Poverty and Access to Treatment for Alcohol Use Disorder: The Potential Impact of Health Insurance

Background/Purpose: Approximately 23 million Americans suffer from diagnosable alcohol use disorder (AUD) in a given year and AUD is particularly elevated among those living in poverty. The high cost of AUD treatment and the lack of coverage of AUDs in health insurance plans create significant barriers to accessing effective treatments. The implementation of the Affordable Care Act (ACA) in the United States is expected to increase access to treatment due to its expansion of coverage by including substance use disorders (SUD) along with AUD as one of ten essential health benefits. Moreover, ACA expands coverage for treatment of sub-clinical alcohol problems (e.g. high-risk drinking) and reimburses alcohol treatment provided in general healthcare settings as opposed to only specialty care settings. Longitudinal research on the impact of poverty and health insurance coverage on access to specific types of alcohol treatment is scarce. To address these gaps, we used population-representative data to make inferences about how ACA expansion might reduce income disparities in access to specific types of alcohol treatment.

Methods: We conducted longitudinal analyses of Wave 1 (W1; 2001-2002) and Wave 2 (W2; 2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The sample included 19,709 respondents who were drinking during both W1 and W2. The dependent variable was the type of alcohol treatment received (no treatment, treatment in general medical settings, treatment in specialty addiction settings) during W2. Income was expressed with three groups in an income-to-poverty ratio measuring closeness to the Official Poverty Threshold in 2001 (<100% “poor”, 100-200% “near poor”, or >200% “not poor”). Health insurance was assessed in W1 as private insurance (with or without public insurance), public insurance, and no insurance/uninsured. Multinomial logistic regression examined insurance and poverty status while controlling for sociodemographic characteristics. We controlled for state-level SUD parity implementation during 2001-2005 because of the known effect of parity legislation on access to treatment.

Results: Over three years of follow-up, persons who were near poor (RRR=3.90, 95% CI=1.33-11.42) and those who were not poor (RRR=3.14, 95% CI=1.26-7.84) were significantly more likely to receive alcohol treatment in general medical settings than those who were poor. Those with private insurance (RRR=0.35, 95% CI=0.15-0.80) and those with no insurance (RRR=0.33, 95% CI=0.18-0.77) were significantly less likely to receive alcohol treatment in specialty care settings than those with public insurance.

Conclusions/Implications: These findings indicate that income disparities may significantly impact access to treatment for alcohol problems in general medical settings. The reduction of copayments in ACA along with the expansion of coverage to those who could not previously afford it will likely ameliorate treatment disparities. Specialty care for alcohol problems has traditionally been funded by public insurance programs due to the lack of coverage of addiction treatment in private insurance programs. Perhaps, the expansion of addiction coverage in private insurance plans may also substantially increase the number of people with private insurance plans who receive treatment. It may be important for states to closely monitor the demand and supply of addiction treatment as ACA is implemented.