The Treatment Workforce: What Will It Look Like under the Affordable Care Act?
- Published on April 19, 2012
The constitutionality of requiring every adult to carry health insurance coverage is but one of a myriad of issues creating public curiosity and work force concern about changes coming under the Affordable Care Act (ACA). What are its implications for counselors and for the substance abuse treatment work force?
The Senate Appropriations Committee had a March 31 deadline to review a report that Congress requested in the fall from the National Association for Addiction Professionals (NAADAC) describing the substance abuse workforce under the ACA. This report was prepared by H. Wesley Clark, M.D., Director of SAMHSAs Center for Substance Abuse Treatment (CSAT) and Linda Kaplan, a special expert at CSAT. It provides insight into what the treatment workforce may look like under the ACA.
Some of the areas of concern include: Will treatment professionals be required to hold a Masters Degree? What, if any, will be the certification requirements? Will the relationships between the various players from primary care doctors to counselors to peer mentors be altered? What does this mean for the patients? Lets look briefly at each of these questions.
The question of competency
In the field of treatment there has been a movement in many states over recent years to require addiction counselors to hold a masters degree, this movement pre-dates the Affordable Care Act (ACA). Many people expected that as part of ACA the federal government would require a masters degree as a minimum requirement for treatment counselors. This is proving not to be the case. In excerpts of an interview published this month by the Alcoholism & Drug Abuse Weekly (ADAW), Clark revealed that the federal government is leaving it to the states to decide whether to require treatment counselors to hold a masters degree. Instead the federal government is emphasizing the need to require core competencies. Competency was defined by Clark as having an outcome that is acceptable to the client, to the insurance company, and to society. To accomplish such outcomes SAMHSA calls for use of evidence-based strategies (approaches whose effectiveness is supported by research) such as motivational interviewing, cognitive behavioral therapy, and medication-assisted treatment. These competencies may be measured by states based on such criteria as a masters degree and/or certification exam(s). Some states may ease the process by offering grandfathering and/or a transition period to its workforce. Mentoring will also be encouraged as a tool for teaching and training. (ADAW, 24/10, 2012) Previously passage of a certification exam had been a primary criterion for qualification to work as a professional addiction counselor. The field was largely composed of persons who had experienced addiction and wanted to help others overcome addiction. There were few if any experts, theories or treatment programs. (Osborn, 2011).
In Indiana the movement to require licensure and formal degrees for addiction counselors began in the early 1990s (Osborn, 2011) but still met with legislative resistance in the mid-2000s. In 2006 a pilot program funded by a Substance Abuse and Mental Health Services Administration (SAMHSA) education grant to Indiana Wesleyan University (IWU) gave Indiana a national leadership role. This education grant to IWU facilitated improvements in academic opportunities for the addiction workforce, based on SAMHSA's Technical Assistance Publication (TAP) 21, entitled Addiction Counseling Competencies: The Knowledge, Skills and Attitudes of Professional Practice. The program offered a certificate with courses leading to a masters degree in addiction counseling. Finally, in 2009 legislation -- the Indiana Addiction Counselor Licensure bill -- passed and became law. It requires treatment counselors to hold a bachelors degree and clinical treatment professionals to hold a masters degree. (Osborn, 2012; Stewart-turner and Stachler, 2011)
The relationship between the various players
Under the ACA a spectrum of health care professionals will coordinate and function increasingly as a team with emphasis on prevention and comprehensive health care, from screening in the primary care setting, to care for all chronic diseases, including addiction. The treatment will be aligned with the persons need, so that for some only a brief intervention will be appropriate, while for others intensive and ongoing care will be given. The bottom line will be providers working as a team, where specialists exist but as members of a team. Potential team members would include professionals and practitioners from the fields of mental health, addiction, prevention, primary care, social work, and nursing. Another example would be public health workers conducting interviews referred to as SBIRT (screening, brief intervention and referral to treatment). Other critical team members would be peers and recovery coaches who help individuals attain and maintain sobriety.
Indiana has been applying this team principle in its work in SBIRT and Access to Recovery (ACT), for which it has major funding through SAMSHSA grants. The Indiana Prevention Resource Center was instrumental in writing the grants which led to the state receiving millions of dollars for these activities. The ACT recovery-oriented care program involves an array of providers that includes representatives of addiction counseling and treatment, advocacy, education, housing, job training, traditional and alternative medicine, trauma services, life skills training, dental services, clergy, and more, all responding to the complex needs of the person battling an addiction to achieve and sustain recovery.
The Indiana Prevention Resource Center is leading the state in the development and promotion of SBIRT services. A SAMHSA grant funded program at the IU School of Medicine aims to promote change by inclusion of SBIRT in the curriculum for the physician residency program. Another SAMHSA grant is creating models for the provision of SBIRT in the primary care setting in outpatient clinics and making use of informational technology in innovative ways. This pilot project is currently underway at Wishard Hospitals Midtown Community Mental Health Center.
In 2014 when the ACA is fully in effect, Americans will have much greater access to substance abuse treatment, because of its greater affordability. This means they will be able to benefit from screening tests, motivational interviewing, cognitive behavioral therapies, and medication-assisted treatment, and from the support of peers and recovery coaches, giving them a much increased opportunity to enjoy good health and realize their dreams. This will impact all of society. The potential benefits to the work force, to crime reduction, to productivity and quality of life are awesome.
Behavioral Health and Human Services Licensing Board [for Addiction Counselor and Mental Health Counselors] Accessed April 17, 2012, at http://www.in.gov/pla/social.htm
Counselors rules to be set by states: SAMHSA, ADAW 24/10 (2012)
House Enrolled Act No. 1376 from 2nd Regular Session, 117th General Assembly (2012) Accessed on April 17, 2012, at http://www.in.gov/legislative/bills/2012/HE/HE1376.1.html (Describes the membership rules and purpose of the DMHA Advisory Council.
Indiana Professional Licensing Agency. Indiana Behavioral Health and Human Services Licensing Board. A Compilation of the Indiana code and Indiana Administrative Code, 2012 Ed. 2012. http://www.in.gov/pla/files/IBHHSLB_2012_Edition.pdf
Indiana University School of Medicine. About SBIRT@IUSM, 2012Accessed April 17, 2012, at http://iusbirt.org/about.
Information Maintained by the Office of Code Revision Indiana Legislative Services Agency, IC 25-23.6-10.5 describing Addiction Counselors; Clinical Addiction Counselors; Licensure; Examinations. Accessed on April 17, 2012, at http://www.in.gov/legislative/ic/code/title25/ar23.6/ch10.5.html [The addiction counselor must have a bachelors degree, the clinical addiction counselor a masters degree.]
Osborn, Donald P. Journey to a profession, Addiction Professional, July 2011. Accessed April 17, 2012 at http://www.addictionpro.com/article/journey-profession.
Stewart Turner-ball and Brent Stachler. Indiana law signals marriage of academic training, professional practice, Addiction Professional. March-April 2011. Accessed on April 17, 2012, at http://www.addictionpro.com/article/moving-licensure
U.S. Department of Health and Human Services, SAMHSA, CSAT. A National Review of State Alcohol and Drug Treatment Programs and Certification Standards for Substance Abuse Counselors and Prevention Professionals. 2005 www.hhs.gov/partnerships/resources/fbci_counselor_standards.pdf
Indiana Addiction Counselor Licensure bill was signed into law by Gov. Mitch Daniels in 2009