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Unintended Consequences of the ACA – Workforce Development Issues in Addiction Treatment Services

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healthcare on January 23, 2014 - 3:31 pm in Column – New

Unintended Consequences

“For every action, there is an equal yet opposite reaction.”  This phrase from Newton’s Third Law of Motion aptly labels how I see the future state of affairs in the health care field as a result of health care reform.  As we are well aware, in 2010 President Obama signed into law the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (together referred to as the Affordable Care Act) making health insurance coverage more affordable and available for individuals, families, and the owners of small businesses.  This new law, recently affirmed by the Supreme Court, not only makes affordable healthcare available to more individuals, but it shifts treatment models from their current, individualized treatment modalities, to that of an integrated model of care.  Models such as “health homes” and “accountable care organizations” are envisioned as providing individuals with coordinated care across the health disciplines.  Health IT enhances this model through the creation of local, state and federal “health information exchanges”, digitally linking a person’s health record to all of their health care providers as well as emergency room personnel, thus allowing for proper, timely, integrated care.

The federal government, through the ACA, has tasked agencies to put into place protocols and funding to expand medical coverage to all Americans.  An increase in Medicaid matching funds from the federal government allows States to increase their funding levels of Medicaid benefits.  In the state of Maryland it is projected that by 2020 roughly 360,000 newly insured individuals will be utilizing primary care services.

In Maryland’s report “Preparing Maryland’s Workforce for Health Reform: Health Care 2020” Lieutenant Governor Anthony Brown wrote: “”Since taking office in 2007, we have expanded access to coverage for 290,000 uninsured Marylanders. … Federal health care reform will cut the number of uninsured by half.”  The federally mandated creation of health insurance exchanges (to be functional in each state by 2014) will further enable individuals to access affordable health insurance through a public exchange of carriers and benefits.

Assuming full implementation of the ACA as intended, Americans will have access to quality, integrated health care at affordable prices.  So why the Newton quote above?  Let me be clear that my intent in this article is not to debate the ACA or its intended benefits.  I am writing as an advocate and clinician in the addiction field for almost 20 years.  It is important that as we tout and celebrate the benefits of reform that we also recognize and acknowledge unintended consequences stemming from these changes.  Pointing out these unintended consequences does not nullify the need or opportunity for change; rather, it enhances the effects of the change if we work to improve the unintended consequences of the change.  Over the years my patients and clients have taught me that change, although positive, comes with a price.  The concept of change generally implies doing or being something different; consequently, the loss of what we used to do or used to have.  Giving up anything, even if it is for the better, invokes in us a grief/loss response.  The ACA, for all of its benefits, shifts treatment modalities and paradigms.  The loss of the “but we’ve always done it that way” can be overcome, but not if we don’t acknowledge it and work toward solutions for these unintended consequences.

Paradigm Shift

I have been an addiction counselor (case manager and administrator) for almost twenty years now, and in that time I have seen many changes in the field resulting in positive outcomes for our clientele.  But if I look further back in the history of the addiction field, the impact of change from the 1950s to the present is enormous!  But still, change doesn’t come easy to a field which has had to struggle to become recognized and respected.  Historically speaking, the field of addiction counseling was, and to some degree still is, looked upon as a step-child to the more noble and professional field of psychotherapy.  Unfortunately, that impression is part of our doing.  Many in the field of addiction counseling were recovering individuals who wanted to “give back,” and help others attain a life of recovery they themselves enjoy.  There is nothing wrong with this, and in my time as a clinical director I was privileged to work with many a gifted counselor.  The issue, though, is until recently (last decade or so) many of these counselors were not required to be certified or licensed by a professional board.  That piece of paper does not necessarily produce an effective counselor, but it does change that person’s status in the eyes of counselors who are certified or licensed.

The addiction counseling field has primarily been a field unto its own, operating independent of the mental health and medical fields.  That is not to say case managers did not refer their patients to ancillary services, but due to federal confidentiality laws and the nature of anonymity by those in recovery, treatment was contained to the treatment facility.  Prior to 2008 and the passage of the “Mental Health Parity and Addiction Equity Act”, many insurance plans restricted their coverage of benefits from addiction services, or, if they covered addiction treatment, placed many barriers in the way of reimbursement.  Now that Parity is enacted, insurance benefits for addiction treatment services must mirror those offered on the medical or mental health services.  This has, positively, opened the way for covered services and more individuals receiving needed treatment.

Now that the ACA has been enacted, the addiction treatment field once again encounters change.  As the ACA insures more individuals, and more insurance plans are covering treatment, greater numbers of people now have access to treatment services.  I mention this very brief history to help us understand the enormity of the paradigm shift for the addiction treatment field.

Be careful what you ask for…

The positive outcomes of the ACA, i.e. increased numbers of individuals with benefits, increased funding and access to Medicaid, and insurance parity needs to be balanced by some of the unintended consequences.  Work force issues, along with budgetary concerns, are among the greatest unintended consequences needing to be addressed.  “Our nationwide shortage of mental health professionals significantly impacts access to needed mental health treatment and contributes to inadequate care and unsafe conditions. ”  Currently, “55 percent of U.S. counties have no practicing psychiatrists, psychologists or social workers. ”  Full implantation of the ACA will greatly increase the amount of individuals seeking services from a service industry already in short supply of quality health care professionals.  Maryland has formed the “Governor’s Workforce Investment Board” which is designed to increase the primary care workforce 10 to 25 percent over a 10 year period.  A noble goal, but increasing the work force also involves changes in training, licensure, and reimbursable rates.

Traditionally addiction treatment facilities were funded by block grants from both the federal and state governments.  The addition of parity and increased funding for Medicaid has caused many locales to shift monies from the block grants to Medicaid where the federal government matches dollar for dollar.  The rationale, besides the obvious budget increase, is that since more people are now eligible for Medicaid, and facilities can bill Medicaid, there is no longer a need for the block grants.  I will not debate this issue, but this shift in funding presupposes the treatment facilities have back-office support for the increased paperwork.  Also, with a block grant, yearly budgeting is consistent, while changing operations to a fee-for-service billing plan complicates the budget process, and in the end facilities may lose money.  Medicaid does not reimburse for all services offered by the facilities, and obviously you cannot bill for missed appointments.  Facilities will either have to merge with other health care facilities or cease operations.

Many in the health care work force and psychological services do not join, or consider becoming a part of, the addiction treatment field for a variety of reasons.  Clients in need of addiction services tend to have complex conditions such as co-occurring mental health and substance use disorders, co-morbid medical conditions, and criminal justice involvement.  These conditions place exceptional demands on the substance use disorder treatment workforce.  Salary is another impediment for those who wish to become an addiction counselor.  “A direct care worker in a 24-hour residential treatment center has a lower median salary than an assistant manager at Burger King ($23,000 vs. $25,589); a social worker with a master’s degree employed in a mental health-addictions treatment organization earns less than a peer at a general healthcare agency ($45,344 vs. $50,470); a registered nurse working in behavioral health earns less than the national average for nurses ($42,987 vs. $66,530) ”  Medicaid and insurance benefits may not be sufficient to cover the budgetary expenses of facilities, thereby keeping these salaries low.

To fully implement the ACA, shifting the paradigm from individualized treatment to an integrated model of care is not only beneficial to the patient, but by combining resources of the addiction, mental health and medical fields, budgetary concerns may to varying degrees be alleviated.  The pressing issue in an integrated care model is that of training.  Traditionally, addiction counselors’ training lacks but the basics of psychotherapy techniques, while the psychologist/social workers’ training lacks but the basics of addiction treatment.  Since most addiction counselors have worked in grant-funded facilities, they also lack the training and skills needed for properly completing insurance reimbursement forms, as well as a lack of the knowledge of proper chart documentation to satisfy the needs of insurance protocols.  State licensing boards will need to address these concerns as they investigate ways of combining training, education, and licensure.

Next Steps

As previously stated, this piece is not meant to be a barrier, or rationale, for not fully implementing ACA and parity.  Rather, to bring to the fore those areas wherein further study and creative solutions will produce benefits for patients and practitioners alike.  I believe that if the following action steps are taken, many of the unintended consequences of the ACA will be alleviated.

  1. Strategic planning for results.  In a collegial and collaborative manner, honesty discuss the barriers to full implementation of the ACA with the goal of practice and effective solutions.
  2. Ensuring reimbursement structures and schedules are in parity while examining current fees and cost structures.
  3. Financial incentives to encourage people to enter the addiction counseling field such as tuition breaks, tax breaks, or loan forgiveness plans.
  4. Educational cross training is needed for both the addiction treatment and mental health fields in the most recent effective evidence-based interventions and prevention models.
  5. Partnerships are needed with universities, hospitals, licensing boards and professional organizations to coordinate the education needs and on-going training of the professional and administrative staffs.

1.  Maryland Health Care Reform Coordinating Council (July 2010). An Interim Report: Appendix F. Retrieved from http://dhmh. maryland.gov/healthreform/ pdf/100726appendixf.pdf

2.  U.S. Department of Health & Human Services, Health Resources and Services Administration (HRSA), Designated Health Professional Shortage Areas (HPSA) Statistics. September 3, 2010. Web. September 4, 2010.

3.  Clark, Westley H., J.D. M.P.H., CAS, FASAM, SAMHSA Strategic Initiatives: Behavioral Health Workforce and Health IT, NASADA/NPN/NTN Annual Meeting. Norfolk, VA. June 3, 2010.

4.  Workforce Issues:  Integrating Substance Abuse Services into Primary Care Summit; Office of National Drug Control Policy  (ONDCP), the
Substance Abuse and Mental Health Services Administration (SAMHSA),  and the Health Resources  and Services  Administration (HRSA).  August 10-11, 2011 in Washington, D.C.


About The Author

Christopher Shea is a nationally and state certified addiction counselor in Maryland.  Shea has worked as a counselor, case manager, clinical director and administrator.  Shea presents seminars and trainings across the country to clinicians, and is published in medical and peer-reviewed journals. Shea is also an adjunct professor at Towson University.

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