September 21, 2016
Did the ACA impact behavioral health treatment disparities?
By Bethany Romano
In 2014, two major aspects of the Affordable Care Act (ACA) took effect: Medicaid expansion in 32 states, and the opening of state-level insurance marketplaces for individuals and families. The groups who stood to benefit most from these changes — the Medicaid-eligible population and those without employer-sponsored insurance — are disproportionately composed of racial and ethnic minorities. Therefore, this expansion in health insurance could eventually both increase access to health care and narrow existing health disparities.
Heller School PhD candidate Tim Creedon and his co-author Benjamin Lê Cook set out to determine whether this is beginning to happen. In particular, they examined mental health and substance abuse treatment rates. Creedon and Lê Cook used 2014 data from the National Survey on Drug Use and Health and published their findings in the June issue of Health Affairs.
Their first question was: Did insurance coverage increase for people who need mental health and substance abuse treatment? “We found that yes, it did,” says Creedon. “Insurance coverage increased significantly for people with substance use disorders or mental health concerns — but disparities did not change.”
The same proved true for access to mental health care. “Mental health treatment rates increased a little bit on average for all racial and ethnic groups, which is good,” says Creedon. “But between groups, the disparities didn’t shrink or change in any big way. We saw a positive trend for Hispanics and Asians, but it wasn’t statistically significant. The disparity problem remains.”
They then looked at substance abuse treatment rates, but saw no significant changes in 2014. One key difference between mental health and substance abuse treatment is that overall, substance abuse treatment rates are very low. “Among those people who needed mental health treatment, close to half were getting it, but less than 10 percent of those who needed substance abuse treatment received it. So we didn’t see any change in substance abuse treatment rates at all. It started much lower and it stayed much lower overall, with no changes for any racial or ethnic group.”
What this study shows is that while insurance coverage is crucial, many other factors may prevent people from accessing the care they need. Despite expansions in insurance coverage, stagnant treatment rates are a sign policymakers should focus their attention on other areas, such as treatment capacity.
“The key takeaway for this study,” says Creedon, “is that insurance expansion is helpful, it’s necessary, but it’s not sufficient. There’s little reason to believe that insurance alone will repair disparities in behavioral health care access. We need to look at providers to determine if there are enough of them, if they’re located in the right communities, if they have the same backgrounds as the people who need to see them, whether they have cultural competence, and whether they accept health insurance at all. The system is huge and complicated, so we can’t expect the solutions to be simple.”