Research has studied extensively how individuals enter addiction treatment, finding that in the U.S. they frequently enter via legal, welfare, employment, or family ultimatums. An extensive literature discusses the social control function of treatment; addiction is often related to problems in many areas of life, including employment, legal, and medical (Institute of Medicine 2006
; Wild 2006
; Wild & Wolfe 2009
). The institutions most bearing the burden of such problems have addressed them by referring to or requiring addiction treatment. Treatment agencies have traditionally been freestanding, and often receive funding from some of these institutions (e.g., criminal justice).
One key characteristic of help-seeking for alcohol and drug problems versus for other medical problems, is that individuals receive intense gratification from using substances. Giving them up is far more difficult than going to treatment to be rid of unpleasurable symptoms, such as depression or physical pain (Institute of Medicine 2006
), even when treatment is available. At the same time, because access to addiction treatment has been inadequate to the need, it is also true that individuals often wait until their problems are severe enough to trigger ultimatums from these sources (Institute of Medicine 2006
). Clearly, both aspects of help-seeking could co-exist. However, research has rarely examined coercion to treatment in systems where availability is not an issue; in this study we examine coercion in a system with good access and availability.
This study is relevant to current national health policy issues, as major developments in health care have affected access to addiction treatment. In 2008, Congress passed the Wellstone and Domenici Mental Health Parity and Addiction Equity Act (Centers for Medicare & Medicaid Services 2008a
), which required health plans that covered addiction and mental health services to provide benefits, including access levels and service utilization, equal to those for other health conditions. Thus, length of stay and number of treatment episodes are based on need and cannot be limited. Although it did not extend insurance to everyone, it did greatly increase the population of those with better access to addiction treatment. The legislation both reflected and encouraged new attitudes to addiction treatment by patients and providers, bringing them a step closer to conceiving of it as a part of general health care (Curley 2008
; Frank et al. 1997
In 2010 Congress also passed health reform legislation (2010 Patient Protection and Affordable Care Act, or ACA) that moves the country closer to universal coverage. It will greatly affect how health systems are organized and facilitate in several ways the integration of addiction and medical treatment. It removes pre-existing conditions (including alcohol and drug problems) as a bar to eligibility for health insurance, required most businesses to provide health insurance, and imposed penalties for not buying coverage. It also adds substantial funding to the public health system for addiction treatment (Mental Health America 2010
; Sisko et al. 2010
). New funding will be available to Federally Qualified Health Centers (FQHCs) (in 2009 the U.S. had over 1200 FQHCs serving 12 million Americans, 75% uninsured or on Medicaid, at 7500 delivery sites, with the number planned to double) (National Association of Community Health Centers 2009
). The ACA provides another $11 billion from 2011 to 2015 to FQHCs and community health centers for addiction services, training, and electronic medical record (EMR) (Blumenthal & Tavenner 2010
; Mental Health America 2010
). The FQHCs are incentivized by the ACA to develop organizations that deliver integrated addiction and health care (Mental Health America 2010
). Medicaid will cover 16 million more individuals by 2019 (Broaddus & Angeles 2010
), with those having substance use problems (and legal referrals) over-represented in the population. Finally, the 2010 “National Drug Control Strategy”
has as a fundamental core, the integration of addiction treatment into health care (Office of National Drug Control Policy 2010
). The legislation is expected to expand access for addiction treatment across private and public systems.
This paper examines as a case study a private non-profit health system that provides unlimited access to addiction treatment. Nationally, this health plan is viewed as one of the most similar to a single-payer system, and the Obama administration has referred to it as a proxy for what health reform might look like. It is capitated, financed by monthly premiums that are fixed regardless of how many services are used; use of services is “managed,” primarily by primary care physicians; and it has inclusive alcohol and drug treatment benefits. The plan’s membership is heterogeneous in socio-economic-status, race, work occupation, gender, and age.
With this case study we have the opportunity to examine how people get to treatment in a health system similar to that now called for in the public system overall and in many private systems. We ask the following questions: In the context of full access to addiction treatment, what is the prevalence of ultimatums (employment, legal, medical, and family) in treatment entry? What are the characteristics of health plan members who receive each type of ultimatum? What predicts multiple sources of ultimatums? Our goal is to provide one window on what entry to addiction treatment might look like when access is not a major issue. Do ultimatums to enter treatment continue to be prevalent, and if so, for whom, and from what sources?