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(p. 119) The Impact of the Affordable Care Act on Substance Use Disorder Treatment for Emerging Adults 

(p. 119) The Impact of the Affordable Care Act on Substance Use Disorder Treatment for Emerging Adults
(p. 119) The Impact of the Affordable Care Act on Substance Use Disorder Treatment for Emerging Adults

Christina M. Andrews

, Clifford Bersamira

, and Melissa Westlake

Page of

date: 21 January 2018


Emerging adults have the highest prevalence of substance use disorders (SUDs) of any age group in the United States. Yet historically, few emerging adults who need SUD treatment—defined here as targeted services to address SUDs that go beyond brief intervention—ever receive it. While the reasons for poor access to treatment are multifaceted and complex, inability to pay is consistently cited as a major barrier to accessing treatment. Enacted in 2010, the Patient Protection and Affordable Care Act (ACA) includes a number of provisions designed to address these challenges. Provisions of the ACA, including the expansion of Medicaid eligibility requirements, the dependent coverage mandate permitting children to stay on their parents’ health plans until age 26, and the creation of insurance marketplace exchanges, have already demonstrated success, as evidenced by a significant drop in the percentage of uninsured emerging adults. Moreover, the ACA requires many health insurance plans to provide at least some coverage for SUD treatment, expanding the reach of federal parity requirements originally limited to large private health insurance plans. Finally, the ACA establishes new incentives for the integration of SUD treatment into mainstream medical care to respond to long-standing challenges in treatment quality and coordination. Taken together, these changes have already resulted in major improvements in the accessibility and quality of SUD treatment for emerging adults. However, to fully realize the ACA’s promise, it will be critical to address ongoing challenges to (p. 120) effective implementation, including inadequate SUD treatment supply, variation in treatment access and quality, and long-standing socioeconomic disparities.

SUD Treatment Prior to Health Reform

In the era prior to the ACA, the financing and organization of SUD treatment were rather different than that of general medical care. Unlike general healthcare, the SUD treatment system was heavily reliant on public sector payment (Frank, McGuire, Regier, Manderscheid, & Woodward, 1994). Spending for SUD treatment in the decades before the ACA was marked by periods of growth and retraction. During the 1980s, health insurance coverage for SUD treatment expanded and access improved. However, during the mid- and late 1980s, with mounting employer concerns about growing healthcare costs, many health insurance plans reduced or eliminated coverage for SUD treatment and imposed new controls on service utilization, primarily via managed care (Mark, Levit, Vandivort-Warren, Buck, & Coffey, 2011).

The overall trend in the 30 years before ACA implementation was slow but steady growth in SUD treatment spending. According to the Substance Abuse and Mental Health Services Administration (SAMHSA) (2013a), SUD treatment spending doubled from $12 billion in 1997 to $24 billion in 2009 (Mark et al., 2000). Yet, this spending has not kept pace with spending in other areas of healthcare, and consequently, spending for SUD treatment has represented a declining proportion of all-health spending for most payers (Mark et al., 2011).

On the eve of the implementation of the ACA’s major insurance expansions in later 2013, public payers accounted for 69% of all SUD treatment spending, with Substance Abuse Prevention and Treatment (SAPT) block grants administered by the SAMHSA accounting for 40% of all SUD treatment spending. State and local payers (excluding state contributions to Medicaid) accounted for 31% (SAMHSA, 2013a). Medicaid accounted for 21% of SUD treatment spending and private insurance accounted for 16%. In the section below, we describe each of the major pre-ACA sources of funding for SUD treatment in greater detail.


Medicaid is the nation’s largest public health insurance program for low-income people. It is a jointly financed intergovernmental program, largely administered by states under a set of federal regulations (Centers for Medicare & Medicaid Services [CMS], 2005). States are responsible for administering Medicaid programs and develop their own eligibility requirements and benefits packages within broad federal guidelines (Stewart & Hogan, 2011). Prior to the ACA, Medicaid eligibility was based on a combination of financial and categorical eligibility requirements. Beneficiaries had to be low income, although states made separate determinations of income thresholds. States were required by federal law to cover children up (p. 121) to age 6 who were under 133% federal poverty level (FPL) and those aged 7–18 under 100% of FPL; pregnant women and infants up to 133% FPL; poor disabled and elderly (65+ years of age) recipients of Supplemental Security Income (SSI); and poor families with dependent children eligible for Temporary Assistance for Needy Families (TANF). States also have the option to extend coverage to other populations and receive the federal contribution. Federal spending levels for Medicaid are determined by the number of people participating, the extent to which enrollees use services, and the scope of services covered.

Medicaid expenditures for SUD treatment increased over the past three decades as a result of expansions in state Medicaid programs’ eligibility and benefits for SUD treatment. Historically, states have had great discretion with regard to Medicaid coverage for SUD treatment. Federal guidelines were vague: While they did not include coverage for SUD treatment, they also did not exclude it. Consequently, states varied greatly with regard to what coverage they provided and who could receive it (Coughlin & Zuckerman, 2002). Some states covered no SUD treatment, and among those that did, there was great variation in the specific types of treatment services covered and reimbursement rates for them. Moreover, states differed with regard to the criteria used to determine eligibility for Medicaid. Some states extend eligibility only to mandatory categories stipulated by federal program guidelines, while others have used Medicaid as a vehicle through which to extend healthcare coverage to a range of vulnerable populations, including low-income, medically needy, and working disabled individuals.

Programmatic barriers to access to SUD treatment for Medicaid enrollees have been well documented (Abraham, Knudsen, Rieckmann, & Roman, 2013). At the time of the ACA’s passage, only about half of SUD treatment programs in the United States accepted Medicaid enrollees, creating potential challenges to treatment availability (Andrews, 2014; Terry-McElrath, Chriqui, & McBride, 2011). Additionally, reimbursement rates for Medicaid in comparison with rates for private insurance have historically been low, making it undesirable to a significant sector of private treatment programs that cater to the insured population. Other programs face different kinds of disincentives to accept Medicaid, including significant challenges in meeting the staffing and technological requirements of many state Medicaid programs to become Medicaid-billable providers. Moreover, many Medicaid programs use managed care to oversee SUD treatment financing and reimbursement, and consequently, many SUD treatment services are subject to a variety of utilization controls, including preauthorization, cost-sharing, and limits of intensity and frequency of services used (Maglione & Ridgeley, 2006). In the vast majority of cases, requirements imposed on SUD treatment have been more restrictive than those placed on other medical services (Garfield, Lave, & Donohue, 2010).

However, the literature on the effects of managed care on SUD treatment access is mixed. After the transition from a fee-for-service to managed care system, treatment access increased considerably in Oregon and Iowa (Deck, McFarland, Titus, Laws, & Gabriel, 2000; McCarty & Argeriou, 2003) and stayed the same in Maryland and Massachusetts (Callahan, Shepard, Beinecke, Larson, & Cavanaugh, (p. 122) 1995; Ettner, Denmead, Dilonardo, Cao, & Belanger, 2003). Only in Michigan was the transition to managed care associated with a decrease in Medicaid beneficiaries receiving treatment (Hodgkin, Shepard, Anthony, & Strickler, 2004). Finally, a national study on the impact of publicly funded managed care on treatment outcomes found that Medicaid behavioral health carve-outs were associated with greater use of treatment (Chuang, Wells & Alexander, 2011).

Private Insurance

The first private health insurance plans began to cover treatment for alcoholism in the 1960s. However, these plans were generally reluctant to offer coverage at similar levels to that of other medical and surgical services (Scott, Greenberg, & Pizzaro, 1992). In the 1970s, advocates for emerging SUD treatment communities attempted to persuade health insurance providers to extend coverage, but with only limited success. To push back at the health insurance industry’s early resistance to covering SUD treatment, some states turned to insurance mandates requiring insurance plans to provide coverage for SUD treatment or offer enrollees the option to purchase it separately. By 1991, 41 states had enacted SUD treatment mandates (Scott et al., 1992). As a consequence of these mandates, private health insurance funding for SUD treatment rose rapidly to account for one-third of all spending for SUD treatment by the 1990s (Rogowski, 1992; Scott et al., 1992). By 1990, 96% of private health plan beneficiaries had access to SUD treatment benefits (Rogowski, 1992).

However, private financing of SUD treatment began to decline shortly thereafter, as managed care organizations (MCOs) reached dominance in the private insurance market (Stewart & Horgan, 2011). As a cost-saving measure, many large group health insurance plans elected to rely on MCOs in response to rapidly rising costs of healthcare across the industry, and the SUD treatment industry was no exception. Enrollment rapidly expanded from 48 million in the early 1990s to about 120 million by the middle of the decade, with the majority insured through private employer-sponsored plans (Institute of Medicine, 1996). Generally, lifetime limits on behavioral healthcare were rare—only 6% of plans used them. However annual limits on behavioral health service utilization were more common; 93% of outpatient SUD treatment placed some kind of limit on use of SUD treatment services in a single year (Hodgkin, Horgan, Garnick, & Merrick, 2009).

From 1986 to 2003, private spending for SUD treatment fell by 8%, to $2.2 billion (Mark & Vandivort-Warren, 2012). Just prior to the ACA implementation, about one-third of enrollees in individual private health insurance plans and 12% of enrollees in employer-sponsored health insurance plans lacked any coverage for SUD treatment (Association for Behavioral Health and Wellness [ASPE], 2011). Moreover, enrollees in plans that did cover SUD treatment typically faced higher cost-sharing and service limits for SUD treatment than other medical and surgical services, particularly within managed care carve-outs (Gabel et al., 2007; Levit et al., 2008). By 2003, managed care plans enrolled 95% of privately insured (p. 123) SUD patients (Hodgkin et al., 2009). MCOs employed a number of strategies to monitor and regulate treatment utilization, including use of preauthorization of service requirements, utilization review, and limits on the frequency, length, and number of treatment sessions (Sosin, 2002). MCOs appear to have had the greatest impact on the frequency and length of SUD treatment provided. SUD treatment programs reporting significant involvement with managed care also reported shorter treatment duration and provided an average of 10 fewer individual sessions than treatment programs with less involvement with managed care (Lemak & Alexander, 2001). From 1992 to 2001, the percentage of private insurance enrollees using SUD treatment declined by 23% (Mark & Coffey, 2004).

Block Grants

The block grant was initially created in 1992, as part of the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act of 1992. The purpose of the block grant is to provide financial assistance to states, tribes, and other U.S. jurisdictions, including for the development and implementation of SUD prevention, treatment, and recovery services (United States Government Publishing Office, 2017). States have the ability to spend grant funds at their discretion in order to meet the objectives of the SAPT block grant within the context of its statutory language. The SAPT block grant is unique in that there is no state match requirement, as there is with Medicaid.

The block grant was developed in the 1980s as a means of distributing federal funds to states to purchase SUD treatment services, while permitting state flexibility in the design and administration of services and limiting the federal government’s role (Stewart & Horgan, 2011). Congress decides on the grant amount on an annual basis, which is then distributed among the states according to a formula (Stewart & Horgan, 2011). The block grant is administered by SAMHSA, the federal agency responsible for overseeing mental health and SUD treatment and funding. SAMHSA allocates block grant funds to the state government agencies, who are in turn responsible for distributing the funds to local agencies to provide SUD treatment.

Block grant funds finance SUD treatment for 2.5 million Americans annually (National Association of State Alcohol and Drug Abuse Directors [NASADAD], 2016). In particular, block grant funds are intended to provide services to people without access to insurance coverage. Additionally, some block grant funds are earmarked for treatment of vulnerable populations, including pregnant and parenting women, intravenous drug users, individuals with HIV/AIDS, and individuals with tuberculosis (United States Government Publishing Office, 2017).

Prior to the ACA, the SAPT block grant constituted approximately 40% of all SUD treatment spending in the United States and was the largest source of state funding for the SUD treatment system (Cowell, McCarty, & Woodward, 2003; NASADAD, 2016). Sixteen states reported that more than half of their spending on SUD prevention and treatment came from the block grant. However, (p. 124) block grant funds have not kept up with healthcare inflation, resulting in a 26% reduction in purchasing value (or $483 million decrease) over the past decade (NASADAD, 2016). From 2009—the period just prior to the implementation of ACA—to 2016, SAPT block grant funding has maintained roughly level funding, from $1.779 billion to $1.858 billion (non-inflation-adjusted dollars). It is also important to note how reliant many SUD treatment providers and states are on SAPT block grant funds. Sixteen states reported relying on the block grant for more than 50% of their SUD prevention and treatment funding.

Other Funding

Additional funding for SUD treatment comes from state and local spending and client out-of-pocket spending. State and local spending on SUD services varies geographically, but, on average, constitutes about 6% of SUD treatment spending (Stewart & Horgan, 2011). In contrast, out-of-pocket spending constituted 11% of spending on SUD treatment in 2009 (SAMHSA, 2013a). Between 1986 and 2003, out-of-pocket spending increased from $1.2 billion to $1.7 billion, at an annual rate of 1.5% (Mark et al., 2007).

Challenges to Treatment Access and Quality

Treatment Access

In the era before the ACA, access to SUD treatment for emerging adults—along with just about every other demographic population in the United States—was poor. Just prior to the passage of the ACA, in 2010, only 7.7% of emerging adults who needed SUD treatment reported receiving it (SAMHSA, 2012b). Low rates of treatment receipt among this population are particularly concerning, as 20.3% of all individuals aged 18–25 were classified as needing treatment in 2010, compared to 7.5% of youth ages 12–17, and 7.4% of individuals 26 and older (SAMHSA, 2012b). Of the 7.7% of emerging adults who were able to receive treatment in 2010, 563,000 sought treatment for illicit drugs, 611,000 sought treatment for alcohol, and 313,000 sought treatment for both. Of individuals age 12 years or older who needed treatment and did not receive it, approximately 341,000—or 33.3%—reported having made unsuccessful efforts to get treatment (SAMHSA, 2012c).

While the challenges to treatment access are as numerous as they are complex, inability to pay has consistently been cited as one of the most serious and intractable barriers to receiving SUD treatment. This is especially true for emerging adults, who have historically had the highest rates of uninsurance in the nation (CMS, 2016f). The population of young adults ranging from ages 18–29 has often been referred to as the “young invincibles,” a term coined in the health insurance industry to refer to the common perception among this group that they (p. 125) are immune from sickness and injury and thus do not need to purchase health insurance. Among emerging adults who needed treatment for an SUD but did not receive it, 37.3% cited a lack of healthcare coverage as their main reason for not receiving treatment. An additional 8.2% said they had healthcare coverage, but that it did not cover treatment costs (SAMHSA, 2014b).

In 2009—just prior to the enactment of the law—only 57.2% of emerging adults aged 21–24 admitted for SUD treatment had health insurance coverage for SUD treatment (Saloner, Antwi, Maclean, & Le Cook, 2015). The majority of emerging adults with SUD are not in the workforce and, consequently, do not have access to employer-sponsored insurance (SAMHSA, 2012b). Most are male young adults without dependents, and before implementation of the ACA, did not qualify for publicly sponsored health insurance programs (SAMHSA, 2012b). In the Medicaid program’s early years, SUDs were recognized as qualifying disabilities for SSI, through which enrollees would become automatically eligible to receive Medicaid coverage. However, in 1997, SUDs were formally excluded as qualifying disabilities for SSI, effectively closing the door, for nearly 20 years, on Medicaid eligibility for many individuals with an SUD who were not eligible for Medicaid through other means (Gresenz, Watkins, & Podus, 1998; Swartz, Lurigio, & Goldstein, 2000).

Variation in SUD treatment access is dependent on insurance status—more so than in other sectors of the healthcare industry (Bouchery, Harwood, Dilonardo & Vandivort-Warren, 2012). SUD treatment spending presents a clear picture of this problem, with federal, state, and local government sources, including Medicaid, accounting for 77% of SUD treatment costs before enactment of the ACA. Just 10% of non-public spending came from private insurance, and the rest came from out-of-pocket spending and other private sources (Open Society Foundations, 2010). In comparison, private insurance covers almost four times the proportion of spending on other medical care (Open Society Foundations, 2010). One of the major reasons for higher amounts of public spending are the frequent restrictions placed on SUD treatment coverage by private insurers. Several studies have suggested that Medicaid beneficiaries have greater access to specialized SUD treatment than those with private or no insurance, as the majority of state plans cover at least some SUD treatment services. In fact, individuals with public insurance such as Medicaid, Medicare, and CHAMPS/VA have been shown to have up to 90% greater odds of receiving SUD treatment when compared to those with private insurance (Bouchery et al., 2012). However, individuals on publicly funded plans such as these make up only 26% of individuals with SUD treatment disorders (70%) (Ridic, Gleason, & Ridic, 2012).

Moreover, emerging adults in some areas of the country are more likely to face challenges in accessing treatment. Historically, people of all ages living in the South, Southwest, and Great Plains regions of the country have reported lower access to SUD treatment than people living in other regions (McAuliffe, LaBrie, Woodworth, Zhang, & Dunn, 2003). Many of the states with the highest birth rates in the country are located in these regions, a phenomenon which may exacerbate this problem over time. State inequities in access to treatment may occur (p. 126) for numerous reasons. First, states vary in their capacity to contribute general funds to supplement federal and private funding for SUD treatment. Wealthier states and those with higher tax rates typically contribute more state funding for SUD treatment than states with fewer resources (McAuliffe et al., 2003). Some states even have limits on the use of state general funds for SUD treatment services. Second, as described earlier, Medicaid coverage for SUD treatment, while typically more comprehensive than private insurance coverage for SUD treatment, varies significantly from state to state (Grogan et al., unpublished manuscript). Third, prior to the expansion of parity requirements under the ACA, states varied with regard to parity law: Some states have legislation requiring that coverage for SUD treatment be no more restrictive than benefits for other medical and surgical services, while others do not (Rowan, McAlpine, & Blewett, 2013). Fourth, states have different sociodemographic profiles. It is well known that gender, race, ethnicity, age, and a host of other factors influence individuals’ likelihood of receiving treatment.

Treatment Quality

The SUD treatment field has struggled historically with poor rates of adoption of evidence-based interventions. This is in part due to an elusive and highly debated etiological understanding of addiction, which permitted the prolonged use of treatment strategies that fail to address addiction as a chronic disease overall, and specifically among emerging adults (McLellan, McKay, Forman, Cacciola, & Kemp, 2004; McLellan & Meyers, 2004). More recently, evidence-based interventions for treatment of SUD among emerging adults have surfaced. However, the adoption of these interventions has been slow, and implementation with fidelity has been limited. As a result, the quality of treatment that patients receive varies significantly across SUD treatment programs. While many factors influence these differences in quality, issues related to financial and organizational resources and the professionalization of staff are especially important (McLellan & Meyers, 2004).

The quality of SUD treatment that people receive is in part dependent on how their treatment is financed. In comparing SUD treatment programs financed by public versus private dollars, privately financed programs (e.g., through private insurance) are more likely to offer core medical and treatment services such as assessment, counseling, medication-assisted treatment (MAT), peer support group services, and continuing care. On the other hand, publicly financed providers (e.g., receiving primarily Medicaid, block grants, and state and local funding) are more likely to also offer wraparound and supportive services that address access and retention issues, facilitate care for individuals, and can be administered on site or through referral linkages. Wraparound services include medical, mental health, HIV/AIDS, transportation, employment/education, and transportation services, among others (Ducharme, Mello, Roman, Knudsen, & Johnson, 2007). Financing is an especially significant issue for emerging adults. Many individuals (p. 127) do not have insurance, or they have plans that provide no or minimal coverage for SUD treatment.

The SUD treatment field employs significantly fewer staff with professional training than staff employed in other fields within the healthcare system. Of primary concern is the historical lack of credentialing, training, licensure requirements, and supervision for counselors and other providers of SUD treatment. The absence of a high-quality professional staff is extremely prevalent; among substance use treatment providers who rely on public sources for the majority of funding, fewer than half employ counselors trained at the master’s degree level, a third do not have a physician, and three-quarters of program directors hold a bachelor’s degree or less (Buck, 2011). Even so, the SUD treatment field has been subject to many of the same requirements as mainstream healthcare financing, despite often lacking the administrative, financial, and infrastructure support required to meet those standards (Buck, 2011). The result is increased barriers to service reimbursement and, in turn, a lack of financial coverage and treatment options for patients, especially emerging adults (Humphreys & McLellan, 2011).

For example, in order for a facility to accept Medicaid as payment for SUD treatment, many states require that a physician be involved in treatment planning and/or that counselors maintain a certain level of education and licensure, along with various other provisions that limit an agency’s ability to accept these enrollees (Knudsen, Oser, Abraham, & Roman, 2012). Private insurance providers set similar standards regarding staff and administrative functioning. Thus issues with quality and professionalization of staff make it much more challenging to receive reimbursement from Medicaid and private-insurance providers for service. In addition, a smaller or less qualified staff often indicates fewer treatment options being available to patients. Evidence-based interventions involving MAT, for example, require the involvement of a qualified physician (Knudsen et al., 2012). Finally, the treatment of co-occurring disorders and general medical care has also been linked to more positive outcomes for individuals in SUD treatment, although many facilities lack the organizational capacity to employ the professionals with the training required to provide and bill for such services (Knudsen et al., 2012).

The result has been poor adoption of evidence-based intervention in SUD treatment settings. MATs, such as methadone, buprenorphine, and naltrexone for opioid use disorders, and disulfiram, acamprosate, and naltrexone for alcohol use disorders, offer one such example of an emerging and highly effective evidence-based treatment yet to become widely available to the public. For persons with alcohol use disorders, MATs are associated with fewer inpatient treatment admissions and 30% less healthcare cost than persons not receiving MATs (Baser, Chalk, Rawson, & Gastfriend, 2011). For individuals with opiate use disorders, MATs have proven to be safe, cost-effective, and capable of reducing the risk of fatal overdose by as much as 50% (Volkow, Frieden, Hyde, & Cha, 2014). Additionally, MATs have been associated with higher rates of treatment retention, improvements in social functioning, and decreases in patient criminal activity and the transmission of infectious diseases (Volkow et al., 2014). Despite the promise of (p. 128) these treatments, MATs are extremely underutilized—roughly one-quarter of individuals with dependence problems ever receive medication assistance, and only 8% of facilities offer this service (SAMHSA, 2012a). Emerging adults represent a large proportion of individuals with opioid-related problems and bear much of the brunt of policy coverage failures for MAT.

Finally, despite growing recognition that SUDs are a chronic condition, there is still a tendency to deliver treatment as if it were an acute disorder (McLellan, Lewis, O’Brien, & Kleber, 2000). This approach falls short in taking into consideration the importance of recovery support services, including housing, education, employment services, peer-delivered support services, and cultural and spiritual supports, among others. Moreover, the universal failure to acknowledge substance use as a highly prevalent chronic condition has led to insufficiencies not just within the specialty treatment sector but also among the many other systems in which individuals with SUDs are likely to reside. Problems with substance use are clearly prevalent and present themselves in schools, primary care practices, mental health clinics, and criminal justice settings, yet there is insufficient training, organization, and reimbursement available for screening, assessment, and referral to treatment for persons with SUD (McLellan & Meyers, 2004).

The ACA’s Impact on SUD Treatment for Emerging Adults

The Affordable Care Act has dramatically expanded coverage for SUD treatment in the United States. Through the creation of state health insurance exchanges, a major expansion of the Medicaid program, and the provision to allow adult children to retain health insurance coverage through a parent’s plan until they reach 26 years of age, the law has increased access to SUD treatment services for as many as 50 million individuals with current SUDs (McLellan & Woodworth, 2014). The ACA has also established a requirement that all enrollees in the newly established state health insurance exchanges and Medicaid expansion plans receive at least some health insurance benefits for treatment of SUD (Buck, 2011; Mechanic, 2012). Finally, the law also requires nearly all large health insurance plans to provide SUD treatment benefits at parity with other medical services. In addition to improving the accessibility and quality of SUD treatment in the United States, these changes have sparked a major transition in SUD treatment away from a specialty treatment system that has historically relied heavily on public grant funds and operated outside of the mainstream of healthcare and toward an insurance-financed system in which SUD treatment is increasingly offered in traditional and integrated medical settings (Andrews, Grogan, Brennan & Pollack, 2015; Humphreys & Frank, 2014; Mechanic, 2012). Arguably, no other sector of the healthcare system will be so profoundly transformed by the ACA.

(p. 129) Health Insurance Expansions under the ACA

As described earlier, few emerging adults with SUDs receive treatment, and inability to pay for treatment has been cited as a major impediment to access. The ACA represents a dramatic step forward in removing financial barriers to SUD treatment access by greatly expanding health insurance coverage. The law achieves this goal through three major provisions: the creation of government-sponsored, privately administered state health insurance exchanges, through which individuals can purchase private health insurance at affordable rates; a major expansion of the Medicaid program; and a provision allowing adult children to retain health insurance coverage through a parent’s or custodian’s plan until age 26. Since the law was enacted in 2010, the percentage of emerging adults without health insurance has been cut in half—from a historic high point of almost 30% to just 14.8% by the first quarter of 2016. By 2016, the percentage of all adults who lacked insurance decreased by 32%—a massive policy accomplishment by any measure (Gallup, 2011, 2016). Moreover, fewer emerging adults reported that cost was a barrier to receiving SUD. In 2012—2 years after implementation of the dependent coverage provision—44% of emerging adults indicated cost was a major impediment to receiving treatment, down from 54% in 2009 (Gallup, 2011).

Medicaid Expansion

The ACA’s expansion of Medicaid represents the largest increase in enrollment in the program’s 50-year history. As it was originally enacted in 2010, the law removed categorical restrictions on Medicaid eligibility that had previously limited enrollment to parents, children, elderly persons, and disabled individuals, extending coverage to millions of the uninsured. Under the ACA, all U.S. citizens, including those with SUD, could qualify to receive Medicaid benefits if they the met the income eligibility requirement stipulating an income no greater than 138% of the FPL (Buck, 2011). Policymakers estimated that as many as 15 million uninsured adults could become eligible for Medicaid by 2014 as a result of the ACA (Kenney, Lynch, Haley & Huntress, 2012).

However, this provision was struck a major blow in June 2012 when the United States’ Supreme Court deemed it unconstitutional in a case entitled National Federation of Independent Business v. Sebelius. The Court stated that the law’s ultimatum to states to adopt the Medicaid expansion or lose all federal funding for their state Medicaid programs was unduly coercive (Kaiser Family Foundation, 2012). As a result of the decision, only 24 states and the District of Columbia adopted the Medicaid expansion at the start of implementation in January 2014. Since that time, an additional six states have opted in (Alaska, Indiana, Michigan, Montana, New Hampshire, and Pennsylvania). Nonetheless, 20 states—home to approximately 3.1 million people who meet the new federal eligibility criteria for Medicaid—remain in opposition to the expansion (Garfield, Damico, Cox, Claxton, & Levitt, 2015).

(p. 130) States that have expanded Medicaid are experiencing a significant infusion of new funding for SUD treatment. Estimates suggest 14% of Medicaid expansion enrollees have an SUD—a rate that is roughly 50% higher than that of the general population (Busch, Meara, Huskamp, & Barry, 2013). Because the majority of the costs for SUD treatment for this substantial population were paid for by states prior to Medicaid expansion, states that have expanded Medicaid report that they anticipate a reduction in use of their general funds to pay for SUD treatment. Reductions in costs among these states range from $7 million to as much as $190 million in 2015 alone (SAMHSA, 2014a). The majority of these states have indicated that they intend to reallocate freed-up funds toward SUD outreach and prevention (Andrews et al., 2015). Emerging adults are among the greatest beneficiaries of these changes, as childless adults, and especially young, single men, make up the largest proportion of newly eligible Medicaid enrollees in these states (Pickens, Dunn & Glebe, 2012). Moreover, among emerging adults who were uninsured in 2010, more than half—52%—are members of families with incomes under 133% of poverty and would therefore be eligible for coverage under the Medicaid expansion (Collins & Nicholson, 2010).

Conversely, many low-income emerging adults in states that have not adopted the Medicaid expansion continue to face substantial financial barriers to SUD treatment access. A large number of individuals with SUD will not receive the benefits of Medicaid expansion because of states’ decisions to opt out. Of uninsured adults ages 18–64 who met criteria for an SUD in the past year, approximately 34.1% would have qualified for treatment coverage under Medicaid but lived in non-Medicaid expansion states in 2013 (SAMHSA, 2015).

Many of the states that have not adopted the expansion—located primarily in the Southeast and Great Plains regions of the country—have some of the highest proportions of low-income residents. These states would yield some of the greatest benefits by opting in to the expansion. Of special concern is the potential of the uneven expansion of Medicaid to exacerbate disparities in access to SUD treatment in the United States. Given the large number of African American and Native American residents living in states that have opted not to expand Medicaid, these populations have benefited disproportionately less from the expansion than other racial and ethnic groups. In 2012—just before the expansion of Medicaid—approximately 60% of African Americans and 70% of Native Americans lived in non-expansion states (Andrews, Guerrero, Wooten, & Legnick-Hall, 2015).

Health Insurance Exchanges

In addition to Medicaid expansion, the ACA includes another major option for young adults who lack affordable health insurance coverage: state health insurance exchanges. Through the exchanges, all Americans are provided with the option to purchase comprehensive health insurance at affordable large-group rates. These insurance exchanges can be set up and regulated by state governments, though states may seek support from the federal government, or default completely to federally facilitated marketplaces. In order to broaden risk pools, some states (p. 131) may enter into partnerships with other states in their region to establish these insurance exchanges. In the case of state-run exchanges, consumers apply for and enroll in coverage using platforms established by the state; in all other instances, consumers use the federal platform——to enroll. Insurance exchanges are administered by for- and non-profit private insurers through qualified health plans that meet federally outlined standards of consumer protection, including coverage of “essential health benefits” and limits on cost-sharing. The exchanges provide options for many Americans who could not afford adequate health insurance coverage prior to the ACA—the majority of whom do not have access to employer-sponsored coverage or have coverage they cannot use owing to high cost-sharing requirements. Uninsured individuals who do not enroll in the exchanges or another health insurance plan are subject to a fine equal to 2.5% of their household income or $695, whichever is higher. Currently, nearly 10 million Americans have health insurance through the exchanges.

To assist with the cost of these health insurance plans, the federal government provides subsidies, either through cost-sharing, which lowers deductibles, copayments and out-of-pocket limits, or premium tax credits. Cost-sharing subsidies are available for households with incomes between 100% and 250% of the FPL, and premium tax credits are extended up to 400% of the FPL (Collins, Gunja, Rasmussen, Doty & Beutel, 2015). All assistance is provided at scale, with those who have lower incomes receiving a greater amount of support. In 2015, 84% of Americans participating in a health insurance exchange received federal tax credits and 56% received cost-sharing subsidies to help cover costs (Collins, Gunja, Rasmussen, Doty, & Beutel, 2015).

The exchanges rely on high levels of enrollment to keep costs down. Because young adults make up a major portion of the population of uninsured Americans with few health problems, enrollment of this population is critical for a broad and diverse risk pool within the exchanges. Despite critics who argued these “young invincibles” would not likely opt in, evidence points to affordability, not invincibility, as the reasoning behind this population’s lack of coverage (Collins, Rasmussen, Garber, & Doty, 2013). The exchanges offer a fitting response to this need, as 6 in 10 emerging adults now qualify for subsidies, resulting in coverage that costs $100 or less per month. Moreover, a low-income emerging adult who enrolls in the one of the exchange’s moderate-cost “silver” plans will receive coverage equivalent to a highest-cost “platinum” level plan, essentially providing the best coverage at the cheapest price for any American (Collins, Gunja, Rasmussen, et al., 2015). It is no wonder, then, that more young adults have signed up for insurance through the exchanges than any other age demographic, accounting for 31% of adult enrollees in 2015 (Collins, Gunja, Doty, & Beutel, 2015). In addition, with more than 80% of the 2013 uninsured emerging adult population meeting eligibility requirements for subsidized marketplace insurance plans or Medicaid, more young adults are expected to gain coverage in the future (Collins et al., 2013). However, awareness is a major barrier to increasing enrollment; only a quarter of emerging adults said they were aware of the marketplaces in 2013, with low-income emerging adults were among the least aware.

(p. 132) Extension of Coverage for Emerging Adults

One provision of the ACA that holds great importance for emerging adults is the allowance for children to remain on a parent’s or custodian’s insurance plan until age 26. All health insurance plans that offer coverage for dependents are subject to the provision. This provision, known as the dependent coverage mandate, applies regardless of many major life changes and circumstances, including living situation, marital or student status, degree of financial independence, or having a dependent of one’s own. To encourage uptake of this option, the ACA allows parents to deduct the value of the cost of coverage of the adult child included on the plan from their taxable income while they remain enrolled.

The dependent coverage mandate has already made a significant impact on the uninsured young adult population. Data from the year prior to the ACA indicate that approximately 42% of emerging adults who had dependent coverage in high school lost that coverage upon graduation (Collins &Nicholson, 2010). Of those individuals, 46% remained uninsured for 2 years or longer. Four years later, when many emerging adults are graduating from 4-year colleges, these numbers jump significantly, with as many as 75% of new graduates losing coverage (Collins &Nicholson, 2010). Since the ACA was enacted, these numbers have changed dramatically. In 2013—3 years after implementation of the dependent coverage mandate—an estimated 15 million young adults aged 19–25 were enrolled in their parent’s insurance plan. Of that 15 million, approximately 7.8 million would not have been eligible to enroll under their parent’s plans before enactment of the ACA (Collins et al., 2013).

Despite this progress, many emerging adults remain uninsured, especially low-income emerging adults, who are at higher risk for substance use. Those individuals with incomes under 133% of FPL are the least likely emerging adults to take advantage of the dependent coverage mandate. Emerging adults are far less likely to have a parent with a health plan they can join, and report less knowledge regarding new opportunities for coverage under the ACA. Still, dependent coverage for low-income adults increased from 17% in 2011 to 26% in 2013 (Collins et al., 2013).

SUD Treatment as an Essential Health Benefit

Not only does the ACA increase the number of people with health insurance, but it also requires that more health insurance plans than ever before include SUD treatment in their scope of benefits. The ACA achieves this goal through the creation of the Essential Health Benefits (EHB), a comprehensive package of health and preventative services that must be offered by non-grandfathered individual and small-group private health insurance plans, qualified health plans (QHPs) participating in the newly established state health insurance exchanges, and the benefits plans serving the Medicaid expansion population. It is estimated that approximately 5.1 million people participating in individual or small-group health insurance plans have gained benefits to cover SUD treatment as a result (p. 133) of the ACA (Beronio, Glied, Po & Skopec, 2013). QHPs participating in a state health insurance exchange cannot put a lifetime limit on coverage for services in any EHB category, including SUD treatment. Undoubtedly, this a major step forward for the SUD treatment field. Not only does the inclusion of SUD treatment in the EHB package insure basic health insurance coverage for treatment of SUD, it also has great symbolic importance: With the ACA, the federal government recognizes SUD not only as a medical condition but one that should be considered a core service provided as part of any healthcare system.

Despite these important steps forward, the EHB provision leaves some important gaps in coverage. For example, the ACA does not provide a clear and consistent definition of what adequate coverage for SUD treatment is. In each state, specific EHB are defined by what is offered in the state’s identified “benchmark plan,” which states can select from any of the following established health insurance plans: the Federal Employees Health Benefit Plan Coverage (FEHBP Health Insurance Coverage); state Employee Health Benefit Coverage; the health maintenance organization plan that has the largest insured commercial, non-Medicaid enrollment in the state; or another Health and Human Services (HHS) Secretary–approved coverage that provides appropriate coverage (CMS, 2016c). If the state’s benchmark plan does not include coverage for SUD treatment, the state must establish a minimum level of coverage. In both cases, what is required is left to the discretion of individual states, both in terms of the selection of the benchmark plan and in the establishment of benefit minimums for EHB services not included in the benchmark plan.

Moreover, there are several large insured populations whose plans are not included in the EHB requirements: traditional, non-expansion Medicaid enrollees, and individuals participating in grandfathered private health insurance plans. To put this in perspective, approximately 25% of covered workers were enrolled in a grandfathered plan in 2015, and approximately 22.7 million adults were enrolled in traditional (i.e., non-expansion programs) Medicaid in 2016 (Kaiser Family Foundation, 2015; CMS, 2016d). These plans are exempt from the requirement to cover SUD treatment, though, fortunately, the majority do provide at least some basic benefit despite the lack of a federal mandate to do so.

Extension of MHPAEA Parity Requirements

Before the ACA, SUD treatment benefits were often subjected to more stringent utilization review and limitations than other medical services. The ACA responds to this concern by requiring health insurance coverage provided through the state health insurance exchanges, Medicaid managed care, and Medicaid alternative benefit plans to comply with statutory parity requirements enacted as part of the Mental Health Parity and Addiction Equity Act (MHPAEA) (Beronio, Glied, Po, & Skopec, 2013). The MHPAEA requires that employers ensure that their limits on use of behavioral health services—including SUD treatment—are no more restrictive than that of other surgical and medical services offered by the plan (p. 134) (Frank, Beronio, & Glied, 2014). Through the parity requirements, legislators have sought to eliminate discriminatory practices targeting treatment of behavioral health disorders, including SUD treatment. The requirements mandate parity across a wide range of service utilization management tools and practices, including “copays, coinsurance, and out-of-pocket maximums; limitations on services utilization, such as limits on the number of inpatient days or outpatient visits that are covered; the use of care management tools; coverage for out-of-network providers; and criteria for medical necessity determinations” (CMS, 2016b).

When passed in 2008, the MHPAEA requirements were restricted to health insurance plans for large employers (i.e., organizations that employed greater than 50 employees) that already covered SUD treatment. The ACA extended the MHPAEA statutory parity requirements to the newly established Medicaid alternative benefit plans for the expansion population, as well as QHPs participating in state health insurance exchanges. As a result of these ACA provisions, it is projected that approximately 5 million people with health insurance have gained coverage for behavioral health services as part of their plan through the ACA (Beronio, Glied, & Frank, 2014). A significant proportion of this population is already insured but is covered under health insurance plans that opted not to provide coverage for behavioral health services, including SUD treatment.

The extension of MHPAEA’s statutory parity requirements to the health insurance exchanges and major segments of the Medicaid population has great potential to improve the accessibility and quality of SUD treatment in the United States. The provision holds promise to bring service provision and clinical recommendation into better alignment by treating SUD much like any other medical condition. However, it remains to be seen how this will play out in practice. Studies that have evaluated the effects of the MHPAEA on service utilization in large health insurance plans have found only a very modest impact on utilization (Busch et al., 2014). This may also turn out to be the case in state health insurance exchanges and Medicaid. Additionally, there have been a number of concerns raised about the lack of regulation of the implementation of the MHPAEA parity requirements within Medicaid and the qualified health plans (Grogan et al., unpublished manuscript). Little is known at this juncture about how well plans are (or are not) complying with these federal regulations. Moreover, the ACA does not require that Medicaid programs comply with MHPAEA requirements in non–managed care plans offered to enrollees who are not enrolled in an alternative benefit plan.

Implications for Treatment Access

As a result of the ACA, an anticipated 500,000 emerging adults are predicted to get SUD treatment in 2020—a 30% increase in treatment receipt (Ali, Teich, Woodward, & Han, 2016; SAMHSA, 2014a). SUD treatment spending is predicted to grow in tandem, from $24.3 billion in 2009 to $42.1 billion in 2020 (SAMHSA, 2014a). SUD treatment spending from public sources is predicted to increase to 71% by 2020, a rate that outpaces the spending increase projected for (p. 135) general healthcare spending (53%). This growth is largely attributable to expanded Medicaid eligibility and federal subsidies for enrollees in state health insurance exchanges (SAMHSA, 2014a).

However, it remains unclear whether simply extending health insurance coverage for SUD treatment will necessarily result in expanded access to treatment. As implementation of the ACA continues to unfold, there is growing concern that the nation’s current SUD system lacks the capacity to respond to increasing demand for its services generated by the ACA. At present, just under half of SUD treatment providers accept Medicaid, and an even smaller percentage of programs accept private insurance (Terry-McElrath et al., 2011). While relatively little is known about the reasons for some SUD treatment programs not accepting insurance, a growing number of stakeholders have raised concerns that some—especially the many private, nonprofit SUD treatment programs that make up the “safety net” treatment system for low-income individuals—may lack the administrative and staffing capacity required to become insurance-certified providers in their states (Andrews, 2014; Andrews et al., 2015; Buck, 2011).

Indeed, some SUD treatment programs lack the capacity to participate in any insurance because they cannot meet basic insurance provider certification requirements. Such barriers to entry into the publicly funded insurance market are rare in general healthcare settings. For example, Medicaid program requirements related to medical billing and reporting require major investment in information technology among SUD treatment programs that do not already have such capabilities. In a nationally representative study of 175 SUD treatment programs, investigators found that 20% had no information technology services (including voice mail), and 50% had information technology services available only for administrative staff (McLellan & Meyers, 2004). Yet, a recent study found few states reporting that they are providing any support to SUD treatment programs to enhance information technology to meet insurance provider requirements (Andrews et al., 2015).

Additionally, SUD treatment programs that rely primarily on paraprofessionals and people in recovery may face challenges in meeting health insurance requirements stipulating involvement of medical and other certified healthcare professionals in the provision of SUD treatment. Prior research suggests that employment of such professionals is severely limited when compared with other areas of healthcare. In the study conducted by McLellan, Carise, and Kleber (2003), less than 50% of SUD treatment programs had either a physician or a nurse on staff. In a study of 3,267 facility directors, clinical directors, and program counselors working state-licensed substance abuse treatment programs, Mulvey, Hubbard, and Hayashi (2003) found that less than 50% of SUD treatment staff had a professional or other master’s degree. These estimates suggest that many SUD treatment programs will need to recruit and retain professional staff who typically require higher levels of pay than paraprofessionals in order to obtain—or maintain—Medicaid certification. Yet, access to capital to make such staffing upgrades may be limited in the SUD treatment system, especially among providers reliant on public grants. Moreover, workforce shortages, recruitment, (p. 136) and retention of staff have been long-standing workforce challenges in the SUD treatment system (SAMHSA, 2013b).

ACA Provisions to Promote Service Integration

Historically, SUD treatment has been provided in specialized settings separate from other general and mental health services. While distinctions between the two arenas of physical and behavioral health have allowed SUD treatment facilities to maintain focus on the specialized needs of individuals with SUD, the current system has faced major challenges in addressing the needs of people with co-occurring and other chronic health conditions. Often these facilities attempt managing one primary condition (i.e., substance use) while the symptoms of other conditions (e.g., depression, anxiety, PTSD) go unaddressed. As a result, co-occurring conditions go untreated, or patients are forced to seek care from multiple physicians and/or facilities. This can lead to poor care coordination, conflicting and poorly managed treatment plans, increasingly negative treatment outcomes, and higher costs. In response to these concerns, several provisions of the ACA were designed to encourage the integration of behavioral and physical healthcare.

According to SAMHSA, integrated care is the most effective approach to providing the best outcomes for patients with multiple healthcare needs. The Agency for Healthcare Research and Quality (2013) defines behavioral health integration as

care resulting from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization. (p. 15)

The ACA attempts to encourage improved service integration by expanding coverage provisions for SUD screening, treatment, and prevention in general medical care settings, as well as by providing financial incentives to promote care coordination and integration within Medicaid.

The push for integrated care models under the ACA is especially relevant considering approximately two-thirds of individuals entering SUD treatment had a co-occurring mental health problem in the past year, with emerging adults at the greatest level of risk (Chan, Dennis, & Funk, 2008). In addition, it has been well established that physical and behavioral health conditions have high rates of co-occurrence (ABHW, 2015). In fact, unmet behavioral health needs are often cited as a major driver of complicating medical treatments for practitioners and have been associated with less desirable patient outcomes due to low treatment adherence and unaddressed behavioral health needs (Burnam & Watkins, 2006). For (p. 137) example, persons diagnosed with SUD are roughly twice as likely to suffer from mood and anxiety disorders (National Institute on Drug Abuse [NIDA], 2008). In addition, circumstances of substance use and related high-risk behaviors may put individuals at increased risk for trauma and other adverse health conditions. One study found rates of co-occurring PTSD and SUD as high as 43% among individuals in inpatient drug treatment, with higher incidences of sexual abuse, physical abuse, and rape (Meisler, 1996). Individuals are also at increased risk for a large range of physical health issues related to substance use, such as cardiomyopathy, gastritis, liver disease, and pneumonia (ABHW, 2015). Thus, providing integrated care is a key step in meeting the complex behavioral, mental, and primary healthcare needs of individuals with SUD.

In addition to improving care coordination for individuals with co-occurring conditions, health service integration has the potential to reduce several barriers to SUD treatment. First, increased integration has the potential to increase prevention, screening, assessment, and referral practices in general healthcare settings such as the emergency department and primary care, as well as within the community, through schools and other related programs with the potential to reach emerging adults. This may be especially important among emerging adults, who are less likely to have a regular source of care than persons from other age groups (McLellan & Meyers, 2004). Second, integration may help reduce the stigma associated with SUD. As it commonly occurs now, SUD treatment provided in specialty settings is cut off from general healthcare, suggesting it is somehow different than other health issues. Emerging adults may be particularly sensitive to the stigma associated with substance use treatment because of the normalization of substance use in social settings. One study, for example, found college students have some of the highest prevalence rates for SUD and also the lowest treatment rates (Blanco et al., 2008). Thus, the integration of SUD screening and treatment services within settings more commonly frequented by emerging adults could prove instrumental to increasing SUD treatment access and retention.

Care Coordination and Value-Based Purchasing Models

The ACA includes two major provisions designed to enhance care coordination and improve integration of primary care and behavioral health services. First, it establishes a new Medicaid option to establish health homes for enrollees with complex healthcare needs. Established under Section 2703 of the Affordable Care Act of 2010, the Medicaid Health Home (HH) program enables states to contract with designated healthcare providers or teams of providers to provide comprehensive, coordinated healthcare to select enrollees with chronic conditions (CMS, 2016e). The aim of health homes is to improve healthcare quality, clinical outcomes, and patient care experience, while also reducing per capita costs through cost-effective services. Health homes are required to offer a range of services, including comprehensive care management; care coordination and health promotion; transition care from inpatient to other care settings; individual and family (p. 138) support; referral to community and social support services; and use of health information technology to link services. To encourage take-up of the option, the ACA authorizes a 90% enhanced federal medical assistance percentage rate for the first 2 years that a state’s Medicaid health home state plan amendment is in effect. At present, 19 states and the District of Columbia have implemented health homes within their Medicaid programs, for a total of 28 approved Medicaid health home models (CMS, 2016a).

Second, through the ACA-established CMS Innovation Center, two demonstration projects are testing the effectiveness of primary care medical home (PCMH) models. The Federally Qualified Health Center (FHQC) Advanced Primary Care Demonstration Project enables interdisciplinary teams working within FHQCs to provide coordinated health services to patients in their care. The Multi-Payer Advanced Primary Care Practice Demonstration is funding eight state-led initiatives that include Medicaid, as well as substantial participation by Medicare and private health insurers. The demonstration program will pay a monthly care management fee for beneficiaries receiving primary care from advanced primary care (APC) practices. The care management fee is intended to cover care coordination, improved access, patient education, and other services to support chronically ill patients. These models may hold special promise for the treatment of emerging adults, who have high rates of co-occurring mental health and substance use disorders and have less experience navigating the healthcare system than other adults.

Promoting SUD Services in Non-Specialty Healthcare Settings

In addition to the many improvements in specialized SUD treatment, the ACA improves coverage for SUD treatment services that can be provided in non-specialty medical care settings, thus providing new incentives for programs that offer SUD screening, treatment, and prevention. As of January 1, 2013, per Section 4106 of the ACA, states can receive a one percentage point increase in their federal Medicaid match rate for preventive services if they cover, without cost-sharing, all the adult preventive services recommended by the federally convened U.S. Preventive Services Task Force and Centers for Disease Control, and Prevention’s Advisory Committee on Immunization Practices (Kaiser Family Foundation, 2014). These preventative services include counseling for nicotine and alcohol use, which may be of particular importance among emerging adults, especially those in college (Monaghan, 2014). In addition, the ACA requires mandatory coverage by Medicaid for tobacco cessation treatment, including both counseling and medication, for pregnant women. Finally, the ACA disallows private insurance plans that cover SUD-related preventative services to require patient cost-sharing. Taken together, these changes help to increase emerging adults’ access to SUD treatment and other related services by addressing some of the barriers related to access, availability, and convenience of services.

(p. 139) As a consequence of these changes, SUD treatment provided outside of specialty settings is expected to increase its share of all SUD treatment from 15% to 19% from 2009 to 2020. These changes are likely to be driven by the expansion of private insurance and Medicaid coverage, the main payers for office-based treatment (SAMHSA, 2014a). Specialty SUD treatment centers are expected to reduce their market share from 42% to 37% from 2009 to 2020, given that many of these specialty providers do not currently have the capacity to accept Medicaid and insurance payment and have had a legacy of treating those without insurance through other funding sources such as block grants and state and local funding (SAMHSA, 2014a). Hospital-based SUD treatment accounted for approximately 31% of spending and is expected to remain at similar levels in 2020 (SAMHSA, 2014a).


Emerging adults are at the greatest risk of developing SUD but are least likely to receive SUD treatment. High rates of uninsurance among this population contribute to this problem; inability to pay is the most cited reason for failure to receive treatment. The ACA has paved the way toward real solutions to these problems as more emerging adults become eligible for healthcare coverage, and more insurers are required to cover SUD treatment at parity with other health services. Some major accomplishments are already evident, as uninsurance among emerging adults has fallen 14% just 1 year after implementations of the dependent coverage provision. Moreover, the expansion of Medicaid eligibility and creation of insurance marketplace exchanges have the potential to extend insurance to over 80% of emerging adults. These coverage expansions have proven instrumental in addressing SUD treatment need among emerging adults, as fewer are citing cost as a major barrier to receiving SUD treatment. However, ensuring treatment access will require an increase in treatment providers who accept public and private insurance, and better coordination and integration of health and behavioral services. The ACA holds the potential to improve integration of SUD treatment with mainstream medical care, but whether the promise of reform becomes reality remains to be seen.

The ACA has already improved the accessibility and quality of SUD treatment for emerging adults in the United States and, barring any major changes, is expected to continue to do so in the years ahead. However, many emerging adults lack awareness of their options for insurance coverage, indicating that outreach and education will also be key to continued progress. Even more critical, however, is the refusal by some state governments to expand Medicaid. With almost 30% of emerging adults living in poverty, those who live in non-expansion states will remain ineligible for Medicaid and subsidized private plans through insurance exchanges (Collins et al., 2013). Thus, improving treatment access brings continuing challenges for implementation of the ACA, including variations in SUD treatment supply, access, and quality, and the persistent sociodemographic barriers and disparities.


Abraham, A. J., Knudsen, H. K., Rieckmann, T., & Roman, P. M. (2013). Disparities in access to physicians and medications for the treatment of substance use disorders between publicly and privately funded treatment programs in the United States. Journal of Studies on Alcohol and Drugs, 74, 258–265.Find this resource:

Agency for Healthcare Research and Quality. (2013). Lexicon for Behavioral Health and Primary Care Integration (AHRQ Publication No. AHRQ 13-IP001-EF). Rockville, MD.Find this resource:

Ali, M., Teich, J., Woodward, A., & Han, B. (2016). The implications of the Affordable Care Act for behavioral health services utilization. Administration & Policy in Mental Health & Mental Health Services Research,43(1), 11–22.Find this resource:

Andrews, C. M. (2014). The relationship of state Medicaid coverage to Medicaid acceptance among substance abuse treatment providers in the United States. Journal of Behavioral Health Services and Research, 41(4), 460–472.Find this resource:

Andrews, C., Abraham, A., Grogan, C. M., Pollack, H. A., Bersamira, C., Humphreys, K., & Friedmann, P. (2015). Despite resources from the ACA, most states do little to help addiction treatment programs implement health care reform. Health Affairs, 34(5), 828–835.Find this resource:

Andrews, C., Grogan, C. M., Brennan, M., & Pollack, H. A. (2015). Lessons from Medicaid’s divergent paths on mental health and addiction services. Health Affairs, 34(7), 1131–1138.Find this resource:

Andrews, C. M., Guerrero, E. G., Wooten, N. R., & Legnick-Hall, R. (2015). The Medicaid expansion gap and racial and ethnic minorities with substance use disorders. American Journal of Public Health,105(S3), S452–S454.Find this resource:

Association for Behavioral Health and Wellness. (2015). Healthcare integration in the era of the Affordable Care Act. Retrieved from

Baser, O., Chalk, M., Rawson, R., & Gastfriend, D. R. (2011). Alcohol dependence treatments: Comprehensive healthcare costs, utilization outcomes, and pharmacotherapy persistence. American Journal of Managed Care, 17(8), 222–234.Find this resource:

Beronio, K., Glied, S., Po, R., & Skopec, L. (2013). Affordable Care Act will expand mental health and substance use disorder benefits and parity protections for 62 million Americans. Retrieved from

Beronio, K., Glied, S., & Frank, R. (2014). How the Affordable Care Act and Mental Health Parity and Addiction Equity Act greatly expand coverage of behavioral health care. Journal of Behavioral Health Services & Research, 41(4), 410–428.Find this resource:

Blanco, C., Okuda, M., Wright, C., Hasin, D. S., Grant, B. F., Liu, S., & Olfson, M. (2008). Mental health of college students and their non-college-attending peers. Archives of General Psychiatry, 65(12), 1429–1437.Find this resource:

Bouchery, E. E., Harwood, H. J., Dilonardo, J., & Vandivort-Warren, R. (2012). Type of health insurance and the substance abuse treatment gap. Journal of Substance Abuse Treatment, 42(3), 289–300.Find this resource:

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.Find this resource:

(p. 141) Burnam, M. A., & Watkins, K. E. (2006). Substance abuse with mental health disorders: Specialized public systems and integrated care. Health Affairs, 25(3), 648–658.Find this resource:

Busch, S. H., Epstein, A. J., Harhay, M. O., Fiellin, D. A., Un, H., Leader Jr., D., & Barry, C. L. (2014). The effects of federal parity on substance use disorder treatment. American Journal of Managed Care, 20(1), 76–82.Find this resource:

Busch, S. H., Meara, E., Huskamp, H. A., & Barry, C. L. (2013). Characteristics of adults with substance use disorders expected to be eligible for Medicaid under the ACA. Psychiatric Services, 64(6), 520–526.Find this resource:

Callahan, J. J., Shepard, D. S., Beinecke, R. H., Larson, M. J., & Cavanaugh, D. (1995). Mental health/substance abuse treatment in managed care: The Massachusetts Medicaid experience. Health Affairs, 14(3), 173–184.Find this resource:

Centers for Medicare & Medicaid Services. (2005). Medicaid at-a-glance, 2005. Retrieved from

Centers for Medicare & Medicaid Services. (2016a). Approved Medicaid health home state plan amendments. Retrieved from

Centers for Medicare & Medicaid Services. (2016b). Behavioral health services. Retrieved from

Centers for Medicare & Medicaid Services. (2016c). Benchmark services. Retrieved from

Centers for Medicare & Medicaid Services. (2016d). Medicaid & CHIP: March 2016 monthly applications, eligibility determinations and enrollment report, May 25, 2016. Retrieved from

Centers for Medicare & Medicaid Services. (2016e). Medicaid health homes: An overview. Retrieved from

Centers for Medicare & Medicaid Services. (2016f). Young adults and the Affordable Care Act: Protecting young adults and eliminating burdens on families and businesses. Retrieved from

Chan, Y. F., Dennis, M. L., & Funk, R. R. (2008). Prevalence and comorbidity of major internalizing and externalizing problems among adolescents and adults presenting to substance abuse treatment. Journal of substance abuse treatment, 34(1), 14–24.Find this resource:

Chuang, E., Wells, R., & Alexander, J. A. (2011). Public managed care and services access in outpatient substance abuse treatment units. Journal of Behavioral Health Services and Research, 38(4), 444–463.Find this resource:

Collins, S. R., Gunja, M., Doty, M. M., & Beutel, S. (2015). To enroll or not to enroll? Why many American have gained insurance under the Affordable Care Act (Issue Brief). Retrieved from

(p. 142) Collins, S. R., Gunja, M., Rasmussen, P. W., Doty, M. M., & Beutel, S. (2015). Are marketplace plans affordable? Perspectives from the Commonwealth Fund Affordable Care Act Tracking Survey, March–May 2015 (Issue Brief). Retrieved from

Collins, S. R., & Nicholson, J. L. (2010). Rite of passage: Young adults and the Affordable Care Act of 2010 (Issue Brief). Retrieved from

Collins, S. R., Rasmussen, P. W., Garber, T., & Doty, M. M. (2013). Covering young adults under the Affordable Care Act: The importance of outreach and Medicaid expansion (Issue Brief). Retrieved from

Coughlin, T. A., & Zuckerman, S. (2002). States use of Medicaid maximization strategies to tap federal revenues: Program implications and consequences. Retrieved from

Cowell, A., McCarty, D., & Woodward, A. (2003). Impact of federal substance abuse block grants on state substance abuse spending: Literature and data review. Journal of Mental Health Policy and Economics, 6(4), 173–180.Find this resource:

Deck, D. D., McFarland, B. H., Titus, J. M., Laws, K. E., & Gabriel, R. M. (2000). Access to substance abuse treatment services under the Oregon Health Plan. Journal of the American Medical Association, 284(16), 2093–2099.Find this resource:

Ducharme, L. J., Mello, H. L., Roman, P. M., Knudsen, H. K., & Johnson, A. J. (2007). Service delivery in substance abuse treatment: Reexamining “comprehensive” care. Journal of Behavioral Health Services & Research, 34(2), 121–136.Find this resource:

Ettner, S. L., Denmead, G., Dilonardo, J., Cao, H., & Belanger, A. J. (2003). The impact of managed care on substance abuse treatment patterns and outcomes of Medicaid beneficiaries: Maryland’s health choice program. Journal of Behavioral Health Services & Research, 31(1), 41–62.Find this resource:

Frank, R. G., Beronio, K., & Glied, S. A. (2014). Behavioral health parity and the Affordable Care Act. Journal of Social Work in Disability & Rehabilitation, 13, 31–43. doi: 10.1080/1536710X.2013.870512Find this resource:

Frank, R. G., McGuire, T. G., Regier, D. A., Manderscheid, R., & Woodward, A. (1994). Paying for mental health and substance abuse care. Health Affairs, 13(1), 337–342.Find this resource:

Gabel, J. R., Whitmore, H., Pickreign, J. D., Levit, K. R., Coffey, R. M., & Vandivort-Warren, R. (2007). Substance abuse benefits: Still limited after all these years. Health Affairs, 26(4), w474–w482. doi: 10.1377/hlthaff.26.4.w474Find this resource:

Gallup. (2011, September). In U.S. significantly fewer 18- to 25-year-olds uninsured. Retrieved from

Gallup. (2016, April). U.S. uninsured rate at 11.0%, lowest in eight-year trend. Retrieved from

Garfield, R., Damico, G., Cox, C., Claxton, G., & Levitt, L. (October, 2015). New estimates of eligibility for ACA coverage among the uninsured. Retrieved from (p. 143)

Garfield, R. L., Lave, J. R., & Donohue, J. M. (2010). Health reform and the scope of benefits for mental health and substance use disorders. Psychiatric Services, 61(11), 1081–1086.Find this resource:

Gresenz, C. R., Watkins, K., & Podus, D. (1998). Supplemental security income, disability insurance, and substance abusers. Community Mental Health Journal, 34(4), 337–350. doi: 10.1023/A:1018779805833Find this resource:

Grogan, C. M., Andrews, C. M., Abraham, A. J., Pollack, H. A., Humphreys, K. N., Smith, B., & Friedmann, P. D. (2017). State Medicaid coverage and limits for substance use disorder treatment services. Manuscript in preparation.Find this resource:

Hodgkin, D., Horgan, C. M., Garnick, D. W., & Merrick, E. L. (2009). Benefit limits for behavioral health care in private health plans. Administration and Policy in Mental Health and Mental Health Services Research, 36(1), 15–23. doi: 10.1007/s10488-008-0196-5Find this resource:

Hodgkin, D., Shepard, D. S., Anthony, Y. E., & Strickler, G. K. (2004). A publicly managed Medicaid substance abuse carve-out: Effects on spending and utilization. Administration and Policy in Mental Health and Mental Health Services Research, 31(3), 197–217.Find this resource:

Humphreys, K., & Frank, R. G. (2014). The Affordable Care Act will revolutionize care for substance use disorders in the United States. Addiction, 109(12), 1957–1958. doi: 10.1111/add.12606Find this resource:

Humphreys, K., & McLellan, T. A. (2011). A policy-oriented review of strategies for improving the outcomes of services for substance use disorder patients. Addiction, 106(12), 2058–2066.Find this resource:

Institute of Medicine. (1996). Managed care. In Pathways of addiction: Opportunities in drug abuse research (pp. 222–249). Washington, DC: National Academies Press.Find this resource:

Kaiser Family Foundation. (July, 2012). A guide to the Supreme Court’s Affordable Care Act decision. Retrieved from

Kaiser Family Foundation. (November, 2014). Appendix A: ACA Section 4106 increase in FMAP for coverage of preventive services in Medicaid. Retrieved from

Kaiser Family Foundation. (2015). 2015 Employer Health Benefits Survey Section Thirteen: Grandfathered health plans. Retrieved from

Kenney, G. M., Lynch, V., Haley, J., & Huntress, M. (2012). Variation in Medicaid eligibility and participation among adults: Implications for the Affordable Care Act. Inquiry, 49, 231–253.Find this resource:

Knudsen, H. K., Oser, C. B., Abraham, A. J. & Roman, P. M. (2012). Physicians in substance abuse treatment workforce: Understanding their employment within publicly funded treatment organizations. Journal of Substance Abuse Treatment, 43(2), 152–160.Find this resource:

Lemak, C. H., & Alexander, J. A. (2001). Managed care and outpatient substance abuse treatment intensity. Journal of Behavioral Health Services & Research, 28(1), 12–29. doi: 10.1007/BF02287231Find this resource:

(p. 144) Levit, K. R., Kassed, C. A., Coffey, R. M., Mark, T. L., Stranges, E. M., Buck, J. A., & Vandivort-Warren, R. (2008). Future funding for mental health and substance abuse: Increasing burdens for the public sector. Health Affairs, 27(6), w513–w522.Find this resource:

Maglione, M., & Ridgely, M. S. (2006). Is conventional wisdom wrong? Coverage for substance abuse treatment under Medicaid managed care. Journal of Substance Abuse Treatment, 30(4), 285–290.Find this resource:

Mark, T. L., & Coffey, R. M. (2004). The decline in receipt of substance abuse treatment by the privately insured, 1992–2001. Health Affairs, 23(6), 157–162.Find this resource:

Mark, T. L., Coffey, R. M., King, E., Harwood, H., McKusick, D., Genuardi, J., . . . Buck, J. A. (2000). Spending on mental health and substance abuse treatment, 1987–1997. Health Affairs, 19(4), 108–120.Find this resource:

Mark, T. L., Levit, K. R., Vandivort-Warren, R., Coffey, R. M., Buck, J. A., & SAMHSA Spending Estimates Team. (2007). Trends in spending for substance abuse treatment, 1986–2003. Health Affairs (Project Hope), 26(4), 1118–1128.Find this resource:

Mark, T. L., Levit, K. R., Vandivort-Warren, R., Buck, J. A., & Coffey, R. M. (2011). Changes in US spending on mental health and substance abuse treatment, 1986–2005, and implications for policy. Health Affairs, 30(2), 284–292.Find this resource:

Mark, T. L., & Vandivort-Warren, R. (2012). Spending trends on substance abuse treatment under private employer-sponsored insurance, 2001–2009. Drug and Alcohol Dependence, 125, 203–207. doi: 10.1016/j.drugalcdep.2012.02.013Find this resource:

McAuliffe, W. E., LaBrie, R., Woodworth, R., Zhang, C., & Dunn, R. P. (2003). State substance abuse treatment gaps. American Academy of Addiction Psychiatry, 12(2), 101–121.Find this resource:

McCarty, D., & Argeriou, M. (2003). The Iowa Managed Substance Abuse Care Plan: Access, utilization, and expenditures for Medicaid recipients. Journal of Behavioral Health Services & Research, 30(1), 18–25.Find this resource:

McLellan, A. T., Carise, D., & Kleber, H. D. (2003). Can the national addiction treatment infrastructure support the public’s demand for quality care? Journal of Substance Abuse Treatment, 25(2), 117–121.Find this resource:

McLellan, A. T., Lewis, D. C., O’Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic mental illness implication for treatment, insurance, and outcomes evaluation. Journal of the American Medical Association, 284(13), 1689–1695.Find this resource:

McLellan, A. T., McKay, J. R., Forman, R., Cacciola, J., & Kemp, J. (2004). Reconsidering the evaluation of addiction treatment: From retrospective follow-up to concurrent recovery monitoring. Addiction, 100, 447–458.Find this resource:

McLellan, A. T., & Meyers, K. (2004). Contemporary addiction treatment: A review of systems problems for adults and adolescents. Biological Psychiatry, 56(10), 764–770.Find this resource:

McLellan, A. T., & Woodworth, A. M. (2014). The Affordable Care Act and treatment for “substance use disorders:” Implication of ending segregated behavioral health care. Journal of Substance Abuse Treatment, 46(5), 541–545.Find this resource:

Mechanic, D. (2012). Seizing opportunities under the affordable care act for transforming the mental and behavioral health system. Health Affairs, 31(2), 376–382.Find this resource:

Meisler, A. W. (1996). Trauma, PTSD, and substance abuse. White River Junction, VT: National Center for PTSD. Retrieved from this resource:

Monaghan, M. (2014). The Affordable Care Act and implications for young adult health. Translational Behavioral Medicine, 4(2), 170–174.Find this resource:

(p. 145) Mulvey, K. P., Hubbard, S., & Hayashi, S. W. (2003). A national study of the substance abuse treatment workforce. Journal of Substance Abuse Treatment, 24(1), 51–57.Find this resource:

National Association of State Alcohol and Drug Abuse Directors. (2016, February). NASADAD fact sheet: Substance Abuse Prevention and Treatment (SAPT) block grant. Retrieved from

National Institute on Drug Abuse. (2008). Research Report Series: Comorbidity: Addiction and other mental illnesses (NIH Publication Number: 10-5771). Retrieved from

Open Society Foundations. (2010). Defining the addiction treatment gap. Retrieved from

Pickens, G., Dunn, D., & Glebe, T. (2012). Medicaid expansion: Profiling the future Medicaid eligible population. Retrieved from

Ridic, G., Gleason, S., & Ridic, O. (2012). Comparisons of health care systems in the United States, Germany, and Canada. Materia Socio-Medica, 24(2), 112–120.Find this resource:

Rogowski, J. A. (1992). Insurance coverage for drug abuse. Health Affairs, 11(3), 137–148.Find this resource:

Rowan, K., McAlpine, D. D., & Blewett, L. A. (2013). Access and cost barriers to mental health care by insurance status, 1999–2010. Health Affairs, 32(10), 1723–1730.Find this resource:

Saloner, B., Antwi, Y. A., Maclean, J. C., & Le Cook, B. (2015). Access to health insurance and utilization of public sector substance use treatment: Evidence from the Affordable Care Act dependent coverage provision. Unpublished manuscript, Department of Economics, Temple University, Philadelphia, Pennsylvania.Find this resource:

Scott, J. E., Greenberg, D., & Pizarro, J. (1992). A survey of state insurance mandates covering alcohol and other drug treatment. Journal of Mental Health Administration, 19(1), 96–118.Find this resource:

Sosin, M. R. (2002). Negotiating case decisions in substance abuse managed care. Journal of Health and Social Behavior, 43(3), 277–295.Find this resource:

Stewart, M. T., & Horgan, C. M. (2011). Health services and financing of treatment. Alcohol Research and Health, 33(4), 389.Find this resource:

Substance Abuse and Mental Health Services Administration. (2009). State inventory of Medicaid MHSUD services 2009. Rockville, MD: Author. Retrieved from:

Substance Abuse and Mental Health Services Administration. (2012a). National Survey of Substance Abuse Treatment Services (N-SSATS): 2012. Retrieved from

Substance Abuse and Mental Health Services Administration. (2012b). Results from the 2010 National Survey on Drug Use and Health: Detailed tables. Retrieved from

Substance Abuse and Mental Health Services Administration. (2012c). Results from the 2010 National Survey on Drug Use and Health, Volume 1: Summary of national findings (HHS Publication No. SMA 11-4658). Rockville, MD: Author.Find this resource:

Substance Abuse and Mental Health Services Administration. (2013a). National expenditures for mental health services and substance abuse treatment, 1986–2009 (HHS Publication No. SMA-13-4740). Rockville, MD: Author.Find this resource:

(p. 146) Substance Abuse and Mental Health Services Administration. (2013b). Report to Congress on the Nation’s Substance Abuse and Mental Health Workforce Issues. Retrieved from:

Substance Abuse and Mental Health Services Administration. (2014a). Projections of national expenditures for treatment of mental and substance use disorders, 2010–2020 (HHS Publication No. SMA-14-4883). Rockville, MD: Author.Find this resource:

Substance Abuse and Mental Health Services Administration. (2014b). The NSDUH Report: Substance use and mental health estimates from the 2013 National Survey on Drug Use and Health: Overview of findings. Retrieved from

Substance Abuse and Mental Health Services Administration. (2015). The CBHSQ Report: State Participation in the Medicaid Expansion Provision of the Affordable Care Act: Implications for uninsured individuals with a behavioral health condition. Retrieved from

Swartz, J. A., Lurigio, A. J., & Goldstein, P. (2000). Severe mental illness and substance use disorders among former Supplemental Security Income beneficiaries for drug addiction and alcoholism. Archives of General Psychiatry, 57(7), 701–707.Find this resource:

Terry-McElrath, Y. M., Chriqui, J. F., & McBride, D. C. (2011). Factors related to Medicaid payment acceptance at outpatient substance abuse treatment programs. Health Services Research, 46(2), 632–653.Find this resource:

United States Government Publishing Office. (2017). Subpart L—Substance Abuse Prevention and Treatment block grant [data file]. Retrieved from

Volkow, N. D., Frieden, T. R., Hyde, P. S., & Cha, S. S. (2014). Medication-assisted therapies—tackling the opioid-overdose epidemic. New England Journal of Medicine, 370, 2063–2066.Find this resource: