Under the Affordable Care Act, Medicaid and other health plans will become primary payers for most addiction treatment services. The current system of direct grants and contracts will dissipate as treatment providers’ reimbursement from Medicaid and commercial health plans increases. State and federal appropriations designated for addiction prevention and treatment are likely to decline as Medicaid health plans become major payers (Buck, 2011). The substance abuse counseling workforce is likely to change because health plans are typically selective in their purchase of service contracts and screen for evidence of quality care. Practitioners that provide evidence of quality care are likely to have competitive advantages. Medicaid and commercial health plans are likely to limit reimbursement to practitioners with graduate degrees and professional licensure (McCarty et al., 2010). The workforce impact may be substantial because only about 50 percent of counselors in most addiction treatment centers have graduate degrees (i.e., 42 percent of total counselors, 58 percent of outpatient counselors) (McCarty et al., 2007a). With the increasing medicalization of substance abuse treatment services (Buck, 2011), freestanding addiction treatment centers that rely on experientially trained counselors and/or counselors with alcohol and drug certification (but not clinical licensure) may struggle to survive (McCarty et al., 2010). The training of the addiction treatment workforce will also need to evolve to meet new requirements.

Accountable Care Organizations and Integrated Care

The Affordable Care Act generally promotes the integration of mental health and SUD treatment with primary care services and makes integrated care a priority for community-based accountable care organizations (ACOs).1 ACOs reflect emerging standards and expectations for integrated, patient-centered care provided within a medical home that is financially responsible for coordinating a patient’s health care, including care for mental health disorders and SUDs. The National Committee for Quality Assurance (NCQA) met with consumer advocates, purchasers of care, and health plans and released accreditation standards for ACOs in November 2011. The ACO accreditation standards encourage coordination of mental health and SUD services with the development of primary care medical homes and address seven dimensions of care (see Box 4-1).

ACOs will support the integration of behavioral health and primary care. Recognition is increasing that general medicine practitioners “should become the first line ‘experts’ for substance abuse” (O’Connor and Samet, 2002, p. 398). Alcohol and other drug use is prevalent among patients

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1 Patient Protection and Affordable Care Act, Public Law 111-148, 111th Cong. (March 23, 2010).



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