And even if a person is diagnosed, a significant disparity exists between coverage of addiction treatment and other health services. Recent initiatives from the Affordable Care Act have mandated that insurance companies provide substance treatment resources, but resources are vastly underused. Most single-state agencies are facilitating the education and training of more addiction counselors, but many states (40%) have not facilitated collaborations between addiction treatment with other medical programs, and nearly half of all states have not provided the infrastructure for insurance participation in addiction treatment (Health Aff. 2015;34[5]828-35). As an example, in Massachusetts, even for insured individuals, structural barriers largely related to insurance issues prevented use of ACA-funded addiction treatment for addictive disorders (Health Aff. 2012 May; 31[5]1000-8).
In addition, despite the availability of evidence-based pharmacologic and psychotherapeutic treatments, a great paucity of qualified addiction medicine physicians and addiction psychiatrists exists. This has become impossible to ignore in the midst of an overdose crisis (Psychiatr Ann. 2015;45[10]522-6). Were addiction truly respected as America’s No. 1 public health crisis, we would see a sizable increase in addiction medicine physicians and addiction psychiatrists. The White House recently offered proposals aimed at alleviating some of these concerns by expanding physician prescribing of buprenorphine and naloxone as well as education on abuse and appropriate prescribing protocols. But if addiction is going to be taken seriously as a disease, we need more physicians practicing with dedicated training in addiction medicine and addiction psychiatry.
Taken together, we cannot expect the impact of substance use, misuse, and dependence to improve without major changes. Advances in medicine continue to manifest at a very fast pace, while addiction and other psychiatric illnesses remain disparately underappreciated, ultimately slowing and even reversing progress on longevity.
Overall, the ACA has been beneficial. But health care reform that fails to provide early diagnosis, intervention, and ready and reliable access to the same range of substance abuse treatments as available to physicians is wholly incomplete, and in a sense, is not reform at all. If we fail to heed this warning, a continuation of the trends described by Professors Case and Deaton is almost a foregone conclusion.
Dr. Srivastava is a second-year psychiatry resident at Washington University in St. Louis. Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University in St. Louis. He also is chairman of the scientific advisory boards for RiverMend Health.