Implications of ACA Medicaid Expansion on Access to Substance Use Treatment Facilities with Specialty Programs for Justice-Involved Clients Open Access

Kaplan, Zoe (Spring 2020)

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As the United States grapples with both historically high incarceration and substance use disorder (SUD) rates, recent health insurance expansions and criminal justice (CJ) reforms offer opportunities to address dual concerns of public health and safety through increased access to evidence-based, cost-effective treatment alternatives. Specifically, clients—those exiting or diverted from the CJ system—are referred to CJ programs, which can entail mandatory treatment contracts delivered in SUD treatment facilities. While insurance expansion studies explore the impact on CJ-clients’ insurance status and treatment admission rates (i.e., demand-side response), none have examined the supply-side response, which is crucial when determining access to treatment. To address this gap, this research analyzed the effect of state Medicaid expansions through the Affordable Care Act (ACA) on the likelihood of SUD facilities offering CJ programs and relevant services. It further explored whether a SUD burden moderates these effects. Two-way fixed effects, difference-in-difference logistic regressions were performed using 2013-2017 National Survey of Substance Abuse Treatment Services (N-SSATS) data to compare change in likelihood following expansion. In secondary models, an interaction term measured the moderating impact of state-level SUD burden in this relationship. While percentage of facilities offering CJ programs increases over time, when controlling for confounders, Medicaid expansion effect was not statistically significant. However, when accounting for the moderating effect, the relationship between expansion and offering a CJ program is statistically significant, varying by SUD burden level. Expansion increases a facility’s probability in states with lower rates of SUD, however, is decreases in states with higher SUD rates (though not statistically significant). Although hypothetically, Medicaid expansion helped, these estimates suggest facilities in expansion states with high SUD burden may crowd justice clients out of treatment, potentially because facilities are discouraged from offering time and resource intensive CJ programs. Hence, while policy intentions may have been genuine, more targeted policies are needed to increase this population’s access to treatment. This study presents numerous avenues for future research; examining long-term implications of this policy change and interactions with constructs outside this scope. Moreover, qualitative studies of justice clients’ treatment accessibility will further explore barriers to patients’ SUD recovery.

Table of Contents

Abstract 1

Chapter 1: Introduction. 2

Chapter 2: Literature Review.. 6

2A: Introduction. 6

2B: Historical Context 7

2C: Movement towards the CJ-Reform with the decriminalization and diversion of SUD.. 9

2D: Treating SUD in the general population: 10

2E: Characteristics and Treatment of the SUD CJ-population. 11

2F: SUD Treatment Facilities with Specialty CJ Programs. 12

2G: Cost-savings compared to incarceration. 12

2H: Barriers and Limitations to Access. 13

2I: Medicaid Expansion and Access to Health Services. 14

2J: Gap in Literature. 16

Chapter 3: Methodology. 18

3A: Theoretical Framework. 18

3B: Conceptual Framework. 19

3C: Hypotheses. 25

3D: Data Description. 25

3E: Measures. 27

3F: Constructs and Measures. 27

3G: Analytic Sample. 30

3H: Analytic Strategy. 31

Chapter 4: Results. 32

4A: Descriptive Statistics. 32

4B: Descriptive Results. 33

4C: Logistic Regressions Results. 34

Chapter 5: Discussion. 37

Chapter 6: Conclusion. 40

6A: Conclusions. 40

6B: Limitations and Strengths. 42

6C: Policy Implications. 43

6D: Recommendations for Further Research. 44

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