Healthcare Reform

Background

While the Patient Protection and Affordable Care Act was debated in Congress, CADCA made the case that substance abuse prevention and the entire continuum of care must be a critical component of the legislation. To ensure that substance abuse prevention was incorporated into the final version of health care reform, CADCA submitted comments on each version of the legislation and provided the following documents to relevant members of Congress and their staffs.

• Including Substance Use/Abuse Prevention In Healthcare Reform
• Prevention Recommendations and Supporting Materials
• Substance Use/Abuse Prevention: Why Is It Relevant in the Broader Healthcare Discussion?
   

Substance Abuse Prevention, Treatment and Recovery Provisions Contained in the Patient Protection and Affordable Care Act

Substance Use Disorder Provisions Contained in Chronic Disease Prevention Initiatives

• The final legislation creates a National Prevention Council, of which the Director of the Office of National Drug Control will be a member. The National Prevention Council is required to submit a report to Congress, and substance use disorders are listed as a national priority that must be included in the report.
• The legislation requires the Substance Abuse and Mental Health Services Administration to be consulted with on issues related to preventing substance use disorders.
• The legislation authorizes grants for school-based community health centers, and requires these centers to provide substance use disorder and mental health services. Preference will be given to applicants who can show that they have evidenced barriers to providing substance use disorder prevention services for children and adolescents, as well as populations of children and adolescents that have historically demonstrated difficulty in accessing substance use disorder prevention services.
• The legislation authorizes the Secretary of Health and Human Services, acting through the Director of the Centers for Disease Control to provide grants to State or local health departments and Indian tribes to carry out 5-year pilot programs to provide public health community interventions, screenings, and where necessary clinical referrals for individuals between the ages of 55 and 64. The community interventions, screenings and referrals may include substance use disorders.

Basic Benefits Package

• The legislation requires basic benefit packages for all health plans in the individual and small group markets to cover substance use disorder and mental health services.
• The legislation requires all plans in the health insurance exchange to comply with the Wellstone/Domenici Parity Act, meaning that substance use disorder and mental health benefits must be covered in the same way as all other covered medical and surgical benefits.

Community Health Team Grants

• The legislation authorizes grants for community health teams. Substance use disorder prevention, treatment, and mental health service providers are eligible to apply for these grants, which will support medical homes

Substance Use Disorder in Workforce Development Initiatives

• The legislation includes the capacity of the behavioral health and mental health workforce as high-priority topics in the bill’s National Workforce Strategy section.

Health Care Reform Implementation

Since the passage of the historic health care reform legislation, named the Patient Protection and Affordable Care Act, CADCA has worked diligently to ensure that substance use prevention is properly included as the law is implemented. It has submitted comments to the Department of Health and Human Services to make the case that: 1) within the Prevention and Public Health (PPH) Fund, there must be an explicit focus on preventing and delaying the age of first use of alcohol, tobacco, illegal drugs, and the misuse and abuse of prescription and over-the-counter drugs; 2) the Drug Free Communities program should be used as a platform upon which to build new ATOD prevention initiatives in the PPH fund; 3) there must be an emphasis on environmental strategies in any new ATOD prevention efforts funded in the PPH fund; and 4) there need to be mechanisms in place to ensure that the necessary data is being collected to track outcomes over time.

The Prevention and Health Promotion Strategy

On October 15, 2010, CADCA submitted comments on the Department of Health and Human Services’ draft framework for the Prevention and Health Promotion Strategy (the Strategy) that was mandated in the Affordable Care Act. The framework contains ten strategic directions, including “counter alcohol/substance misuse,” that address ways to prevent significant causes of death by focusing on risk factors.

The Prevention and Health Promotion Strategy is being developed by the National Prevention and Health Promotion Council (the Council), and must:

(a) set specific goals and objectives for improving the health of the United States through federally supported prevention, health promotion, and public health programs, consistent with ongoing goal setting efforts conducted by specific agencies;

(b) establish specific and measurable actions and timelines to carry out the strategy, and determine accountability for meeting those timelines, within and across Federal departments and agencies; and

(c) make recommendations to improve Federal efforts relating to prevention, health promotion, public health, and integrative health-care practices to ensure that Federal efforts are consistent with available standards and evidence.

The intent of the strategic directions is to “frame specific actionable proposals to meet the goals and achieve the vision for the Strategy; and serve as a lens through which to view federal and non‐federal activities in order to identify how they can best promote wellness and effective prevention.” To view the framework in its entirety, click here

Although the draft framework contains a broad emphasis on countering alcohol and substance misuse, CADCA recommended that it focus not only on screening and brief intervention as a prevention mechanism, but that it also specifically includes an emphasis on environmental strategies. CADCA also recommended that the Strategy specifically focuses on the misuse and abuse of prescription and over-the-counter drugs; and that it builds upon the DFC model to achieve population level outcomes.

Revised Prevention and Health Promotion Strategy

On December 22, 2010, HHS released a revised version of its Prevention and Health Promotion Strategy, which can be viewed here at http://www.healthcare.gov/center/councils/nphpphc/final_intro.pdf. On January 13, 2011, CADCA submitted comments on the revised version of the Strategy and made the following recommendations:

• Add over-the-counter drugs and products to Strategic Direction 6, which focuses on reducing alcohol and drug abuse, including prescription drug abuse;
• Build on the extremely effective Drug Free Communities Program within the federal government;
• Utilize evidence-based strategies, capable of achieving population level outcomes; and
• Collect a core data set to measure incidence, prevalence, age of initiation, perceptions of harm and social disapproval for alcohol, tobacco, illegal drugs and the misuse and abuse of prescription and over the counter drugs and products to measure progress over time

The National Healthcare Quality Strategy and Plan

CADCA submitted comments to the Department of Health and Human Services on October 15, 2010 on the National Healthcare Quality Strategy and Plan, both of which will play a critical role in the implementation of the Patient and Protection and Affordable Care Act (the Affordable Care Act).

The goal of the Strategy and Plan is to identify priorities to improve the delivery of health care services, patient health outcomes, and population health. “The National Prevention Strategy will take a community approach to implement prevention efforts that will reduce the incidence of the leading causes of death and disability. Both the National Quality Strategy and the National Prevention Strategy seek to generate, align, and focus collaboration among public and private sector partners. The National Prevention Strategy will also be developed by consultation across the federal government. The two strategies will share common goals and priorities for healthy people and communities.”

In its comments, CADCA recommended that the Healthy People/Healthy Communities goal in the Strategy and Plan should:

• Explicitly address the prevention of substance use (defined as the use of alcohol, tobacco, illegal drugs and the misuse and abuse of prescription and over-the-counter drugs);
• Focus not only on explicit substance use prevention that addresses alcohol and tobacco, but also on illegal drug use and the use and abuse of prescription and over-the-counter medicines; and
• Include a goal to implement environmental strategies to achieve population level changes in substance use rates at the national level, as well as in states and communities throughout the country.

CADCA also recommended that the Strategy include an aspirational goal of increasing the age of initiation and reducing substance use rates over the next five years and that questions pertaining to perceptions of risk play for the use of alcohol, tobacco and other drugs, be added as metrics in the Youth Risk Behavior Surveillance Survey.

Finally, CADCA recommended that the Strategy and Plan engage community anti-drug coalitions throughout the country, including Drug Free Communities grantees, as they utilize a comprehensive, multi-sector, data driven model and therefore have access to a diverse set of stakeholders in both the public and private sectors and can be tremendously helpful in ensuring its success.

The Description of a Modern Addictions and Mental Health Service System

On June 16, 2010, CADCA submitted comments to SAMHSA on its stakeholder paper, titled Description of a Modern Addictions and Mental Health Service System. This document was designed to foster discussion among the Department of Health and Human Service Operating Divisions and other federal agencies on how best to integrate substance use disorders into the health reform implementation agenda.

In its comments, CADCA noted that the public health model, as implemented by the Centers for Disease Control, should address the agent, host and environment. While the draft document did an excellent job of addressing the recommended changes to the addiction and mental health services system regarding the agent and host, the environmental component of this model was mostly absent. CADCA also noted that public health model involves data-based planning and targeted implementation in multiple community sectors with comprehensive strategies to change community environments and norms that lead to population level outcomes.

Therefore, CADCA proposed changes to explicitly include what the environmental component of a modern addictions and mental health service system would comprise. Specifically, CADCA recommended that the paper include references to a comprehensive community wide approach (based on both the Strategic Prevention Framework and the Drug Free Communities program models) that builds and strengthens infrastructure and capacity for data-driven decision making and identifying, implementing and evaluating effective environmental strategies, as well as specific programs and services across the continuum of care.

Coalition for Whole Health

CADCA also is a part of a broader coalition, the Coalition for Whole Health, which has been working to ensure that in addition to substance abuse prevention, treatment, recovery, and full and equitable parity for mental health and addiction is included in the final legislation.

To view all of the documents submitted by the Coalition for Whole Health, click here

Criteria for Determining Essential Benefits Package to Institute of Medicine (IOM)

As part of its most recent work with the Coalition For Whole Health, CADCA signed on in support of comments sent to the Institute of Medicine on December 17, 2010 by the Coalition for Whole Health regarding criteria to consider when determining the essential benefits package. The Coalition’s comments focused on ten key questions asked by the IOM that will be critical determinants in health reform implementation.

These included:

1. What is your interpretation of the word “essential” in the context of an essential benefit package?
    
2. How is medical necessity defined and then applied by insurers in coverage determinations? What are the advantages/disadvantages of current definitions and approaches?
    
3. What criteria and methods, besides medical necessity, are currently used by insurers to determine which benefits will be covered? What are the advantages/disadvantages of these current criteria and methods?
    
4. What principles, criteria, and process(es) might the Secretary of HHS use to determine whether the details of each benefit package offered will meet the requirements specified in the Affordable Care Act?
5. What type of limits on specific or total benefits, if any, could be allowable in packages given statutory restrictions on lifetime and annual benefit limits? What principles and criteria could/should be applied to assess the advantages and disadvantages of proposed limits?
    
6. How could an “appropriate balance” among the ten categories of essential care be determined so that benefit packages are not unduly weighted to certain categories? The ten categories are: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorders services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; pediatric services, including oral and vision care.
    
7. How could it be determined that essential benefits are “not subject to denial to individuals against their wishes” on the basis of age, expected length of life, present or predicted disability, degree of medical dependency or quality of life? Are there other factors that should be determined?
    
8. How could it be determined that the essential health benefits take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups?
    
9. By what criteria and method(s) should the Secretary evaluate state mandates for inclusion in a national essential benefit package? What are the cost and coverage implications of including current state mandates in requirements for a national essential benefit package?
    
10. What criteria and method(s) should HHS use in updating the essential package? How should these criteria be applied? How might these criteria and method(s) be tailored to assess whether: (1) enrollees are facing difficulty in accessing needed services for reasons of cost or coverage, (2) advances in medical evidence or scientific advancement are being covered, (3) changes in public priorities identified through public input and/or policy changes at the state or national level?