TREATMENT FUNDING AND SERVICE DELIVERY

No single accepted method or setting exists for the treatment of substance abuse—alcohol and other drug-abuse disorders. Treatment is offered in specialty units of general and psychiatric hospitals, residential facilities, halfway houses, outpatient clinics, mental-health centers, jails and prisons, and the offices of private practitioners.

In the United States during the 1970s and 1980s, drug abusers were commonly treated in programs distinct from those serving alcoholics. By the 1990s, the two treatment systems were merged; in 1991, of the estimated 11,000 substance-abuse treatment programs in the United States, 79 percent reported that they served both drug and alcohol abusers. Some 88 percent were enrolled in outpatient programs. Another 10 percent were in residential facilities. Only 2 percent were hospital inpatients.

The cost of treatment varied greatly depending on setting. In the early 1990s, hospital inpatient care was the most expensive on a daily basis ($300-600/day), but it was usually of short duration (30 days or less). Treatment in nonhospital residential programs was less expensive ($50-60/ day), but it commonly lasted longer (a few months to 2 years). Programs that did not require the individual to live in a specialized facility were the least expensive, both on a daily basis ($5-15/day) and over a full course of treatment.

PRIVATE HEALTH INSURANCE

The availability of private health-insurance coverage for substance-abuse treatment grew in the 1980s. By 1990, better than 90 percent of health-insurance plans had explicit coverage for drug treatment. Individuals with such private insurance have a greater range of treatment providers from which to choose than those who are indigent and have only government-funded programs at their disposal. Programs that mainly rely on insurance reimbursement, however, tend to be more expensive than those that receive the bulk of their support from government sources.

U.S. GOVERNMENT FINANCING

In the U.S. general health-care system, 68 percent of the cost of services is borne by the individual, insurance company, or other private third-party payer. For substance-abuse or mental-health care, in contrast, the government supplies 63 percent of the funds for substance-abuse treatment. After the private sector, which provides 37 percent of the funds, the states traditionally have been the major source of treatment support (31%), followed by the federal government (24%), and then county and local agencies (8%). States often finance treatment by reimbursing providers through public-welfare programs or through grants or contracts. Some states transfer funds to county and local governments, which, in turn, purchase services from providers. Another financing mechanism is Medicaid, a combined state and federal program that pays medical bills for low-income persons. Under Medicaid, states can pay for substance-abuse care in inpatient general hospitals, clinics, outpatient hospital and rehabilitation services, and in group homes with sixteen or fewer beds.

A federal program that pays the health-care costs of persons 65 years of age or older, or those who are disabled, is Medicare. This primarily covers inpatient hospital treatment of alcohol or drug abuse, as well as some medically necessary services in outpatient settings. The primary federal mechanism for paying for alcohol and drug treatment is the Substance Abuse Block Grant, administered by the Department of Health and Human Services. Funds from the block grant are distributed to the states (and territories) using a formula that takes the characteristics of the state's population into account. In fiscal year 1994, Congress appropriated approximately 1.3 billion dollars for the Substance Abuse Block Grant. The federal government also makes grants to individual treatment providers to support innovative treatment approaches, improve the quality of treatment, or to ensure services for underserved or special populations.

(See also: Treatment ; U.S. Government Agencies )

BIBLIOGRAPHY

Health Insurance Association of America. (1991). Source book of health insurance data. Washington, D.C.: Author.

Institute of Medicine. (1991). Treating drug problems, vol. 1. Washington, D.C.: National Academy Press.

Institute of Medicine. (1990). Broadening the base of treatment for alcohol problems. Washington, D.C.: National Academy Press.

Substance Abuse and Mental Health Services Administration. (1992). Highlights from the 1991 National Drug and Alcoholism Treatment Unit Survey (NDATUS). Rockville, MD: Author.

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