Health Insurance Status of Adult Substance Abuse Treatment Admissions Aged 26 or Older: 2011

In Brief
  • In 2011, three fifths of substance abuse treatment admissions aged 26 or older (59.6 percent) reported having no health insurance, 21.3 percent reported having Medicaid, and 10.5 percent reported having private insurance
  • For admissions aged 26 or older, a higher proportion of male admissions than female admissions reported having no health insurance (63.8 vs. 51.2 percent)
  • About two thirds (67.5 percent) of admissions aged 26 or older that were referred to substance abuse treatment by the criminal justice system had no health insurance, which substantially exceeded the percentages for most other referral sources

In 2011, an estimated 19.3 million Americans aged 12 or older needed but did not receive substance abuse treatment.1 The vast majority of them (98.5 percent) either did not believe they needed treatment or did not make an effort to obtain treatment.1 However, an estimated 281,000 people believed they needed treatment, made an effort to obtain treatment, but ultimately did not receive treatment.1 Among these people, the most common reason for not receiving treatment was lack of health insurance and inability to afford the cost of treatment (37.3 percent); an additional 10.1 percent said that they had health insurance, but it did not cover substance abuse treatment.1 In fact, a high proportion of individuals who receive care pay for treatment out-of-pocket. For 2011, data show that among persons who received substance use treatment in the past year, 46.4 percent reported using their "own savings or earnings" as a source of payment for all or part of the cost of their most recent treatment episode, and 26.0 percent reported using funds from family members.1 Such expenses can be financially crippling to individuals and their families, and may result in decisions to delay or not pursue treatment.2

In March 2010, the Patient Protection and Affordable Care Act3 and the Health Care and Education Reconciliation Act of 20104 (together referred to as the Affordable Care Act, or "ACA") were signed into law. Through insurance subsidies, the establishment of health insurance exchanges, and expanded eligibility for Medicaid, the ACA is intended to make health insurance coverage more affordable for individuals, families, and small business owners. Once the ACA is fully implemented in 2014,5 access to health care services for substance use disorders is expected to improve as previously uninsured people gain insurance coverage, and fewer people will be competing for limited publicly funded treatment. As the ACA implementation process unfolds, understanding the characteristics of those who enter substance abuse treatment with different types of health insurance coverage can serve as a baseline for policy and budget planning.

The Treatment Episode Data Set (TEDS) is a national data system of annual admissions to substance abuse treatment facilities. Treatment programs receiving any public funds are requested to provide TEDS data on publicly and privately funded clients. TEDS records represent admissions rather than individuals, as a person may be admitted to treatment more than once. TEDS includes a Minimum Data Set that contains 2011 data for 48 reporting States and jurisdictions; however, type of health insurance is a Supplemental Data Set item that was reported by 34 States and jurisdictions for 2011, and the admissions data presented in this report are restricted to those 34 States and jurisdictions.6 Health insurance status specifies the type of health insurance reported by each admission (if any).

TEDS does not record whether the health insurance covers substance abuse treatment or whether the insurance was used to pay for treatment. Four categories of health insurance status are used in this report: no health insurance; private insurance, such as Blue Cross/Blue Shield or HMO; Medicaid; and other insurance, including Medicare, CHAMPUS, and Tricare.

The goal of this report is to provide baseline characteristics for health insurance coverage among adults for future comparison. Notably, this analysis restricts admissions to those aged 26 or older at treatment entry given the ACA's provision that extends health care coverage in family policies to adult children until age 26.3 In 2011, there were 565,818 admissions to substance abuse treatment programs aged 26 or older with valid data on health insurance.

Note that TEDS is a census of all admissions to treatment facilities reported to SAMHSA by State substance abuse agencies. Because TEDS involves actual counts rather than estimates, statistical significance and confidence intervals are not applicable. The differences between subgroups mentioned in the text of this report have Cohen's h effect size ≥ 0.20, indicating that they are considered to be meaningful.


Types of Insurance

In 2011, three fifths (59.6 percent) of substance abuse treatment admissions aged 26 or older reported having no health insurance (Table 1). The most frequently reported type of insurance was Medicaid, which accounted for 21.3 percent of admissions. Private insurance was reported by 10.5 percent of admissions. All other forms of insurance totaled 8.5 percent.

Table 1. Substance Abuse Treatment Admissions Aged 26 or Older, by Type of Health Insurance: 2011*
Type of Health
Insurance
Number of
Admissions
Percent Percent
Male
Percent
Female
No Insurance 337,405 59.6% 63.8% 51.2%
Any Insurance 228,413 40.4% 36.2% 48.8%
Private Insurance   59,569 10.5% 11.0%   9.7%
Medicaid 120,799 21.3% 17.2% 29.7%
Other Insurance   48,045   8.5%   8.0%   9.4%
* The percentages of No Insurance and Any Insurance or types of insurance may not total to 100 percent due to rounding.
Source: SAMHSA Treatment Episode Data Set (TEDS), 2011.


Gender, Age, and Race/Ethnicity

For admissions aged 26 or older, a higher proportion of male admissions than female admissions reported having no health insurance (63.8 vs. 51.2 percent), but there was little difference in the percentage of male and female admissions with private insurance (Table 1). A higher proportion of female admissions than male admissions reported having Medicaid coverage (29.7 vs. 17.2 percent).

More than half of admissions in each of the age groups had no health insurance, ranging from 50.1 percent among those aged 55 or older to 61.8 percent among those aged 26 to 34 (Figure 1). Admissions aged 55 or older had a higher percentage of private health insurance coverage (16.7 percent) than the 26 to 34 age group (8.6 percent).

Figure 1. Health Insurance Status, by Age Group among Admissions Aged 26 or Older: 2011*
This is a bar graph comparing health insurance status, by age group among admissions aged 26 or older: 2011*. Accessible table located below this figure.

Figure 1 Table. Health Insurance Status, by Age Group among Admissions Aged 26 or Older: 2011*
Health Insurance
Status
Aged 26
to 34
Aged 35
to 54
Aged 55
or Older
None 61.8% 59.5% 50.1%
Private   8.6% 11.0% 16.7%
Medicaid 21.9% 21.2% 19.4%
Other   7.7%   8.3% 13.8%
* Percentages may not sum to 100 percent due to rounding.
Source: SAMHSA Treatment Episode Data Set (TEDS), 2011.

Similarly, in each racial/ethnic group, more than half of admissions had no health insurance (Figure 2). Medicaid was reported as the most common source of coverage across all racial/ethnic groups, with the exception of American Indians/Alaska Natives, of which 22.6 percent reported having "other" health insurance coverage.


Figure 2. Health Insurance Status among Admissions Aged 26 or Older, by Race/Ethnicity: 2011*
This is a bar graph comparing health insurance status among admissions aged 26 or older, by race/ethnicity: 2011*. Accessible table located below this figure.

Figure 2 Table. Health Insurance Status among Admissions Aged 26 or Older, by Race/Ethnicity: 2011*
Health Insurance Status White Black Hispanic Asian/Pacific
Islander
American Indian/
Alaska Native
None 58.7% 60.4% 65.4% 53.4% 62.4%
Private 12.3%   5.0% 11.5% 15.7%   5.1%
Medicaid 20.4% 27.5% 17.9% 25.7%   9.8%
Other   8.7%   7.2%   5.2%   5.3% 22.6%
* Percentages may not sum to 100 percent due to rounding.
Source: SAMHSA Treatment Episode Data Set (TEDS), 2011.


Education and Employment

Over 60 percent of admissions aged 26 or older with a high school education or less had no insurance (Table 2). The percentage of admissions with private insurance was highest among those admissions reporting college education (28.2 percent). Conversely, the percentage reporting Medicaid was highest among those with less than a high school education (26.1 percent) and lowest among those with college education (12.9 percent).

Table 2. Health Insurance Status among Admissions Aged 26 or Older, by Education and Employment: 2011*
Type of
Health
Insurance
Education Employment
Less than a
High School
Education
(Percent)
High School
Education/
GED
(Percent)
Some
College
(Percent)
College
Education
(Percent)
Full Time
(Percent)
Part Time
(Percent)
Unemployed
(Percent)
Not in the
Labor Force
(Percent)
No Insurance 60.7% 60.8% 59.0% 50.9% 54.4% 68.0% 69.7% 45.6%
Any Insurance 39.3% 39.2% 41.0% 49.1% 45.6% 32.0% 30.3% 54.4%
Private   5.1%   9.7% 13.0% 28.2% 31.6%   9.3%   5.1%   6.5%
Medicaid 26.1% 20.9% 19.1% 12.9%   7.1% 15.1% 17.8% 36.5%
Other   8.2%   8.6%   8.9%   8.0%   6.9%   7.6%   7.4% 11.4%
* Percentages may not sum to 100 percent due to rounding.
Source: SAMHSA Treatment Episode Data Set (TEDS), 2011.

Almost 70 percent of admissions aged 26 or older that were not employed or that were employed part time did not have health insurance at treatment entry (69.7 and 68.0 percent, respectively). In contrast, 45.6 percent of admissions that were employed full time and 54.4 percent of admissions that were not in the labor force were reported as having some type of health insurance. Specifically, compared with the other admissions groups, admissions that were employed full time had the highest percentage with private insurance (31.6 percent), and admissions that were not in the labor force had the highest proportion with Medicaid coverage (36.5 percent).

Substances of Abuse

The uninsured comprised over 60 percent of admissions aged 26 or older that reported primary abuse of alcohol (60.7 percent), marijuana (65.1 percent), or cocaine (60.9 percent), and over 70 percent of admissions aged 26 or older that reported primary abuse of stimulants (71.3 percent) (Figure 3). Among the admissions groups, the largest percentage of admissions with private insurance coverage was observed among admissions for primary alcohol abuse (15.2 percent). Compared with the other admissions groups, primary heroin admissions had the highest proportion of Medicaid coverage (37.2 percent).

Figure 3. Health Insurance Status among Admissions Aged 26 or Older, by Primary Substance of Abuse: 2011*
This is a bar graph comparing health insurance status among admissions aged 26 or older, by primary substance of abuse: 2011*. Accessible table located below this figure.

Figure 3 Table. Health Insurance Status among Admissions Aged 26 or Older, by Primary Substance of Abuse: 2011*
Health Insurance Status Alcohol Marijuana Cocaine Heroin Opiates Other
than Heroin
Stimulants
None 60.7% 65.1% 60.9% 51.6% 58.2% 71.3%
Private 15.2%   6.4%   5.0%   4.0%   9.4% 5.6%
Medicaid 15.2% 19.9% 26.6% 37.2% 23.9% 13.1%
Other   8.8%   8.6%   7.5%   7.1%   8.4%   9.9%
* Percentages may not sum to 100 percent due to rounding.
Source: SAMHSA Treatment Episode Data Set (TEDS), 2011.


Referral Source

About two thirds (67.5 percent) of admissions aged 26 or older that were referred to substance abuse treatment by the criminal justice system had no insurance, substantially exceeding the percentages for most other referral sources (Table 3). Admissions referred by an employer or an Employee Assistance Program had the highest percentage of private insurance (43.0 percent), but even in this group, 45.8 percent of admissions had no insurance. Admissions that were referred to substance abuse treatment by schools had the largest proportion of Medicaid coverage (35.3 percent) compared with other admissions groups.

Table 3. Health Insurance Status among Admissions Aged 26 or Older, by Referral Source: 2011*
Type of Health
Insurance
Criminal
Justice System
(Percent)
Individual
(Percent)
Alcohol or
Drug Abuse
Care Provider
(Percent)
Other Health
Care Provider
(Percent)
Employer/EAP
(Percent)
School
(Percent)
Other
Community
Referral
(Percent)
No Insurance 67.5% 55.8% 48.8% 54.8% 45.8% 45.8% 61.3%
Any Insurance 32.5% 44.2% 51.2% 45.2% 54.2% 54.2% 38.7%
Private 11.5% 10.3%   8.5% 12.8% 43.0%   8.0%   7.2%
Medicaid 11.3% 27.1% 33.9% 23.9%   3.4% 35.3% 23.5%
Other   9.7%   6.8%   8.9%   8.5%   7.9% 10.9%   8.1%
* Percentages may not sum to 100 percent due to rounding.
Source: SAMHSA Treatment Episode Data Set (TEDS), 2011.


Discussion

This report shows that prior to the ACA's implementation, 3 out of 5 substance abuse treatment admissions aged 26 or older had no health insurance, and that these admissions differed by several demographic and socio-economic characteristics. With full ACA implementation, access to affordable insurance will increase among the uninsured. For example, as shown in this report, a higher proportion of female admissions had some form of insurance compared with male admissions, and this difference was largely due to a greater percentage of female admissions having Medicaid coverage compared with male admissions. As eligibility for Medicaid coverage expands under the ACA in many States to those who were not previously eligible (e.g., low-income adults without children3 and the criminal justice population7), the composition of treatment admissions reporting Medicaid coverage might change.

While 59.6 percent of treatment admissions were able to access treatment despite having no health insurance, millions of Americans with substance use disorders do not receive treatment due to a lack of health insurance.1,8,9 As States and the Federal Government implement the ACA, updates of this report will help track the proportion of treatment admissions without health insurance over time. Individuals who are in need of substance abuse treatment and are unsure how the ACA may impact their ability to gain health care coverage can get useful information from the following Web sites:


End Notes
1 Substance Abuse and Mental Health Services Administration. (2012). Results from the 2011 National Survey on Drug Use and Health: Summary of national findings (NSDUH Series H-44, HHS Publication No. SMA 12-4713). Rockville, MD: Author.
2 National Association of State Alcohol and Drug Abuse Directors. (2010, March). The effects of health care reform on access to, and funding of, substance abuse services in Maine, Massachusetts, and Vermont. Washington, DC: Author.
3 The Patient Protection and Affordable Care Act. (2010, March 23). Pub. L. No. 111-148, 124 Stat. 119.
4 Health Care and Education Reconciliation Act of 2010. (2010, March 30). Pub. L. No. 111-152, 124 Stat. 1029.
5 For more information about the ACA timeline, please refer to this Web site: http://www.whitehouse.gov/healthreform.
6 For more information about which States reported health insurance information in 2011, please see the following table from SAMHSA's Treatment Episode Data Set (TEDS): 2001-2011 report: http://www.samhsa.gov/data/2k13/TEDS2011/TEDS2011NTblA.3.htm. The full report may be found at the following link: http://www.samhsa.gov/data/2k13/TEDS2011/TEDS2011N.pdf.
7 Cuellar, A. E., & Cheema, J. (2012). As roughly 700,000 prisoners are released annually, about half will gain health coverage under federal laws. Health Affairs, 31(5), 931-938.
8 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2009, April 9). The NSDUH Report: Alcohol treatment: Need, utilization, and barriers. Rockville, MD: Author.
9 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2003, November 7). The NSDUH Report: Reasons for not receiving substance abuse treatment. Rockville, MD: Author.



Suggested Citation
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (February 6, 2014). The TEDS Report: Health Insurance Status of Adult Substance Abuse Treatment Admissions Aged 26 or Older: 2011. Rockville, MD.

The Treatment Episode Data Set (TEDS) is an administrative data system providing descriptive information about the national flow of admissions aged 12 or older to providers of substance abuse treatment. TEDS intends to collect data on all treatment admissions to substance abuse treatment programs in the United States receiving public funds. Treatment programs receiving any public funds are requested to provide TEDS data on publicly and privately funded clients.

TEDS is one component of the Behavioral Health Services Information System (BHSIS), maintained by the Center for Behavioral Health Statistics and Quality (CBHSQ), Substance Abuse and Mental Health Services Administration (SAMHSA). TEDS records represent admissions rather than individuals, as a person may be admitted to treatment more than once. Information on treatment admissions is routinely collected by State administrative systems and then submitted to SAMHSA in a standard format.

There are significant differences among State data collection systems. Sources of State variation include the amount of public funding available and the constraints placed on the use of funds, facilities reporting TEDS data, clients included, services offered, and completeness and timeliness of reporting. See the annual TEDS reports for details. TEDS received approximately 1.8 million treatment admission records from 46 States, the District of Columbia, and Puerto Rico for 2011.

Definitions of demographic, substance use, and other measures mentioned in this report are available in Appendix B of the annual TEDS report on national admissions (see latest report at http://www.samhsa.gov/data/2k13/TEDS2011/TEDS2011NAppB.htm).

The TEDS Report is prepared by the Center for Behavioral Health Statistics and Quality, SAMHSA; Synectics for Management Decisions, Inc., Arlington, VA; and RTI International, Research Triangle Park, NC. Information and data for this issue are based on data reported to TEDS through October 15, 2012.

Latest TEDS reports:
http://www.samhsa.gov/data/DASIS.aspx#TEDS

Latest TEDS public use files and variable definitions:
http://datafiles.samhsa.gov

Other substance abuse reports:
http://www.samhsa.gov/data

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