Free Substance Abuse Treatment

In Brief
Private non-profit organizations operated the majority of facilities offering "all free" care and "partial free" facilities (73.8 and 68.1 percent, respectively); among facilities offering "no free" care, approximately equal percentages were operated by private for-profit (46.9 percent) and private non-profit (46.4 percent) organizations Facilities offering "all free" care (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 "All free" facilities were less likely than either "partial free" or "no free" facilities to have a specially designed group or program for DUI/DWI clients (5.2 vs. 28.5 vs. 30.5 percent)

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.

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.

Table 1. Percent Distribution of Facilities, by Facility Operation and Availability of Free Care (Row Percents): 2008
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."

Table 2. Percent Distribution of Facilities, by Facility Operation and by Availability of Free Care (Column Percents): 2008
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).

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.

Figure 1. Substance Abuse Treatment Facilities, by Whether Facility Offers Some Type of Payment Assistance: 2008

Note: Percentages may not sum to 100 percent due to rounding. Source: 2008 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS).

Figure 1 Table. Substance Abuse Treatment Facilities, by Whether Facility Offers Some Type of Payment Assistance: 2008
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).

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.

Table 3. Clinical/Therapeutic Approaches Used Always or Often, by Availability of Free Care: 2008
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).

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.

Table 4. Programs or Groups for Specific Client Types, by Availability of Free Care: 2008
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).

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.

Table 5. Treatment Services, by Availability of Free Care: 2008
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).

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.

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

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (April 15, 2010). The N-SSATS Report: Free Substance Abuse Treatment. Rockville, MD.