February 3, 2014

For years, the Affordable Care Act (ACA) has been touted by supporters — led by the federal government — as the solution to treatment providers whose patients have no money for services. Put another way, the ACA, combined with parity, was supposed to help people who needed treatment but didn’t have insurance for it and, ultimately, be a bright new funding stream for treatment providers who have seen nothing but cutbacks.

But some cautious officials have been warning that the ACA would not miraculously mean new patients with Medicaid and private insurance would start streaming through the doors on January 1, 2014, and calls this past week have revealed that, in fact, it’s far too early for anyone to know what effect the ACA is having on treatment demand.

The only information that the Centers for Medicare and Medicaid Services (CMS) could provide to ADAW was raw data on how many people have enrolled in the exchanges and Medicaid. There was no information on whether any of these people had tried to access any treatment, much less a specific kind of treatment.

Jerry Rhodes, president of the recovery division of CRC Health Group, the nation’s largest chain of substance use disorder (SUD) treatment providers, told ADAW last week that any changes will take months — “maybe years” — to see.

“We have not seen any wholesale change or increase in patients, and I expected that,” said Rhodes, who, like virtually all treatment providers, strongly supported the ACA and parity. “This is going to be an evolution as these populations come into the exchanges,” he said, referring to the private marketplaces where people can buy plans and get subsidies under the ACA.

“People thought it’s a black-andwhite thing — that you would flip the ACA switch and suddenly we’re in nirvana,” said Rhodes. “It doesn’t work that way.”

Parity is local

And the promise of parity, under which all treatment for SUDs and mental illness must be provided on the same basis as medical and surgical treatment, still has a long way to go. “I don’t know that the exchanges fully comprehend what parity does or does not do,” said Rhodes. “I think we’re going to be in a period of several years before the dust settles.”

Getting into the private networks is difficult for all providers, especially SUD treatment providers (see sidebar, page 3). “We’ve got to work harder as providers to start the dialogue in terms of getting access,” said Rhodes, noting that this has to take place on a local, regional basis.

“There’s no national overview of this,” he said. Networks are set up at county levels, and insurance companies, to keep the costs down — marketplace plans are relatively inexpensive — are limiting the number of providers.

Medicaid better than exchanges

Medicaid offers a better opportunity for treatment providers than the exchanges, said Rhodes. “That’s a very viable population,” he said, noting that of course this depends on the state. Some state Medicaid plans have very limited SUD treatment services — even with parity the law of the land — while others have generous benefits and have expanded under the ACA. “There’s going to be a high degree of variability,” he said.

Noting that no CRC program is in any marketplace network, Rhodes said that implementing parity is going to be essential, but that cultivating local relationships with plans and other providers is more practical at this point. “I would look at regional and local opportunities,” he said. “But in the future, as this evolves, as exchanges see the necessity of implementing the parity act, I think there will be significant opportunities for reaching out on how to service this population.” First, the exchange plans have to understand the costs overall of not treating SUDs — a lesson that seems to have to be relearned. “It’s going to be months, maybe even longer, before there’s any clarity on it,” he said.

On the bright side, the ACA and parity have “clearly put SUD treatment front and center,” said Rhodes. “There’s a greater recognition by society, and that’s important, that has elevated the status of treatment, that SUDs are analogous to a medical condition.” That imposes equity in the healthcare system that didn’t exist before, said Rhodes. But he noted that the healthcare system itself has insurance “issues,” he said. “If people are thinking that with parity, there will suddenly be a significant advantage, that’s not true,” he said. “The healthcare system still has the same issues in terms of interactions with insurance and other payers. We’re not going back to the old days.”

But Rhodes conceded that there are flagrant violations of parity and the ACA imposed at the state level: some states refuse to allow Medicaid to pay for methadone or buprenorphine treatment, for example. Some states are still openly defying the ACA even as residents seek coverage.

“There are some major policy issues that CMS needs to deal with,” he said.

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