The Affordable Care Act will revolutionize care for substance use disorders in the United States

The 2010 Affordable Care Act and its extensions of the 2008 Mental Health Parity and Addiction Equity Act will dramatically expand access to substance use disorder care in the United States. The law also has the potential to augment the quality of substance use disorder care and its integration with the rest of the health-care system. The first critical impact of the law is to expand access to care, which in the US market-based health-care system is accomplished through increasing health insurance coverage. To understand the impact of the Affordable Care Act in this domain, one must first appreciate a related piece of legislation passed in the closing days of the George W. Bush Administration whose regulations were written in the Obama Administration: the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA). Most Americans who have privately purchased health insurance receive it through 'large-group employers' (i.e. those with more than 50 full-time workers). Historically, employers were legally able to impose limits on the insurance coverage they offered for substance use disorder care that were more restrictive than coverage for other conditions (e.g. charge a $25 co-pay for an out-patient substance use disorder treatment visit versus $10 for other types of out-patient care). MHPAEA made such restrictions illegal. This was an important expansion in coverage for the majority of Americans, but it did not affect individuals who worked for smaller companies, purchased insurance on their own in the individual market or had no insurance at all. Further, while MHPAEA required employer-sponsored insurance to make any offered benefits for substance use disorder care be at parity with those for other disorders, it did not compel them to offer such benefits in the first place. The Affordable Care Act incorporates the MHPAEA standards and expands them in three significant ways 1. First, the law defines substance use disorder screening, brief intervention and treatment as essential insurance benefits that must be offered in all health plans. Second, by providing insurance to what is ultimately projected to be more than 27 million people, the Affordable Care Act extends this access to the previously uninsured population, which historically has had a high rate of substance use disorder but limited access to care. Thirdly, the Affordable Care Act extends the protections of MHPAEA to individuals who receive insurance through small employers or purchase it on the individual market. These changes are projected to expand access to care to 62.5 million Americans, in addition to the more than 100 million Americans whose insurance coverage was subject to the provisions of MHPAEA 2. Two other provisions of the Affordable Care Act also expand access to substance use disorder care, even though neither of them were adopted primarily for that purpose. First, parents are now allowed to keep children on their own insurance until the age of 26 years, replacing the prior standard of removing children from policies at age 19 (or 22 in the case of full-time students). This expands access to substance use disorder care for individuals in the young adult years, during which substance use disorders are prevalent. Secondly, the Affordable Care Act bans the once-common insurance industry practice of refusing to sell insurance policies to individuals with pre-existing disorders. An individual with a documented addiction, for example from a prior treatment episode, who might formerly have been turned down for health insurance, will now not be able to be denied. This dramatic change from past practice further expands access to substance use disorder care. The Affordable Care Act's benefits are not limited to enhancing access to care. The law should also aid the US substance use disorder treatment system in its long struggle with the mutually reinforcing problems of uneven quality and isolation from mainstream medicine 3. The Affordable Care Act addresses these problems through closely linked reforms in the delivery system and its underlying payment structure 4. The law creates new institutions for the provision of care and sets out new payment arrangements in Medicare (which covers disabled individuals and those aged 65 years and older) and Medicaid (which covers lower-income individuals). These changes offer potential for greater integration and coordination of the substance use disorder, medical care and long-term services that are frequently required to promote recovery. The high-level strategy of the law is to bring more services and dollars under budgets that would be managed by clinical organizations with the capabilities to integrate and coordinate a broad array of services to meet population health needs. The law enables the formation of Medicaid Health Homes, Coordinated Care Entities for dually eligible beneficiaries of Medicare and Medicaid, Accountable Care Organizations and Patient Centered Medical Homes. The Medicaid Health Homes and the Coordinated Care Entities have specific foci on people with multiple chronic conditions, including substance use disorders. In all cases, these organizations operate under budget targets and are expected to have the capacity to effectively integrate broad arrays of services to meet the needs of the populations they serve. These arrangements create important new opportunities to improve care for people with substance use disorders. How these new care organizations evolve and ultimately perform with respect to substance use disorder care will depend upon the development of effective accountability systems. That said, the law clearly creates an unprecedented opportunity for innovators to treat and manage substance use disorders in the same fashion that has proved effective for other chronic health problems. In summary, although designed to improve all aspects of the US health care system, the Affordable Care Act will have particularly pronounced benefits for the screening, brief intervention and treatment of substance use disorders. The result should be a far more accessible, coordinated, equitable and high-quality system for responding to one of the nation's most prevalent and destructive health problems. The authors worked with Members of Congress on the MHPAEA and subsequently served in the Obama Administration, where they were involved in the inclusion of substance use disorder care in the Affordable Care Act. K.H. was supported by a Senior Career Research Scientist Award from the Veterans Affairs Health Services Research and Development Service.