(e.g., number of visits per year) as long as the
caps are equivalent to those placed on medical
services.^163 Placing blanket limitations on
allowed visits or length of stay, however, does
not accord with best practices for treating cases
of addiction that are chronic and relapsing.^164
Challenges to implementing MHPAEA in
practice include a lack of education among
medical professionals in how to screen,
intervene and treat addiction and a lack of
addiction physician specialists.^165
With regard to state parity laws, self-insured
employer-sponsored health plans are exempt
from state regulation under the federal
Employee Retirement Income Security Act
(ERISA) of 1974.^166 Furthermore, coverage for
mental health and addiction services varies
dramatically by state, depending on the strength
of the state’s parity law.
With regard to the ACA, despite the
improvements in treatment coverage that will
arise from its passage, many limitations remain
both in policy and practice. Its impact on
treatment access remains to be seen since many
of the provisions of the law have not yet taken
effect. For example, the expansion of Medicaid
as a payer likely will result in reductions in
federal and state grants for residential care
(which is not covered by Medicaid). As a result,
care may transition toward outpatient
treatment^167 which may be inadequate in some
cases, such as for treating patients with more
severe addiction.
Expanding access to insurance is necessary but
alone is not sufficient to expand access to care.
In 2006, Massachusetts enacted health care
reform legislation similar to the ACA which,
among other things, established universal health
insurance through individual mandates to
purchase insurance and government subsidies.^168
In the years following, addiction treatment
admission rates did not increase significantly.
Despite the fact that the total uninsured
population dropped to three percent, a large
number (23-30 percent) of patients with
addiction remained uninsured, either due to non-
compliance with the mandate to obtain
insurance, inability to pay even with subsidies or
logistical barriers such as lack of documentation
or a stable home address. For some of those
who were successful in becoming insured, co-
insurance and co-payments rendered treatment
unaffordable.^169 Furthermore, expanding
insurance coverage does not automatically
translate into expanded screening and diagnosis
by health professionals or capacity to treat large
numbers of newly-insured patients.
Similarly, requiring parity for addiction benefits
in Federal Employee Health Benefit (FEHB)
plans did not result in increased treatment rates.
An analysis of nine large FEHB plans in the two
years before and after the parity requirement
found that the number of new diagnoses of
addiction increased; however,^ utilization rates
for addiction treatment benefits were
unaffected.^170The ACA includes 10 categories of essential
health benefits (EHB)--including addiction
treatment--that must be provided by newly-
created individual and small group plans.^171 Yet
rather than defining what these services must
include, the federal government has proposed
that each state design its own EHB package,* 172
meaning that benefits will vary across states.
Furthermore, the EHB provisions do not apply
to self-insured group health plans, large group
market health plans or already existing small and
individual market (“grandfathered”) health
plans.^173 The provisions that would expand
coverage and require EHBs do not go into effect
until 2014.^174Efforts to control spending and legal challenges
may limit some intended effects of the ACA.
States may respond to fiscal challenges by
attempting to control costs in their Medicaid
programs by cutting services.^175 Moreover, the
ACA faces challenges in the U.S. Supreme* Within limits--the plan must be comparable to a
benchmark plan: (1) the largest plan by enrollment in
any of the three largest small group insurance
products in the state’s small group market; (2) any of
the largest three state employee health benefit plans
by enrollment; (3) any of the largest three national
FEHBP plan options by enrollment; or (4) the largest
insured commercial non-Medicaid HMO operating in
the state.