February 11, 2010

Uninsured Employed Admissions to Treatment

Recent figures show that 46 million persons younger than age 65 do not have health insurance.¹ Most individuals with a full-time job and health insurance have coverage through their employers. However, as health insurance premiums have increased, many employers have eliminated or reduced health insurance coverage, including behavioral health benefits, or they have passed on the increased premium costs to their employees. As a result, many full-time employees either work for employers that do not offer health insurance or are unable to afford the health care coverage that is available through their employers, and many may not be eligible for publicly funded programs because of their employment status and wages. Understanding the characteristics of substance abuse treatment admissions that are employed full time but do not have health insurance may help treatment providers reach out to a community that lacks the access and resources to obtain care.

Data from the Treatment Episode Data Set (TEDS) can be used to examine substance abuse treatment admissions by employment status and health insurance coverage. This report focuses on the characteristics of adult substance abuse treatment admissions aged 18 or older that were employed full time but did not have health insurance (hereafter referred to as "employed uninsured admissions"). Comparisons are made with adult admissions that were employed full time and did have health insurance (hereafter referred to as "employed insured admissions"). TEDS includes a Minimum Data Set collected by all States and a Supplemental Data Set collected by some States. Health insurance is a Supplemental Data Set item. Only data on admissions for the 30 States with a response rate of 75 percent or higher on this item for 2007 were used in this report. Of the approximately 185,000 admissions employed full time in these 30 States in 2007, 61.5 percent (or 113,800) did not have health insurance.²

Demographic Characteristics

When compared, there were differences by gender, race/ethnicity, age, and educational level between employed uninsured and employed insured admissions (Table 1). Most employed uninsured substance abuse treatment admissions were male (81.0 percent), and the majority were non-Hispanic White (67.7 percent). More than half (58.7 percent) of employed uninsured admissions were between the ages of 18 and 34 making them, on average, younger at the time of admission than their insured counterparts (33.2 vs. 35.5 years old). Employed uninsured admissions were more likely than employed insured admissions to have had less than a high school education (28.2 vs. 17.8), and they were less likely to have had some college (23.4 vs. 36.0 percent).

Primary Substance of Abuse and Prior Treatment Admissions

The three most common primary substances of abuse among employed uninsured admissions were alcohol, marijuana, and cocaine. Employed uninsured admissions were less likely than their counterparts with health insurance to have reported primary alcohol abuse (54.5 vs. 60.8 percent) (Figure 1). However, they were more likely to have reported primary marijuana abuse (14.9 vs. 9.4 percent).

The majority of employed uninsured admissions had never been in treatment before. This was also the case among employed admissions with health insurance. However, the proportion was higher among the employed uninsured than among the employed insured (58.2 vs. 53.9 percent).

Principal Source of Referral

The most common sources of referral to treatment among employed uninsured admissions were the criminal justice system and individual or self-referrals. This was also the case for employed admissions with health insurance. However, employed uninsured admissions were more likely than their insured counterparts to be referred to treatment by the criminal justice system (59.8 vs. 46.1 percent) but less likely to be individual or self-referrals (21.9 vs. 28.8 percent) (Figure 2). A very small proportion of both groups were referred to treatment by their employers or an employee assistance program (EAP) (1.0 and 3.2 percent).

Expected/Actual Primary Source of Payment

Government funding, such as money made available through State and local governments and Federal Block Grants, was the most common primary source of payment for employed uninsured admissions, followed by self-payment.³ In fact, these admissions were more than three times as likely as employed admissions with health insurance to report government funding as the primary source of payment for the current treatment episode (45.1 vs. 13.5 percent) (Figure 3). Equally large proportions of both groups were self-pay clients (41.7 percent each). Employed uninsured admissions were more likely than employed admissions with health insurance to have received treatment at no charge through a charity, as part of special research, or at a teaching facility (6.0 vs. 2.4 percent).

Co-occurring Psychiatric Disorders

Among employed uninsured admissions, 13.7 percent had a psychiatric disorder in addition to a substance use problem.⁴ In comparison, more than one fifth (21.3 percent) of employed admissions with health insurance had a co-occurring psychiatric disorder.

Discussion

Even though the majority of full-time employed substance abuse treatment admissions reported to TEDS for 2007 did not have health insurance, they were able to access treatment for their addictions. This finding is encouraging because it indicates that even without health insurance access to treatment is possible.

However, individuals who do not have health insurance have less access to health care services. They may not seek or they may delay seeking the services they need to treat their addiction because treatment is expensive and often spans a significant portion of time. If they do obtain services, they must pay the cost themselves. In fact, a sizeable proportion of employed admissions without health insurance were self-pay clients. Because treatment is expensive, it is unrealistic to expect that most individuals can afford to take time off of work to receive treatment and pay the full cost of the services.

Even employed admissions with health insurance may end up paying for treatment themselves. In fact, a sizeable proportion of employed admissions with health insurance were also self-pay clients. This finding may indicate that the potential stigma associated with substance abuse treatment leads individuals with a full-time job that provides health insurance coverage to pay for treatment themselves because they do not want their employers to be aware of their substance use problems.

End Notes

¹ DeNavas-Walt, C., Proctor, B. D., amp&; Smith, J. C. (2009). Income, poverty, and health insurance coverage in the United States: 2008 (Current Population Reports, P60-236). Washington, DC: U.S. Government Printing Office.
² Health insurance is a Supplemental Data Set item. The 30 States and jurisdictions in which it was reported for at least 75 percent of all admissions in 2007—AR, AZ, CO, DE, HI, ID, IL, IN, KS, KY, LA, MA, MD, ME, MT, ND, NE, NH, NJ, NM, NV, OK, OR, PA, PR, SC, SD, TX, UT, WY—accounted for 45 percent of all substance abuse treatment admissions in 2007. The following categories are included as part of the health insurance variable: (1) private insurance (other than Blue Cross/Blue Shield or an HMO), (2) Blue Cross/Blue Shield, (3) Medicare, (4) Medicaid, (5) Health Maintenance Organization (HMO), (6) other (e.g., TRICARE, CHAMPUS), (7) none.
³ Health insurance and expected/actual primary source of payment are Supplemental Data Set items. The 18 States and jurisdictions in which both were reported for at least 75 percent of all admissions in 2007—AR, CO, DE, HI, ID, KS, KY, LA, ND, NH, NJ, NV, PA, PR, SC, SD, TX, UT—accounted for 24 percent of all substance abuse treatment admissions in 2007.
⁴ Health insurance and psychiatric problem in addition to alcohol or drug problem are Supplement Data Set items. The 20 States and jurisdictions in which both were reported for at least 75 percent of all admissions in 2007—AR, CO, DE, ID, IL, KS, KY, LA, MA, MD, ME, ND, NE, NM, OK, PR, SC, SD, UT, WY—accounted for 27 percent of all substance abuse treatment admissions in 2007.

Suggested Citation

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (February 11, 2010). The TEDS Report: Uninsured Employed Admissions to Treatment. Rockville, MD.