PAC 411 Module 8 Social Policy and Services Example

Coverage Is Treatment: Parity, Medicaid Expansion and a Social Work Agency's Case for Policy Change

Student Name

Psychology and Addiction Studies Program, Aspen University

PAC 411: Social Work as a Profession

Instructor Name

Month Day, Year

Coverage Is Treatment: Parity, Medicaid Expansion and a Social Work Agency's Case for Policy Change

Westgate runs an addiction program in a composite state that has not expanded Medicaid and whose legislature is debating whether to do so. Three clients this year show why the debate matters. Angela, a thirty-two-year-old waitress with opioid use disorder, earns too much for the state's narrow Medicaid program but cannot afford private insurance; she has paid cash for buprenorphine when she can and gone without when she cannot. Jerome, forty-five, a factory worker with employer insurance, was denied residential treatment years ago under a plan that limited substance use treatment more than medical care. Paul, twenty-eight, left jail last month with no coverage and no prescription. This paper analyzes the policies behind their situations and sets out an advocacy plan. The three clients and the legislative debate are invented for this assignment; the studies of parity and expansion are not.

Parity in Insurance Coverage

Busch (2012) analyzed the Mental Health Parity and Addiction Equity Act, passed in 2008, which requires that group health plans that cover mental health and substance use treatment do so on terms no more restrictive than those for medical and surgical care. The law applies to financial requirements, such as copayments and deductibles, and to treatment limitations, including quantitative limits, such as caps on visits or days, and nonquantitative limits, such as stricter prior authorization or medical necessity criteria. Busch noted that nonquantitative limits had often been used to restrict substance use treatment in ways that were harder to see, and that the law's effects would depend on how vigorously it was implemented and enforced. Parity does not require plans to cover substance use treatment at all, but later legislation extended coverage requirements to many individual and small group plans.

Jerome's earlier denial is the kind of restriction parity was designed to prevent.

Medicaid Expansion and Medication Treatment

For people like Angela and Paul, the question is not parity but coverage itself. Under the Affordable Care Act, states could expand Medicaid to most low-income adults. Wen et al. (2017) compared states that expanded Medicaid with states that did not and found that expansion was associated with a substantial increase in Medicaid-covered prescriptions for buprenorphine and in Medicaid spending on buprenorphine for opioid use disorder. Saloner et al. (2018), using national prescription data, similarly found larger increases in Medicaid-paid buprenorphine-naloxone prescriptions in expansion states, while prescriptions for opioid pain relievers changed little. Both studies were observational, comparing states that made different policy choices, but they consistently pointed to expansion increasing access to medication treatment.

The Policies and the Three Clients

How Policy Reaches the Program

Policy shapes not only individual clients' access but Westgate's ability to serve them. Most of its addiction clients are uninsured, so the program depends on grants and sliding fees that cover only part of the cost of care. It cannot hire a full-time prescriber, so buprenorphine appointments are limited to two afternoons a week, and the waiting list for them is three weeks long. When clients are insured, through employer plans protected by parity or through Medicaid, the program can bill for counseling and medication management, which in turn pays for staff. In expansion states, programs like Westgate have been able to add prescribers and extend hours. For Angela and Paul, expansion would mean coverage; for Westgate, it would mean the capacity to see them promptly.

What Happens at Reentry

Paul's situation shows a particular gap. People leaving jail face a high risk of overdose in their first weeks, yet many leave without insurance or medication. In some expansion states, jails help people enroll in Medicaid before release, so that coverage begins the day they walk out, and some begin buprenorphine before release. Without coverage, Paul's first weeks out depend on whether he can find a free clinic with an opening. Advocacy for expansion therefore includes advocacy for enrollment at reentry, a practical step that turns a coverage policy into treatment at the moment it is most needed.

Arguments on Both Sides

Opponents of expansion argue that it costs the state money, that it may encourage dependence on public programs and that federal funding may not last. Supporters point to the federal government's large share of expansion costs, to evidence that expansion increases treatment for opioid use disorder and to costs avoided when people receive treatment rather than emergency care or incarceration. A fair analysis acknowledges real budget concerns while noting that the evidence on treatment access is consistent and that untreated addiction carries costs of its own, borne by hospitals, jails and families.

The Agency's Advocacy Plan

Social work's commitment to social justice includes policy work. Westgate will document the number of uninsured clients it serves and the treatment they forgo, using its own records. With written consent, Angela and Paul may share their stories, in person or in writing, with legislators. The agency's director will testify at the legislative hearing, presenting data from Wen and colleagues and Saloner and colleagues alongside local figures. Westgate will join a coalition of hospitals, clinics and recovery organizations supporting expansion and will meet with its local legislators. It will also review its own employer clients' insurance plans for parity violations and help clients like Jerome appeal denials.

Conclusion

Angela, Jerome and Paul show that policy decides who receives treatment. Busch explains how parity protects people with insurance from unequal limits, while Wen and colleagues and Saloner and colleagues show that Medicaid expansion increases access to medication for opioid use disorder. Westgate's advocacy, grounded in data and clients' own voices, carries forward the tradition with which this course began: helping individuals while working to change the conditions around them.

References

Busch, S. H. (2012). Implications of the Mental Health Parity and Addiction Equity Act. American Journal of Psychiatry, 169(1), 1-3. https://doi.org/10.1176/appi.ajp.2011.11101543

Saloner, B., Levin, J., Chang, H.-Y., Jones, C., & Alexander, G. C. (2018). Changes in buprenorphine-naloxone and opioid pain reliever prescriptions after the Affordable Care Act Medicaid expansion. JAMA Network Open, 1(4), e181588. https://doi.org/10.1001/jamanetworkopen.2018.1588

Wen, H., Hockenberry, J. M., Borders, T. F., & Druss, B. G. (2017). Impact of Medicaid expansion on Medicaid-covered utilization of buprenorphine for opioid use disorder treatment. Medical Care, 55(4), 336-341. https://doi.org/10.1097/MLR.0000000000000703