April 15, 2010 |
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According to the 2008 National Survey on Drug Use and Health, the most common reason why individuals with substance use problems do not seek treatment is the financial burden imposed by a lack of health insurance or health insurance without a behavioral health benefit, and/or insufficient means to pay for treatment.1 Nevertheless, a review of admissions to substance abuse treatment in 2007 shows that nearly 60 percent of all admissions did not have health insurance of any kind.2
Treatment providers recognize that paying for treatment can be a burden to their clients. To help defray the costs of treatment, some facilities offer treatment at no charge and/or a sliding fee scale based on income and other factors. Data from the 2008 National Survey of Substance Abuse Treatment Services (N-SSATS) allows a comparison of facilities that offer free care with others that do not.
In 2008, there were 13,688 substance abuse treatment facilities that responded to N-SSATS. Of these facilities, 539 (3.9 percent) provided free treatment to ALL clients, 6,609 (48.3 percent) offered treatment at no charge to clients who could not afford to pay, and 6,540 (47.8 percent) did not offer free treatment. For this report, facilities that provide free treatment for all clients will be referred to as "all free," those that provide free treatment to clients who cannot afford to pay will be referred to as "partial free," and the final group will be referred to as "no free" facilities.
Facility Operation
Private non-profit organizations operated the vast majority of "all free" (73.8 percent) and "partial free" (68.1 percent) facilities (Table 1). Among "no free" facilities, approximately equal percentages were operated by private for-profit (46.9 percent) and private non-profit (46.4 percent) organizations.
Facility Payment Group |
Total | Facility Operation | ||||||||
---|---|---|---|---|---|---|---|---|---|---|
Federal Government | ||||||||||
Private For-profit | Private Non-profit | State Government | Local Government | Tribal Government |
Department of Veterans Affairs | Department of Defense | Indian Health Service | Other | ||
All Free | 100.0% | 2.6% | 73.8% | 6.7% | 6.3% | 5.9% | 0.2% | 2.2% | 2.0% | 0.2% |
Partial Free | 100.0% | 14.1% | 68.1% | 4.4% | 8.3% | 1.8% | 2.4% | 0.5% | 0.4% | <0.1% |
No Free | 100.0% | 46.9% | 46.4% | 1.5% | 3.6% | 0.5% | 0.2% | 0.7% | 0.1% | <0.1% |
Note: Percentages may not sum to 100 percent due to rounding. Source: 2008 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS). |
However, among specific operation groups, other differences were apparent. Among substance abuse treatment facilities operated by a private for-profit organization, 76.4 percent were "no free" and 23.2 percent were "partial free," whereas among facilities operated by a private non-profit organization, 38.3 percent were "no free" and 56.7 percent were "partial free" (Table 2). Among federally operated facilities, those operated by the Department of Veterans Affairs (VA) and the Indian Health Service (IHS) were more likely to be "partial free" than "no free," while those operated by the Department of Defense (DoD) were more likely to be "no free" than "partial free."
Facility Payment Group |
Facility Operation | ||||||||
---|---|---|---|---|---|---|---|---|---|
Federal Government | |||||||||
Private For-profit | Private Non-profit | State Government | Local Government | Tribal Government |
Department of Veterans Affairs | Department of Defense | Indian Health Service | Other | |
Total | 100.0% | 100.0% | 100.0% | 100.0% | 100.0% | 100.0% | 100.0% | 100.0% | 100.0% |
All Free | 0.3% | 5.0% | 8.4% | 4.1% | 17.8% | 0.6% | 12.9% | 25.0% | 33.3% |
Partial Free | 23.2% | 56.7% | 68.1% | 67.1% | 65.5% | 90.8% | 35.5% | 63.6% | 33.3% |
No Free | 76.4% | 38.3% | 23.4% | 28.8% | 16.7% | 8.6% | 51.6% | 11.4% | 33.3% |
Note: Percentages may not sum to 100 percent due to rounding. Source: 2008 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS). |
Types of Payment
By definition, facilities in the "all free" group provided free care to all their clients. Because they did not accept any type of client payment, they are excluded from the discussion of types of client payments accepted.
Overall, equivalent percentages of "partial free" and "no free" facilities accepted client payments of cash/self payment (91.7 vs. 94.6 percent), Medicare (40.0 vs. 33.8 percent), Federal military insurance (38.0 vs. 34.8 percent), and private health insurance (65.4 vs. 67.5 percent). "Partial free" facilities were more likely than "no free" facilities to accept Medicaid (64.7 vs. 49.0 percent) or State-financed health insurance (48.8 vs. 36.1 percent).
Facilities within the "partial free" group were more likely than those within the "no free" group to use a sliding fee scale that was based on income or other factors (78.2 vs. 50.3 percent). Therefore, even though there was no provision for free treatment among approximately 6,500 facilities (the "no free" group), about half of them used a sliding fee scale for eligible clients.
Of the "no free" group, substance abuse treatment facilities operated by private non-profit organizations (57.9 percent), State governments (63.6 percent), local governments (77.9 percent), or tribal governments (55.2 percent) were more likely than those operated by private for-profit organizations (41.1 percent) to use a sliding fee scale. In general, Federal Government-operated facilities, whether "partial free" or "no free," did not use a sliding fee scale. Among the "partial free" group, there was little difference by facility operation in the percentages using a sliding fee scale (private for-profit—76.0 percent, private non-profit—81.3 percent, State government—79.7 percent, local government—88.5 percent). Just over one third of "partial free" tribal government-operated substance abuse treatment facilities (35.6 percent) used a sliding fee scale.
Therefore, overall 76.3 percent of all facilities offered some type of payment assistance to some proportion of their clients, whether free care or a sliding fee scale (Figure 1). Only 23.7 percent of all facilities did not offer any form of payment assistance.
Many facilities may also receive revenue from various public sources, such as grants or other funding from the Federal Government or from State, county, or local governments to support their substance abuse treatment programs. "All free" (82.4 percent) and "partial free" (78.0 percent) facilities were more likely than "no free" (42.3 percent) facilities to have received these funds.
Note: Percentages may not sum to 100 percent due to rounding. Source: 2008 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS). |
Type of Payment Assistance | Percent |
---|---|
All Free | 4.0% |
Partial Free with a Sliding Fee Scale | 37.8% |
Partial Free without a Sliding Fee Scale | 10.5% |
No Free with a Sliding Fee Scale | 24.0% |
No Free without a Sliding Fee Scale | 23.7% |
Note: Percentages may not sum to 100 percent due to rounding. Source: 2008 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS). |
Type of Care
Outpatient care was the most prevalent type of care offered by substance abuse treatment facilities regardless of the extent of payment assistance offered. However, facilities in the "no free" group (84.1 percent) and "partial free" group (78.4 percent) were more likely than those in the "all free" group (55.3 percent) to offer outpatient care. Conversely, facilities in the "all free" group (51.6 percent) were more likely than those in the "partial free" (30.5 percent) or "no free" (20.6 percent) groups to offer non-hospital residential care. Few facilities in any of the groups offered hospital inpatient care (1.7–6.8 percent).
Almost all facilities, regardless of the availability (or not) of free care, provided individual counseling (95.4–97.8 percent) and group counseling (89.6–94.5 percent) (Table 3). While fewer facilities offered family counseling (62.5–74.0 percent) or marital/couples counseling (39.2–48.0 percent), their percentages were roughly similar among "all free," "partial free," and "no free" facilities.
Likewise, there were few differences based on the clinical/therapeutic approaches used by the facilities in each of the payment groups.
Clinical/Therapeutic Approach | Percent of "All Free" Facilities |
Percent of "Partial Free" Facilities |
Percent of "No Free" Facilities |
---|---|---|---|
Substance Abuse Counseling | 97.8% | 97.4% | 96.1% |
12-step Facilitation | 49.1% | 59.9% | 55.7% |
Brief Intervention | 35.7% | 38.0% | 33.9% |
Cognitive-behavioral Therapy | 46.6% | 67.3% | 65.6% |
Contingency Management/Motivational Incentives | 28.1% | 29.7% | 25.3% |
Motivational Interviewing | 51.2% | 57.9% | 48.4% |
Trauma-related Counseling | 21.1% | 23.7% | 18.9% |
Anger Management | 37.3% | 43.6% | 35.3% |
Matrix Model | 10.8% | 17.5% | 13.0% |
Community Reinforcement Plus Vouchers | 8.9% | 6.4% | 3.6% |
Rational Emotive Behavioral Therapy (REBT) | 12.6% | 16.9% | 18.0% |
Relapse Prevention | 88.6% | 90.0% | 87.2% |
Source: 2008 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS). |
Specially Designed Groups or Programs
Many facilities offer specially designed programs or groups tailored to the treatment needs of specific client types. These groups may be designed around age, physical health status, or particular aspects of a substance use disorder which has brought the client to treatment.
While there were minor differences among the three groups of facilities concerning the availability of special groups or programs, striking differences were apparent for a few specific client types. "All free" facilities were less likely than either "partial free" or "no free" facilities to have a special group or program for driving under the influence/driving while intoxicated (DUI/DWI) clients (5.2 vs. 28.5 vs. 30.5 percent) (Table 4). "All free" and "partial free" facilities were more likely than "no free" facilities to have a special group for adult women. "All free" facilities were more likely than "partial free" facilities, who in turn were more likely than "no free" facilities, to have a special group for adult men.
Programs for Special Groups | Percent of "All Free" Facilities |
Percent of "Partial Free" Facilities |
Percent of "No Free" Facilities |
---|---|---|---|
Driving Under the Influence/Driving While Intoxicated (DUI/DWI) | 5.2% | 28.5% | 30.5% |
Adolescents | 51.9% | 66.9% | 57.4% |
Clients with Co-occurring Mental and Substance Abuse Disorders | 30.7% | 44.4% | 36.0% |
Criminal Justice Clients (other than DUI/DWI) | 22.1% | 33.5% | 27.5% |
Persons with HIV or AIDS | 10.3% | 12.4% | 7.8% |
Gays or Lesbians | 4.6% | 6.7% | 5.1% |
Seniors or Older Adults | 6.7% | 8.8% | 6.6% |
Adult Women | 41.5% | 43.5% | 31.4% |
Pregnant or Postpartum Women | 19.9% | 20.1% | 13.3% |
Adult Men | 45.5% | 33.9% | 24.5% |
Source: 2008 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS). |
Services
In addition to substance abuse treatment, many facilities also offer various services that either directly support recovery (such as substance abuse education, screening for substance abuse, and discharge planning) or support recovery by improving the skills, health, and abilities of the individual (such as social skills development, health education, and employment counseling).
Similar percentages of facilities in each of the three payment groups provided many of the services that directly support recovery such as screening for substance abuse (89.6–92.9 percent), comprehensive substance abuse assessment or diagnosis (80.5–90.3 percent), substance abuse education (93.3–95.7 percent), and discharge planning (90.5–93.9 percent) (Table 5). However, "partial free" and "no free" facilities were more likely than "all free" facilities to offer most testing services such as breathalyzer, drug or alcohol urine screening, screening for hepatitis B and C, etc.
"No free" facilities were less likely than "all free" or "partial free" facilities to offer many ancillary services that build the individual such as social skills development, mentoring or peer support, assistance with obtaining social services, employment counseling, assistance in locating housing for clients, health education, or transportation assistance to treatment.
Services | Percent of "All Free" Facilities |
Percent of "Partial Free" Facilities |
Percent of "No Free" Facilities |
---|---|---|---|
Assessment and Pre-Treatment Services | |||
Screening for Substance Abuse | 89.6% | 92.9% | 92.9% |
Screening for Mental Health Disorders | 50.0% | 66.8% | 60.4% |
Comprehensive Substance Abuse Assessment or Diagnosis | 80.5% | 90.3% | 89.3% |
Comprehensive Mental Health Assessment or Diagnosis | 34.7% | 45.6% | 42.6% |
Outreach to Persons in the Community Who May Need Treatment | 63.2% | 58.6% | 41.9% |
Interim Services for Clients When Immediate Admission is Not Possible | 48.6% | 48.5% | 31.7% |
Testing | |||
Breathalyzer or Other Blood Alcohol Testing | 38.2% | 59.8% | 60.3% |
Drug or Alcohol Urine Screening | 71.8% | 84.4% | 82.1% |
Screening for Hepatitis B | 13.8% | 23.6% | 21.6% |
Screening for Hepatitis C | 14.9% | 24.6% | 22.8% |
HIV Testing | 24.8% | 33.2% | 25.8% |
STD Testing | 12.6% | 21.7% | 20.8% |
TB Screening | 29.2% | 36.5% | 33.7% |
Transitional Services | |||
Discharge Planning | 90.5% | 93.9% | 90.8% |
Aftercare/Continuing Care | 76.9% | 83.1% | 81.1% |
Ancillary Services | |||
Case Management Services | 85.7% | 82.6% | 70.7% |
Social Skills Development | 83.9% | 72.9% | 61.8% |
Mentoring/Peer Support | 68.7% | 51.1% | 39.8% |
Child Care for Clients' Children | 13.0% | 11.2% | 4.2% |
Assistance with Obtaining Social Services | 64.6% | 62.4% | 41.4% |
Employment Counseling or Training for Clients | 56.4% | 40.3% | 27.4% |
Assistance in Locating Housing for Clients | 60.0% | 52.7% | 34.0% |
Domestic Violence—Family or Partner Violence Services | 28.1% | 39.7% | 32.3% |
Early Intervention for HIV | 37.7% | 31.1% | 18.3% |
HIV or AIDS Education, Counseling, or Support | 66.1% | 61.7% | 47.5% |
Health Education other than HIV/AIDS | 64.9% | 56.4% | 42.4% |
Substance Abuse Education | 95.0% | 95.7% | 93.3% |
Transportation Assistance to Treatment | 62.6% | 45.6% | 26.8% |
Mental Health Services | 46.9% | 58.7% | 54.7% |
Self-help Groups | 50.2% | 53.2% | 41.6% |
Source: 2008 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS). |
Discussion
The financial and societal costs of untreated substance abuse disorders are enormous. A National Institute on Drug Abuse report estimated that "[t]he cost to society of drug abuse in the year 2002 was $181 billion—$107 billion associated with drug-related crime."3
Nevertheless, each year thousands of people in need of treatment do not receive the services which they need. Although there are many reasons why an individual might not seek treatment, the issue of cost need not necessarily be a barrier. The data from N-SSATS show clearly that not only is such treatment available, but also that the facilities offering free care provide a rich array of therapeutic approaches, special programs, and other ancillary services.
Individuals seeking free treatment and those making referrals for impoverished clients may wish to use the Substance Abuse Treatment Facility Locator sponsored by the Office of Applied Studies at SAMHSA. The locator can be found at http://findtreatment.samhsa.gov/. To locate facilities offering free or reduced cost services, select from the "Payment Assistance" options when designing your search.
End Notes
1 Substance Abuse and Mental Health Services Administration. (2009). Results from the 2008 National Survey on Drug Use and Health: National findings (Office of Applied Studies, NSDUH Series H-36, HHS Publication No. SMA 09-4434). Rockville, MD: Author.
2 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2009). Treatment Episode Data Set (TEDS): 1997–2007. National admissions to substance abuse treatment services (DASIS Series: S-47, HHS Publication No. SMA 09-4379). Rockville, MD: Author.
3 NIDA announces recommendations to treat drug abusers, save money, and reduce crime [NIDA News Release]. (2006, July 24). Retrieved January 8, 2010, from http://www.drugabuse.gov/newsroom/06/NR7-24.html
Suggested Citation
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (April 15, 2010). The N-SSATS Report: Free Substance Abuse Treatment. Rockville, MD.
The National Survey of Substance Abuse Treatment Services (N-SSATS) is an annual survey of all substance abuse treatment facilities in the United States, both public and private, that are known to the Substance Abuse and Mental Health Services Administration (SAMHSA). N-SSATS is one component of the Drug and Alcohol Services Information System (DASIS), an integrated data system maintained by the Office of Applied Studies, SAMHSA. N-SSATS collects three types of information from facilities: characteristics of individual facilities such as services offered and types of treatment provided, primary focus of the facility, and payment options; client count information such as counts of clients served by service type and number of beds designated for treatment; and general information such as licensure, certification, or accreditation and facility website availability. In 2008, N-SSATS collected information from 13,688 facilities from all 50 States, the District of Columbia, the Federated States of Micronesia, Guam, Palau, Puerto Rico, and the Virgin Islands. Information and data for this report are based on data reported to N-SSATS for the survey reference date March 31, 2008. The N-SSATS Report is prepared by the Office of Applied Studies, SAMHSA; Synectics for Management Decisions, Inc., Arlington, Virginia; and by RTI International in Research Triangle Park, North Carolina (RTI International is the trade name of Research Triangle Institute). Information on the most recent N-SSATS is available in the following publication: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2009). National Survey of Substance Abuse Treatment Services (N-SSATS): 2008. Data on Substance Abuse Treatment Facilities (DASIS Series: S-49, DHHS Publication No. (SMA) 09-4451). Rockville MD: Author. Access the latest N-SSATS reports
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The N-SSATS Report is published periodically by the Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA). All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA. Additional copies of this report or other reports from the Office of Applied Studies are available online: http://oas.samhsa.gov. Citation of the source is appreciated. For questions about this report, please e-mail: shortreports@samhsa.hhs.gov. N-SSATS_202 |
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