(WITHDRAWN) The Significance of Place: An Examination of the Socio-Spatial Context and Substance Use Disorder Treatment Accessibility in the Era of Healthcare Reform

Background and Purpose: As the opioid epidemic continues to be a vexing public health problem, it is important to examine whether state behavioral health policies have had an impact on access to substance use disorder (SUD) treatment programs to meet the needs of those most affected by this crisis. This multilevel longitudinal study examines the effect of state Medicaid program addiction benefits coverage and state Substance Abuse Prevention and Treatment (SAPT) Block Grants on service availability and workforce capacity of outpatient addiction treatment programs in the US, and how geography, as measured by the area deprivation index (ADI) may moderate this relationship.

Methods: Data and samples: All data are from 2014-2017. State-level data consisted of two waves (n=51) of the SUD Coverage Survey (SUDCov). The ADI comprised neighborhood-level data. Organizational-level data was from waves 8 (n=695) and 9 (n=657) of the National Drug Abuse Treatment System Survey (NDATSS) of a national representative sample of outpatient SUD treatment programs. Multilevel Poisson regression analyses were used.

Measures (importance of the ADI): The ADI, composed of 17 American Community Survey (ACS) socioeconomic variables on poverty, housing, employment, and education, is a validated measure developed for measuring health iniquities across time and space. This measure was selected for its greater validity, robustness and explanatory power than single area measures in documenting and measuring the extent of health and health access disparities.

Results: There were no significant relationship of state addiction coverage policy or funding on service availability. Compared to the average organization in non-expansion states, those in Medicaid expansion states had an 18.2% greater capacity. For every one unit increase in state block grant funding generosity for addiction treatment, there was a 23.3% increase in capacity. Every one unit increase in Medicaid coverage generosity was associated with a 7.9% increase in the effect of state block grant funding on capacity. For every one unit increase in ADI, there was a 1.4% decrease in capacity. Thus, the difference in capacity between an organization in a county with average ADI compared one in the most disadvantaged area was 138%. ADI was also a significant moderator. A one unit increase in ADI was associated with a 0.1% decrease in the effect of block grant funding generosity and a 0.3% decrease in the effect of Medicaid coverage generosity on capacity. All significant results were at the 0.01 alpha-level.

Conclusions and Implications: While state policy and funding efforts to increase access showed no effects on service availability, they were associated with significant increases in capacity. Moreover, the location of programs does matter as it influences state policy and funding effectiveness in increasing access. Organizations in more disadvantaged areas had lower capacity. Funding and technical assistance should be targeted at organizations in higher disadvantaged areas. Study findings enable the identification of programs in greater need of support in order to adequately serve the needs of those with an opioid use disorder and more equitably allocate limited resources.