies, the establishment of health insurance exchanges, the minimum coverage provision, and expanded eligibility for Medicaid, the Affordable Care Act is intended to make health insurance coverage more affordable for individuals, families, and small business owners.8 Once the Affordable Care Act is fully implemented, access to health care services for substance use disorders is expected to improve as previously uninsured people gain insurance coverage and fewer people will be competing for limited publicly funded treatment.9,10,11 Moreover, the loss of employment will no longer mean the loss of health insurance because the recently unemployed will have expanded insurance options.

This report describes the social and economic characteristics of substance abuse treatment admissions between 2006 and 2011 using the Treatment Episode Data Set (TEDS). The report also uses data from the National Survey of Substance Abuse Treatment Services (N-SSATS) to characterize the level of support services offered by substance abuse treatment facilities during these same years. The 2006 to 2011 time period encompasses both the U.S. recession and the start of the post-recession recovery. The 2006 to 2011 data examined in this report will also provide baseline characteristics for health insurance coverage among adults aged 22 or older for future comparisons.

TEDS is a national data system of annual admissions to substance abuse treatment facilities reported to Substance Abuse and Mental Health Services Administration (SAMHSA) by state substance abuse agencies. TEDS data can be used to examine social and economic characteristics of treatment admissions, including: employment status at treatment entry, health insurance status, expected source of payment, living arrangement, and educational attainment.12 For the analysis, treatment admissions were restricted to those aged 22 or older to include adults who were more likely than admissions aged 21 or younger to be in the workforce, out of school, and out of their parents' households.

N-SSATS is an annual census of all known substance abuse treatment facilities in the United States, both public and private. N-SSATS data can be used to describe trends in types of client payment or insurance accepted at treatment facilities, as well as trends in the provision of supportive services including employment counseling, housing assistance, transportation assistance to treatment, and assistance obtaining social services.

Because TEDS and N-SSATS both involve censuses and actual counts rather than estimates, statistical significance and confidence intervals are not applicable. The differences between subgroups mentioned in the text of this report have Cohen's h effect size ≥ 0.20, indicating that they are considered to be meaningful.


Admissions to Substance Abuse Treatment Facilities

Between 2006 and 2011, there were 1.5 to 1.7 million annual substance abuse treatment admissions aged 22 or older. This represents about 83 percent of the total admissions each year.

Employment Status of Admissions at Treatment Entry

Across all years, the majority of substance abuse treatment admissions aged 22 or older were either unemployed or not in the labor force (Figure 1). The percentage of admissions that were unemployed at treatment entry was highest in 2011 (41.6 percent) and lowest in 2006 (33.2 percent). During that period, the highest percentage of admissions employed full time was 23.1 percent in 2006, whereas the lowest percentage was 15.7 percent in 2011. Part-time employment remained steady at about 7 percent across all years.

Figure 1. Substance abuse treatment admissions aged 22 or older, by employment status: TEDS, 2006 to 2011
This is a line graph comparing substance abuse treatment admissions aged 22 or older, by employment status: TEDS, 2006 to 2011. Accessible table located below this figure.

Figure 1 Table. Substance abuse treatment admissions aged 22 or older, by employment status: TEDS, 2006 to 2011
Employment Status 2006 2007 2008 2009 2010 2011
Unemployed 33.2% 34.5% 36.6% 40.3% 41.3% 41.6%
Not in labor force 36.9% 36.0% 34.6% 35.1% 35.5% 35.8%
Full time 23.1% 22.6% 21.8% 17.4% 16.1% 15.7%
Part time   6.8%   6.9%   7.0%   7.1%   7.1%   6.9%
Source: SAMHSA Treatment Episode Data Set (TEDS), 2006 to 2011.

Health Insurance Status of Treatment Admissions

Between 2006 and 2011, the majority of admissions aged 22 or older reported having no health insurance coverage; percentages ranged from a high of 62.4 percent in 2006 to a low of 58.1 percent in 2011 (Figure 2).12 Fewer than 1 in 5 (16.9 percent) admissions aged 22 or older reported having Medicaid coverage in 2006; by 2011, this percentage had increased to 21.3 percent. The proportion of admissions with private health insurance, health maintenance organization, Blue Cross/Blue Shield, and Medicare remained stable from 2006 to 2011.

Figure 2. Substance abuse treatment admissions aged 22 or older, by health insurance status: TEDS, 2006 to 2011
This is a stacked bar graph comparing substance abuse treatment admissions aged 22 or older, by health insurance status: TEDS, 2006 to 2011. Accessible table located below this figure.

Figure 2 Table. Substance abuse treatment admissions aged 22 or older, by health insurance status: TEDS, 2006 to 2011
Health Insurance Status 2006 2007 2008 2009 2010 2011
No health insurance 62.4% 61.5% 61.4% 61.6% 60.1% 58.1%
Medicaid 16.9% 16.9% 16.4% 18.1% 20.0% 21.3%
Other (e.g., TRICARE, CHAMPUS)   6.2%   6.6%   8.1%   7.0%   6.8%   6.5%
Private (not BC/BS or HMO)   6.1%   6.3%   5.9%   5.7%   5.5%   5.5%
Health maintenance organization (HMO)   3.8%   3.9%   3.5%   3.2%   3.0%   3.7%
Blue Cross/ Blue Shield (BC/BS)   2.6%   2.7%   2.9%   2.7%   2.9%   3.1%
Medicare   1.9%   2.0%   1.7%   1.7%   1.7%   1.8%
NOTE. —Percentages may not sum to 100 because of rounding.
Source: SAMHSA Treatment Episode Data Set (TEDS), 2006 to 2011

Expected Source of Payment by Treatment Admissions

Among admissions aged 22 or older across all years, the most commonly reported sources of payment in each year from 2006 to 2011 were government payments (e.g., Medicaid or Medicare) followed by self-payment (Figure 3).12 In 2006, slightly less than half of treatment admissions aged 22 or older expected to pay for their treatment using Medicaid, Medicare, or other government payments (49.1 percent); by 2011, 55.3 percent expected to pay for their treatment using such payments. Between 2006 and 2011, the percentage of admissions that were not expecting to be charged for substance abuse treatment (free, charity, special research, or teaching) decreased from 12.1 to 5.9 percent. The proportions of admissions with other primary sources of payment remained stable.

Figure 3. Substance abuse treatment admissions aged 22 or older, by expected primary source of payment: TEDS, 2006 to 2011
This is a line graph comparing substance abuse treatment admissions aged 22 or older, by expected primary source of payment: TEDS, 2006 to 2011. Accessible table located below this figure.

Figure 3 Table. Substance abuse treatment admissions aged 22 or older, by expected primary source of payment: TEDS, 2006 to 2011
Primary Source of Payment 2006 2007 2008 2009 2010 2011
Medicaid, Medicare, or other government payments 49.1% 47.0% 47.3% 48.7% 54.1% 55.3%
Self-pay 21.1% 22.4% 21.4% 21.5% 20.5% 17.7%
Other source of payment 12.7% 12.8% 14.0% 14.3% 14.2% 15.9%
No charge 12.1% 12.9% 12.5% 11.1%   6.5%   5.9%
Blue Cross/Blue Shield or other health insurance company   5.0%   5.0%   5.0%   4.0%   5.0%   5.0%
Source: SAMHSA Treatment Episode Data Set (TEDS), 2006 to 2011.

Education

From 2006 and 2011, the educational attainment levels of admissions aged 22 or older were similar. In 2006, 31.3 percent reported having less than a high school education, 44.4 percent reported a high school education or equivalent, and 24.3 percent reported having at least some college education. In 2011, 28.5 percent reported having less than a high school education, 44.6 percent reported a high school education or equivalent, and 26.9 percent reported having at least some college education (data not shown).

Living Arrangement

Between 2006 and 2011, about 15.0 percent of treatment admissions aged 22 or older reported being homeless at treatment entry (data not shown).12 The percentages of admissions in independent (68.2 percent) or dependent (16.8 percent) living situations also remained stable between 2006 and 2011.


Characteristics of Treatment Facilities

The number of substance abuse treatment facilities responding to the N-SSATS survey remained stable between 2006 (13,771 facilities) and 2011 (13,720 facilities).

Types of Client Payment or Insurance Accepted by Facilities

Most substance abuse treatment facilities reported that they accepted cash or self-payment as a form of payment for substance abuse treatment; this remained stable at about 90 percent between 2006 and 2011 (Table 1). Over half of the substance abuse treatment facilities accepted Medicaid between 2006 (52 percent) and 2011 (57 percent). The percentage of facilities accepting a state-financed health insurance plan was lowest in 2006 (32 percent) and highest in 2011 (39 percent). The proportion of facilities offering sliding fee scales remained stable between 2006 and 2011 (63 percent in 2006 and 62 percent in 2011; data not shown).


Table 1. Substance abuse treatment facilities, by type of client payment or insurance accepted: N-SSATS, percentages, 2006 to 2011
Payment or insurance type 2006 2007 2008 2009 2010 2011
Cash or self-payment 90% 90% 89% 90% 90% 90%
Private health insurance 64% 63% 62% 63% 63% 64%
Medicaid 52% 53% 53% 54% 55% 57%
State-financed health insurance 32% 34% 38% 38% 39% 39%
Medicare 33% 34% 34% 33% 32% 33%
Federal military insurance (e.g., TRICARE) 32% 32% 32% 32% 32% 33%
Access To Recovery (ATR) vouchers 10% 10% 12% 13% 13% 12%
No payment accepted (free treatment)   4%   4%   4%   4%   4%   3%
Source: SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS), 2006 to 2011.

Ancillary Services Provided by Treatment Facilities

Between 2006 and 2011, the proportions of N-SSATS facilities that provided ancillary services designed to assist clients in obtaining needed resources, services, or skills were relatively stable with the exception of social skills development (Table 2). The proportion of facilities offering social skills development increased from 60 percent in 2006 to 72 percent in 2011.

Table 2. Substance abuse treatment facilities, by selected ancillary services offered: N-SSATS, percentages, 2006 to 2011
Ancillary services offered 2006 2007 2008 2009 2010 2011
Social skills development 60% 66% 67% 68% 69% 72%
Assistance with obtaining social services 54% 52% 52% 52% 53% 55%
Assistance in locating housing 45% 43% 43% 44% 45% 48%
Transportation assistance to treatment 35% 36% 37% 37% 38% 39%
Employment counseling or training services 37% 34% 34% 34% 34% 37%
Source: SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS), 2006 to 2011.

Across all years, about half of facilities offered assistance in obtaining social services (e.g., Medicaid; Women, Infants, and Children payments; Supplemental Security Income; and Social Security Disability Insurance; ranging from 52 to 55 percent) and locating housing (ranging from 43 to 48 percent). Between 2006 and 2011, more than one-third of facilities offered transportation assistance to treatment (ranging from 35 to 39 percent) and employment counseling or training services (ranging from 34 to 37 percent).


Discussion

This report shows that from 2006 to 2011, a high percentage of treatment admissions aged 22 or older lacked health insurance coverage and were not employed (Table 3). In light of these economic barriers, the acceptance of Medicaid reported by a large proportion of facilities may play a crucial role in facilitating access to treatment for individuals experiencing economic hardship. As the Affordable Care Act is implemented through 2014, it is anticipated that there will be upward trends in Medicaid coverage as the program has been expanded to include those individuals who were formerly ineligible.13 Moreover, access to health care services for substance use is expected to improve as the previously uninsured gain health insurance coverage.

Table 3. Summary of admission and facility trends: TEDS and N-SSATS, 2006 to 2011
Social or economic
indicator
Between 2006 and 2011,
treatment admissions reported…
Between 2006 and 2011,
treatment facilities reported…
Employment and education Stable and high proportions of unemployment and low educational attainment levels High proportions of offering social skills development

Low, steady proportions of offering employment counseling or training services
Social and other services Similar proportions of being homeless at treatment entry Stable and high proportions of offering assistance in obtaining social services (e.g., Medicaid, WIC)

Stable and high proportions of offering assistance locating housing

Stable proportions of offering transportation assistance to treatment
Health insurance status and treatment payment Similar and high proportions of not having health insurance coverage

Similar and high proportions of expecting to use Medicaid, Medicare, or other government payments to pay for treatment
Steady and high acceptance rates for Medicaid and state-financed insurance plans

Steady and high proportions of sliding fee scales offered
Source: SAMHSA Treatment Episode Data Set (TEDS) and National Survey of Substance Abuse Treatment Services (N-SSATS), 2006 to 2011.

Additionally, over half of facilities provided supportive services for clients with economic problems, such as helping clients obtain social services, using a sliding fee scale for payment, and accepting government payments. By 2011, nearly half of facilities reported offering assistance in locating housing, which is notable given that nearly one-sixth of admissions aged 22 or older were homeless at treatment entry during each of the years studied.

Services that support employment are critical because employment before or during substance abuse treatment is associated with longer stays in treatment, a greater likelihood of a successful treatment outcome, and reduced occurrence and severity of relapse.14 Although employment is commonly cited as an important drug and alcohol abuse treatment outcome and is often a treatment goal, just over one-third of facilities offered employment counseling across all years. Facilities not currently offering employment counseling and rehabilitation may consider adding these services, particularly if the facilities serve populations in economically depressed and disadvantaged areas.

Individuals who need assistance finding substance abuse treatment, as well as health and community professionals making referrals for clients with economic challenges, should use the Behavioral Health Treatment Services Locator sponsored by SAMHSA, at http://findtreatment.samhsa.gov/. The Locator allows users to search for facilities by specific characteristics, such as social or economic services. For example, individuals interested in free or reduced-cost services can search for facilities using the "Payment Assistance" options.


End Notes
1 Center for Behavioral Health Statistics and Quality. (2013). Results from the 2012 National Survey on Drug Use and Health: Summary of national findings (HHS Publication No. 13–4795, NSDUH Series H–46). Rockville, MD: Substance Abuse and Mental Health Services Administration.
2 Storti, C., De Grauwe, P., Sabadash, A., & Montanari, L. (2011). Unemployment and drug treatment. International Journal of Drug Policy, 22(5), 366–373.
3 Dávalos, M. E., Fang, H., & French, M. T. (2012). Easing the pain of an economic downturn: Macroeconomic conditions and excessive alcohol consumption. Health Economics, 21(11), 1318–1335. doi: 10.1002/hec.1788
4 Kalousova, L., & Burgard, S. A. (2014). Unemployment, measured and perceived decline of economic resources: Contrasting three measures of recessionary hardships and their implications for adopting negative health behaviors. Social Science & Medicine, 106, 28–34. doi: 10.1016/j.socscimed.2014.01.007
5 National Bureau of Economic Research. (2010, September 20). Business Cycle Dating Committee, National Bureau of Economic Research. Retrieved from http://www.nber.org/cycles/sept2010.html
6 Bureau of Labor Statistics. (2012). BLS spotlight on statistics: The recession of 2007–2009. Retrieved from http://www.bls.gov/spotlight/2012/recession/pdf/recession_bls_spotlight.pdf
7 Cawley, J., Moriya, A. S., & Simon, K. (2013, November 14). The impact of the macroeconomy on health insurance coverage: Evidence from the great recession. Health Economics. doi: 10.1002.hec.3011
8 Holahan, J. (2011). The 2007–09 recession and health insurance coverage. Health Affairs, 30(1), 145–152.
9 The Patient Protection and Affordable Care Act. (2010, March 23). Pub. L. No. 111–148, 124 Stat. 119.
10 Health Care and Education Reconciliation Act of 2010. (2010, March 30). Pub. L. No. 111–152, 124 Stat. 1029.
11 Buck, J. A. (2011). The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act. Health Affairs, 30(8), 1402–1410.
12 Health insurance status, expected source of payment, and living arrangement are Supplemental Data Set items. In this report, only supplemental data from states and jurisdictions with response rates of 75 percent or greater in each year from 2006 to 2011 were used for the variable of interest.
13 Croft, B., & Parish, S. L. (2013). Care integration in the Patient Protection and Affordable Care Act: Implications for behavioral health. Administration and Policy in Mental Health and Mental Health Services Research, 40(4), 258–263.
14 Center for Substance Abuse Treatment. (2000). Integrating substance abuse treatment and vocational services (HHS Publication No. SMA 00–3470, Treatment Improvement Protocol [TIP] Series 38). Rockville, MD: Substance Abuse and Mental Health Services Administration.


Suggested Citation
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (October 30, 2014). The BHSIS Report: Substance Abuse Treatment Before the Affordable Care Act: Trends in Social and Economic Characteristics of Facilities and Admissions, 2006 to 2011. Rockville, MD.

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.
The Treatment Episode Data Set (TEDS) is an administrative data system that provides descriptive information about the national flow of admissions aged 12 or older to providers of substance abuse treatment. TEDS intends to collect data on all treatment admissions to substance abuse treatment programs in the United States receiving public funds. Treatment programs receiving any public funds are requested to provide TEDS data on publicly and privately funded clients.

TEDS is one component of the Behavioral Health Services Information System (BHSIS), maintained by the Center for Behavioral Health Statistics and Quality (CBHSQ), SAMHSA. TEDS records represent admissions rather than individuals, as a person may be admitted to treatment more than once. Information on treatment admissions is routinely collected by state administrative systems and then submitted to SAMHSA in a standard format.

There are significant differences among state data collection systems. Sources of state variation include the amount of public funding available and the constraints placed on the use of funds, facilities reporting TEDS data, clients included, services offered, and completeness and timeliness of reporting. See the annual TEDS reports for details. In 2011, TEDS received approximately 1.8 million treatment admission records from 46 states, the District of Columbia, and Puerto Rico. Definitions of demographic, substance abuse, and other measures mentioned in this report are available in Appendix B of the annual TEDS report on national admissions (see the 2011 report at: http://www.samhsa.gov/data/sites/default/files/TEDS2011N_Web/TEDS2011NAppB.htm). Information and data for this issue are based on data reported to TEDS through October 15, 2012.

TEDS Reports are prepared by the Center for Behavioral Health Statistics and Quality, SAMHSA; Synectics for Management Decisions, Inc., Arlington, VA; and RTI International, Research Triangle Park, NC.

Latest TEDS reports:
http://www.samhsa.gov/data/client-level-data-teds

Latest TEDS public use files and variable definitions:
http://datafiles.samhsa.gov

Other substance abuse reports:
http://www.samhsa.gov/data

The National Survey of Substance Abuse Treatment Services (N-SSATS) is an annual survey designed to collect information from all facilities in the United States, both public and private, that provide substance abuse treatment. N-SSATS provides the mechanism for quantifying the dynamic character and composition of the United States substance abuse treatment delivery system. The objectives of N-SSATS are to collect multipurpose data that can be used to assist the Substance Abuse and Mental Health Services Administration (SAMHSA) and state and local governments in assessing the nature and extent of services provided and in forecasting treatment resource requirements, to update SAMHSA's Inventory of Behavioral Health Services (I-BHS), to analyze general treatment services trends, and to generate the Behavioral Health Treatment Services Locator [http://findtreatment.samhsa.gov/].

N-SSATS is one component of the Behavioral Health Services Information System (BHSIS), maintained by the Center for Behavioral Health Statistics and Quality (CBHSQ), SAMHSA. N-SSATS collects three types of information from facilities: (1) characteristics of individual facilities such as services offered and types of treatment provided, primary focus of the facility, and payment options; (2) client count information such as counts of clients served by service type and number of beds designated for treatment; and (3) general information such as licensure, certification, or accreditation and facility Web site availability. In 2011, N-SSATS collected information from 13,720 facilities from all 50 states, the District of Columbia, Puerto Rico, the Federated States of Micronesia, Guam, Palau, and the Virgin Islands. Information and data for this report are based on data reported to N-SSATS for the survey reference dates March 31, 2006 and 2008 to 2011, and March 30, 2007.

N-SSATS Reports are prepared by the Center for Behavioral Health Statistics and Quality, SAMHSA; Synectics for Management Decisions, Inc., Arlington, VA; and RTI International, Research Triangle Park, NC.

Latest N-SSATS reports:
http://www.samhsa.gov/data/substance-abuse-facilities-data-nssats

Latest N-SSATS public use files and variable definitions:
http://datafiles.samhsa.gov

Other substance abuse reports:
http://www.samhsa.gov/data

 

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