|
In 2011, an estimated 19.3 million Americans aged 12 or older needed but did not receive substance abuse treatment.1 The vast majority of them (98.5 percent) either did not believe they needed treatment or did not make an effort to obtain treatment.1 However, an estimated 281,000 people believed they needed treatment, made an effort to obtain treatment, but ultimately did not receive treatment.1 Among these people, the most common reason for not receiving treatment was lack of health insurance and inability to afford the cost of treatment (37.3 percent); an additional 10.1 percent said that they had health insurance, but it did not cover substance abuse treatment.1 In fact, a high proportion of individuals who receive care pay for treatment out-of-pocket. For 2011, data show that among persons who received substance use treatment in the past year, 46.4 percent reported using their "own savings or earnings" as a source of payment for all or part of the cost of their most recent treatment episode, and 26.0 percent reported using funds from family members.1 Such expenses can be financially crippling to individuals and their families, and may result in decisions to delay or not pursue treatment.2
In March 2010, the Patient Protection and Affordable Care Act3 and the Health Care and Education Reconciliation Act of 20104 (together referred to as the Affordable Care Act, or "ACA") were signed into law. Through insurance subsidies, the establishment of health insurance exchanges, and expanded eligibility for Medicaid, the ACA is intended to make health insurance coverage more affordable for individuals, families, and small business owners. Once the ACA is fully implemented in 2014,5 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. As the ACA implementation process unfolds, understanding the characteristics of those who enter substance abuse treatment with different types of health insurance coverage can serve as a baseline for policy and budget planning.
The Treatment Episode Data Set (TEDS) is a national data system of annual admissions to substance abuse treatment facilities. Treatment programs receiving any public funds are requested to provide TEDS data on publicly and privately funded clients. TEDS records represent admissions rather than individuals, as a person may be admitted to treatment more than once. TEDS includes a Minimum Data Set that contains 2011 data for 48 reporting States and jurisdictions; however, type of health insurance is a Supplemental Data Set item that was reported by 34 States and jurisdictions for 2011, and the admissions data presented in this report are restricted to those 34 States and jurisdictions.6 Health insurance status specifies the type of health insurance reported by each admission (if any).
TEDS does not record whether the health insurance covers substance abuse treatment or whether the insurance was used to pay for treatment. Four categories of health insurance status are used in this report: no health insurance; private insurance, such as Blue Cross/Blue Shield or HMO; Medicaid; and other insurance, including Medicare, CHAMPUS, and Tricare.
The goal of this report is to provide baseline characteristics for health insurance coverage among adults for future comparison. Notably, this analysis restricts admissions to those aged 26 or older at treatment entry given the ACA's provision that extends health care coverage in family policies to adult children until age 26.3 In 2011, there were 565,818 admissions to substance abuse treatment programs aged 26 or older with valid data on health insurance.
Note that TEDS is a census of all admissions to treatment facilities reported to SAMHSA by State substance abuse agencies. Because TEDS involves 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.
In 2011, three fifths (59.6 percent) of substance abuse treatment admissions aged 26 or older reported having no health insurance (Table 1). The most frequently reported type of insurance was Medicaid, which accounted for 21.3 percent of admissions. Private insurance was reported by 10.5 percent of admissions. All other forms of insurance totaled 8.5 percent.
Type of Health Insurance |
Number of Admissions |
Percent | Percent Male |
Percent Female |
---|---|---|---|---|
No Insurance | 337,405 | 59.6% | 63.8% | 51.2% |
Any Insurance | 228,413 | 40.4% | 36.2% | 48.8% |
Private Insurance | 59,569 | 10.5% | 11.0% | 9.7% |
Medicaid | 120,799 | 21.3% | 17.2% | 29.7% |
Other Insurance | 48,045 | 8.5% | 8.0% | 9.4% |
* The percentages of No Insurance and Any Insurance or types of insurance may not total to 100 percent due to rounding. Source: SAMHSA Treatment Episode Data Set (TEDS), 2011. |
For admissions aged 26 or older, a higher proportion of male admissions than female admissions reported having no health insurance (63.8 vs. 51.2 percent), but there was little difference in the percentage of male and female admissions with private insurance (Table 1). A higher proportion of female admissions than male admissions reported having Medicaid coverage (29.7 vs. 17.2 percent).
More than half of admissions in each of the age groups had no health insurance, ranging from 50.1 percent among those aged 55 or older to 61.8 percent among those aged 26 to 34 (Figure 1). Admissions aged 55 or older had a higher percentage of private health insurance coverage (16.7 percent) than the 26 to 34 age group (8.6 percent).
Health Insurance Status |
Aged 26 to 34 |
Aged 35 to 54 |
Aged 55 or Older |
---|---|---|---|
None | 61.8% | 59.5% | 50.1% |
Private | 8.6% | 11.0% | 16.7% |
Medicaid | 21.9% | 21.2% | 19.4% |
Other | 7.7% | 8.3% | 13.8% |
* Percentages may not sum to 100 percent due to rounding. Source: SAMHSA Treatment Episode Data Set (TEDS), 2011. |
Similarly, in each racial/ethnic group, more than half of admissions had no health insurance (Figure 2). Medicaid was reported as the most common source of coverage across all racial/ethnic groups, with the exception of American Indians/Alaska Natives, of which 22.6 percent reported having "other" health insurance coverage.
Health Insurance Status | White | Black | Hispanic | Asian/Pacific Islander |
American Indian/ Alaska Native |
---|---|---|---|---|---|
None | 58.7% | 60.4% | 65.4% | 53.4% | 62.4% |
Private | 12.3% | 5.0% | 11.5% | 15.7% | 5.1% |
Medicaid | 20.4% | 27.5% | 17.9% | 25.7% | 9.8% |
Other | 8.7% | 7.2% | 5.2% | 5.3% | 22.6% |
* Percentages may not sum to 100 percent due to rounding. Source: SAMHSA Treatment Episode Data Set (TEDS), 2011. |
Over 60 percent of admissions aged 26 or older with a high school education or less had no insurance (Table 2). The percentage of admissions with private insurance was highest among those admissions reporting college education (28.2 percent). Conversely, the percentage reporting Medicaid was highest among those with less than a high school education (26.1 percent) and lowest among those with college education (12.9 percent).
Type of Health Insurance |
Education | Employment | ||||||
---|---|---|---|---|---|---|---|---|
Less than a High School Education (Percent) |
High School Education/ GED (Percent) |
Some College (Percent) |
College Education (Percent) |
Full Time (Percent) |
Part Time (Percent) |
Unemployed (Percent) |
Not in the Labor Force (Percent) |
|
No Insurance | 60.7% | 60.8% | 59.0% | 50.9% | 54.4% | 68.0% | 69.7% | 45.6% |
Any Insurance | 39.3% | 39.2% | 41.0% | 49.1% | 45.6% | 32.0% | 30.3% | 54.4% |
Private | 5.1% | 9.7% | 13.0% | 28.2% | 31.6% | 9.3% | 5.1% | 6.5% |
Medicaid | 26.1% | 20.9% | 19.1% | 12.9% | 7.1% | 15.1% | 17.8% | 36.5% |
Other | 8.2% | 8.6% | 8.9% | 8.0% | 6.9% | 7.6% | 7.4% | 11.4% |
* Percentages may not sum to 100 percent due to rounding. Source: SAMHSA Treatment Episode Data Set (TEDS), 2011. |
The uninsured comprised over 60 percent of admissions aged 26 or older that reported primary abuse of alcohol (60.7 percent), marijuana (65.1 percent), or cocaine (60.9 percent), and over 70 percent of admissions aged 26 or older that reported primary abuse of stimulants (71.3 percent) (Figure 3). Among the admissions groups, the largest percentage of admissions with private insurance coverage was observed among admissions for primary alcohol abuse (15.2 percent). Compared with the other admissions groups, primary heroin admissions had the highest proportion of Medicaid coverage (37.2 percent).
Health Insurance Status | Alcohol | Marijuana | Cocaine | Heroin | Opiates Other than Heroin |
Stimulants |
---|---|---|---|---|---|---|
None | 60.7% | 65.1% | 60.9% | 51.6% | 58.2% | 71.3% |
Private | 15.2% | 6.4% | 5.0% | 4.0% | 9.4% | 5.6% |
Medicaid | 15.2% | 19.9% | 26.6% | 37.2% | 23.9% | 13.1% |
Other | 8.8% | 8.6% | 7.5% | 7.1% | 8.4% | 9.9% |
* Percentages may not sum to 100 percent due to rounding. Source: SAMHSA Treatment Episode Data Set (TEDS), 2011. |
About two thirds (67.5 percent) of admissions aged 26 or older that were referred to substance abuse treatment by the criminal justice system had no insurance, substantially exceeding the percentages for most other referral sources (Table 3). Admissions referred by an employer or an Employee Assistance Program had the highest percentage of private insurance (43.0 percent), but even in this group, 45.8 percent of admissions had no insurance. Admissions that were referred to substance abuse treatment by schools had the largest proportion of Medicaid coverage (35.3 percent) compared with other admissions groups.
Type of Health Insurance |
Criminal Justice System (Percent) |
Individual (Percent) |
Alcohol or Drug Abuse Care Provider (Percent) |
Other Health Care Provider (Percent) |
Employer/EAP (Percent) |
School (Percent) |
Other Community Referral (Percent) |
---|---|---|---|---|---|---|---|
No Insurance | 67.5% | 55.8% | 48.8% | 54.8% | 45.8% | 45.8% | 61.3% |
Any Insurance | 32.5% | 44.2% | 51.2% | 45.2% | 54.2% | 54.2% | 38.7% |
Private | 11.5% | 10.3% | 8.5% | 12.8% | 43.0% | 8.0% | 7.2% |
Medicaid | 11.3% | 27.1% | 33.9% | 23.9% | 3.4% | 35.3% | 23.5% |
Other | 9.7% | 6.8% | 8.9% | 8.5% | 7.9% | 10.9% | 8.1% |
* Percentages may not sum to 100 percent due to rounding. Source: SAMHSA Treatment Episode Data Set (TEDS), 2011. |
This report shows that prior to the ACA's implementation, 3 out of 5 substance abuse treatment admissions aged 26 or older had no health insurance, and that these admissions differed by several demographic and socio-economic characteristics. With full ACA implementation, access to affordable insurance will increase among the uninsured. For example, as shown in this report, a higher proportion of female admissions had some form of insurance compared with male admissions, and this difference was largely due to a greater percentage of female admissions having Medicaid coverage compared with male admissions. As eligibility for Medicaid coverage expands under the ACA in many States to those who were not previously eligible (e.g., low-income adults without children3 and the criminal justice population7), the composition of treatment admissions reporting Medicaid coverage might change.
While 59.6 percent of treatment admissions were able to access treatment despite having no health insurance, millions of Americans with substance use disorders do not receive treatment due to a lack of health insurance.1,8,9 As States and the Federal Government implement the ACA, updates of this report will help track the proportion of treatment admissions without health insurance over time. Individuals who are in need of substance abuse treatment and are unsure how the ACA may impact their ability to gain health care coverage can get useful information from the following Web sites:
The Treatment Episode Data Set (TEDS) is an administrative data system providing 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), Substance Abuse and Mental Health Services Administration (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. TEDS received approximately 1.8 million treatment admission records from 46 States, the District of Columbia, and Puerto Rico for 2011. Definitions of demographic, substance use, and other measures mentioned in this report are available in Appendix B of the annual TEDS report on national admissions (see latest report at https://www.samhsa.gov/data/2k13/TEDS2011/TEDS2011NAppB.htm). The TEDS Report is 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. Information and data for this issue are based on data reported to TEDS through October 15, 2012. Latest TEDS reports: |
TEDS_134