Journal of Adolescent Health 54 (2014) 627e628
www.jahonline.org Editorial
The Racial and Ethnic Gap in Substance Use Treatment: Implications for U.S. Healthcare Reform
The Institute of Medicine has identified that racial and ethnic minority youth experience significant barriers to behavioral health treatment and receive lower quality services than their nonminority counterparts in the United States [1]. Data from the National Survey on Drug Use and Health highlight that black and Hispanic adolescents are less likely than white adolescents to receive treatment for substance use disorders (SUDs) [2], the vast majority of which involve marijuana and alcohol misuse [3]. Myriad economic, social, environmental, and individual factors contribute to this access gap. Minority youth are less likely to have health insurance, to be identified and referred for SUD, and to have close geographic proximity to SUD treatment facilities; they may also be more mistrustful of providers and experience competing life stressors [4]. With the Patient Protection and Affordable Care Act (ACA) greatly expanding insurance coverage for addiction services [5], it is imperative to address gaps in how racial and ethnic minorities experience quality of care. In this issue of the Journal of Adolescent Health, Saloner et al. [6] use the 2007 Treatment Episode Data Set (TEDS) to demonstrate that black and Hispanic 12- to 17-year-olds in publicly funded SUD treatment programs in the United States are less likely than their white counterparts to complete alcohol and marijuana treatment. Among white adolescents, treatment noncompletion was 35% and 39% for marijuana and alcohol treatment, respectively, but among black and Hispanic adolescents, treatment noncompletion was 49% and 50%, respectively. The authors highlight that Hispanic youth left treatment against medical advice more frequently, whereas black youth more frequently had their treatment terminated by the facility or became incarcerated during treatment. Treatment completion rates were significantly lower among Hispanic youth living in areas with fewer addiction services and where Medicaid acceptance rates were lower, factors that helped explain the whiteHispanic gap in treatment completion in the authors’ analyses. The study’s strengths include its use of a large national data set drawn from publicly funded treatment programs. Indeed, since the majority of financing for substance use treatment in the
United States stems from public sources [5], use of TEDS data provides results that may be generalizable to many jurisdictions in the country [3]. Unfortunately, the social service sector and individual variables included in TEDS and assessed by Saloner et al. do not fully elucidate underlying mechanisms. For example, the authors found that the racial and ethnic composition of a client’s metropolitan area explained a high proportion of the minority-white gap in treatment completion, a finding that may be better explained by other unmeasured social, economic, and environmental factors. Exactly why minorities are less likely to complete treatment remains somewhat unanswered. Nonetheless, the authors’ results are consistent with new data from Cummings et al. [7] illustrating the scarcity of Medicaidaccepting SUD treatment programs in areas with higher proportions of minorities. Further, many countries offer only one treatment program, resulting in limited choice and, one might hypothesize, services that are less culturally competent and inadequate for non-English-speaking patients. This is critical, since providers’ cultural competence has been linked to SUD treatment outcomes [4,8]. Poor cultural competence and/or insufficient language services may underlie the findings of Saloner et al. that Hispanic adolescents tended to leave alcohol and marijuana treatment against medical advice. Given that the ACA explicitly provides new funding for provider training in cultural competence, this should be an area of further study and development [9]. The results of Saloner et al. have significant implications as the landscape of behavioral health services changes under the ACA. As insurance coverage for adolescents in the United States expands [10], it is critical that clinicians and policymakers address the limited availability of Medicaid-accepting treatment facilities and providers in many areas. The complementary results of Cummings and Saloner show, respectively, that areas with higher proportions of minorities are less likely to have Medicaidaccepting treatment programs [7], and that in these same areas, adolescents may be less likely to successfully complete treatment. In a recent report to Congress, the Substance Abuse and Mental Health Services Administration described a serious workforce
See Related Article p. 646
1054-139X/$ e see front matter Ó 2014 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2014.03.015
628
Editorial / Journal of Adolescent Health 54 (2014) 627e628
shortage of specialty-trained providers in addiction medicine [10]; the availability of well-trained adolescent addiction treatment providers who offer culturally competent care is likely even more limited [4]. In sum, the current substance use treatment infrastructure in the United States may not be sufficient to meet the needs of all adolescents living with addiction. The ACA provides for expanded coverage of and access to SUD prevention and treatment. Specifically, the ACA mandates the inclusion of SUD treatment in the “essential benefits” that state health insurance exchanges must offer, prohibits exclusions for pre-existing behavioral health conditions, and broadens the national mental health parity law to new Medicaid plans, so that limits applied to behavioral health services cannot be more restrictive than limits applied to medical and surgical services [10]. Further, young adults up to age 26 can be covered under parental insurance, which should decrease “aging out” of insurance during the times that they are at high risk for behavioral health problems [5]. Care integration and medical home initiatives will offer expanded access to mental health screening and treatment, and collaboration among community health and mental health centers should improve access to treatment services for patients in geographic areas with limited healthcare resources [7,11]. Finally, extension of Medicaid coverage may result in new and more consistent reimbursement for addiction treatment services, which in turn may incentivize the creation of new programs [5,7]. Reliable revenue streams may also drive greater efficiency through investment in evidence-based approaches, information technology, and improvements in business administration [5]. Adolescents who do not address their alcohol and drug use can experience lifelong health and economic consequences [4]. Adolescent providers and policymakers must advocate for expanded coverage and access to SUD prevention and treatment, as well as increased research for high-quality and effective treatments. The results of Saloner et al. underscore the criticality of ensuring access to high-quality addiction treatment services for all adolescentsdregardless of race, ethnicity, or location. Funding Sources Dr. Hadland and Dr. Baer are supported by the Division of Adolescent/Young Adult Medicine at Boston Children’s Hospital and the Leadership Education in Adolescent Health Training Program T71 MC00009 (MCH/HRSA).
Scott E. Hadland, M.D., M.P.H. Division of Adolescent/Young Adult Medicine Boston Children’s Hospital Harvard Medical School Boston, Massachusetts Tamara E. Baer, M.D. Division of Adolescent/Young Adult Medicine Boston Children’s Hospital Harvard Medical School Harvard School of Public Health Boston, Massachusetts
References [1] National Research Council. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, eds. Washington, DC: The National Academies Press; 2003. [2] Cummings JR, Wen H, Druss BG. Racial/ethnic differences in treatment for substance use disorders among U.S. adolescents. J Am Acad Child Adolesc Psychiatry 2011;50:1265e74. [3] SAMHSA. Treatment episode data set (TEDS). Highlights - 2007. National Admissions to Substance Abuse Treatment Services. DASIS Series: S-45, DHHS Publication No. (SMA) 09e4360. Available at: http://wwwdasis. samhsa.gov/teds07/tedshigh2k7.pdf; 2009. Accessed March 31, 2014. [4] Alegria M, Carson NJ, Goncalves M, et al. Disparities in treatment for substance use disorders and co-occurring disorders for ethnic/racial minority youth. J Am Acad Child Adolesc Psychiatry 2011;50:22e31. [5] Buck JA. The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act. Health Aff (Millwood) 2011;30:1402e10. [6] Saloner B, Carson N, Lê Cook B. Explaining racial/ethnic differences in adolescent substance abuse treatment completion in the United States: A decomposition analysis. J Adolesc Health 2014;54:646e53. [7] Cummings JR, Wen H, Ko M, et al. Race/ethnicity and geographic access to Medicaid substance use disorder treatment facilities in the United States. JAMA Psychiatry 2014;71:190e6. [8] Guerrero EG. Enhancing access and retention in substance abuse treatment: the role of Medicaid payment acceptance and cultural competence. Drug Alcohol Depend 2013;132:555e61. [9] Saenz M. Health disparities and the Affordable Care Act. Washington, DC: National Conference of State Legislatures; 2010. Available at: http://www. ncsl.org/documents/health/HDandACA.pdf. Accessed March 11, 2014. [10] Beronio K. Po R. Skopec L. et al. Affordable Care Act will expand mental health and substance use disorder benefits and parity protections for 62 million Americans. 2013. Available at: http://aspe.hhs.gov/health/reports/ 2013/mental/rb_mental.pdf. Accessed March 17, 2014. [11] SAMHSA. Report to Congress on the Nation’s substance abuse and mental health workforce issues. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. Available at: http://store.samhsa. gov/shin/content/PEP13-RTC-BHWORK/PEP13-RTC-BHWORK.pdf. Accessed March 13, 2014.
www.jahonline.org Editorial
The Racial and Ethnic Gap in Substance Use Treatment: Implications for U.S. Healthcare Reform
The Institute of Medicine has identified that racial and ethnic minority youth experience significant barriers to behavioral health treatment and receive lower quality services than their nonminority counterparts in the United States [1]. Data from the National Survey on Drug Use and Health highlight that black and Hispanic adolescents are less likely than white adolescents to receive treatment for substance use disorders (SUDs) [2], the vast majority of which involve marijuana and alcohol misuse [3]. Myriad economic, social, environmental, and individual factors contribute to this access gap. Minority youth are less likely to have health insurance, to be identified and referred for SUD, and to have close geographic proximity to SUD treatment facilities; they may also be more mistrustful of providers and experience competing life stressors [4]. With the Patient Protection and Affordable Care Act (ACA) greatly expanding insurance coverage for addiction services [5], it is imperative to address gaps in how racial and ethnic minorities experience quality of care. In this issue of the Journal of Adolescent Health, Saloner et al. [6] use the 2007 Treatment Episode Data Set (TEDS) to demonstrate that black and Hispanic 12- to 17-year-olds in publicly funded SUD treatment programs in the United States are less likely than their white counterparts to complete alcohol and marijuana treatment. Among white adolescents, treatment noncompletion was 35% and 39% for marijuana and alcohol treatment, respectively, but among black and Hispanic adolescents, treatment noncompletion was 49% and 50%, respectively. The authors highlight that Hispanic youth left treatment against medical advice more frequently, whereas black youth more frequently had their treatment terminated by the facility or became incarcerated during treatment. Treatment completion rates were significantly lower among Hispanic youth living in areas with fewer addiction services and where Medicaid acceptance rates were lower, factors that helped explain the whiteHispanic gap in treatment completion in the authors’ analyses. The study’s strengths include its use of a large national data set drawn from publicly funded treatment programs. Indeed, since the majority of financing for substance use treatment in the
United States stems from public sources [5], use of TEDS data provides results that may be generalizable to many jurisdictions in the country [3]. Unfortunately, the social service sector and individual variables included in TEDS and assessed by Saloner et al. do not fully elucidate underlying mechanisms. For example, the authors found that the racial and ethnic composition of a client’s metropolitan area explained a high proportion of the minority-white gap in treatment completion, a finding that may be better explained by other unmeasured social, economic, and environmental factors. Exactly why minorities are less likely to complete treatment remains somewhat unanswered. Nonetheless, the authors’ results are consistent with new data from Cummings et al. [7] illustrating the scarcity of Medicaidaccepting SUD treatment programs in areas with higher proportions of minorities. Further, many countries offer only one treatment program, resulting in limited choice and, one might hypothesize, services that are less culturally competent and inadequate for non-English-speaking patients. This is critical, since providers’ cultural competence has been linked to SUD treatment outcomes [4,8]. Poor cultural competence and/or insufficient language services may underlie the findings of Saloner et al. that Hispanic adolescents tended to leave alcohol and marijuana treatment against medical advice. Given that the ACA explicitly provides new funding for provider training in cultural competence, this should be an area of further study and development [9]. The results of Saloner et al. have significant implications as the landscape of behavioral health services changes under the ACA. As insurance coverage for adolescents in the United States expands [10], it is critical that clinicians and policymakers address the limited availability of Medicaid-accepting treatment facilities and providers in many areas. The complementary results of Cummings and Saloner show, respectively, that areas with higher proportions of minorities are less likely to have Medicaidaccepting treatment programs [7], and that in these same areas, adolescents may be less likely to successfully complete treatment. In a recent report to Congress, the Substance Abuse and Mental Health Services Administration described a serious workforce
See Related Article p. 646
1054-139X/$ e see front matter Ó 2014 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2014.03.015
628
Editorial / Journal of Adolescent Health 54 (2014) 627e628
shortage of specialty-trained providers in addiction medicine [10]; the availability of well-trained adolescent addiction treatment providers who offer culturally competent care is likely even more limited [4]. In sum, the current substance use treatment infrastructure in the United States may not be sufficient to meet the needs of all adolescents living with addiction. The ACA provides for expanded coverage of and access to SUD prevention and treatment. Specifically, the ACA mandates the inclusion of SUD treatment in the “essential benefits” that state health insurance exchanges must offer, prohibits exclusions for pre-existing behavioral health conditions, and broadens the national mental health parity law to new Medicaid plans, so that limits applied to behavioral health services cannot be more restrictive than limits applied to medical and surgical services [10]. Further, young adults up to age 26 can be covered under parental insurance, which should decrease “aging out” of insurance during the times that they are at high risk for behavioral health problems [5]. Care integration and medical home initiatives will offer expanded access to mental health screening and treatment, and collaboration among community health and mental health centers should improve access to treatment services for patients in geographic areas with limited healthcare resources [7,11]. Finally, extension of Medicaid coverage may result in new and more consistent reimbursement for addiction treatment services, which in turn may incentivize the creation of new programs [5,7]. Reliable revenue streams may also drive greater efficiency through investment in evidence-based approaches, information technology, and improvements in business administration [5]. Adolescents who do not address their alcohol and drug use can experience lifelong health and economic consequences [4]. Adolescent providers and policymakers must advocate for expanded coverage and access to SUD prevention and treatment, as well as increased research for high-quality and effective treatments. The results of Saloner et al. underscore the criticality of ensuring access to high-quality addiction treatment services for all adolescentsdregardless of race, ethnicity, or location. Funding Sources Dr. Hadland and Dr. Baer are supported by the Division of Adolescent/Young Adult Medicine at Boston Children’s Hospital and the Leadership Education in Adolescent Health Training Program T71 MC00009 (MCH/HRSA).
Scott E. Hadland, M.D., M.P.H. Division of Adolescent/Young Adult Medicine Boston Children’s Hospital Harvard Medical School Boston, Massachusetts Tamara E. Baer, M.D. Division of Adolescent/Young Adult Medicine Boston Children’s Hospital Harvard Medical School Harvard School of Public Health Boston, Massachusetts
References [1] National Research Council. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, eds. Washington, DC: The National Academies Press; 2003. [2] Cummings JR, Wen H, Druss BG. Racial/ethnic differences in treatment for substance use disorders among U.S. adolescents. J Am Acad Child Adolesc Psychiatry 2011;50:1265e74. [3] SAMHSA. Treatment episode data set (TEDS). Highlights - 2007. National Admissions to Substance Abuse Treatment Services. DASIS Series: S-45, DHHS Publication No. (SMA) 09e4360. Available at: http://wwwdasis. samhsa.gov/teds07/tedshigh2k7.pdf; 2009. Accessed March 31, 2014. [4] Alegria M, Carson NJ, Goncalves M, et al. Disparities in treatment for substance use disorders and co-occurring disorders for ethnic/racial minority youth. J Am Acad Child Adolesc Psychiatry 2011;50:22e31. [5] Buck JA. The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act. Health Aff (Millwood) 2011;30:1402e10. [6] Saloner B, Carson N, Lê Cook B. Explaining racial/ethnic differences in adolescent substance abuse treatment completion in the United States: A decomposition analysis. J Adolesc Health 2014;54:646e53. [7] Cummings JR, Wen H, Ko M, et al. Race/ethnicity and geographic access to Medicaid substance use disorder treatment facilities in the United States. JAMA Psychiatry 2014;71:190e6. [8] Guerrero EG. Enhancing access and retention in substance abuse treatment: the role of Medicaid payment acceptance and cultural competence. Drug Alcohol Depend 2013;132:555e61. [9] Saenz M. Health disparities and the Affordable Care Act. Washington, DC: National Conference of State Legislatures; 2010. Available at: http://www. ncsl.org/documents/health/HDandACA.pdf. Accessed March 11, 2014. [10] Beronio K. Po R. Skopec L. et al. Affordable Care Act will expand mental health and substance use disorder benefits and parity protections for 62 million Americans. 2013. Available at: http://aspe.hhs.gov/health/reports/ 2013/mental/rb_mental.pdf. Accessed March 17, 2014. [11] SAMHSA. Report to Congress on the Nation’s substance abuse and mental health workforce issues. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. Available at: http://store.samhsa. gov/shin/content/PEP13-RTC-BHWORK/PEP13-RTC-BHWORK.pdf. Accessed March 13, 2014.
