Alcohol, Drug Abuse, and Mental Health
Care for Uninsured and Insured Adults
Kenneth B. Wells, Cathy Donald Sherbourne, Roland Sturm,
Alexander S. Young, and M. Audrey Burnam
Objective. To compare adults with different insurance coverage in care for alcohol,
drug abuse, and mental health (ADM) problems.
Data Sources/Study Setting. From a national telephone survey of 9,585 respon-
Design. Follow-up of adult participants in the Community Tracking Study.
Data Collection. Self-report survey of insurance plan (Medicare, Medicaid, unman-
and treatments, and satisfaction with care in the last 12 months.
Principal Methods. Logisticandlinearregressionswereusedtocomparepersonsby
insurance type in ADM use.
Principal Findings. The likelihood of ADM care was highest under Medicaid and
lowest for the uninsured and those under Medicare. Perceived unmet need was highest
for the uninsured and lowest under Medicare. Persons in fully rather than partially
managed private plans tend to be more likely to have ADM care and ADM treatments
given need. Satisfaction with care was high in public plans and low for the uninsured.
Conclusions. The uninsured have the most problems with access to and quality of
ADM care, relative to the somewhat comparable Medicaid population. Persons in fully
managed plans had better rather than worse access and quality compared to partially
tend to be satisfied. Across plans, unmet need for ADM care was high, suggesting
changes are needed in policy and practice.
Key Words. Insurance plans, managed care, uninsured, mental health care,
substance abuse care, unmet need
The recent Surgeon General’s Report on Mental Health (U.S. Department of
Health and Human Services 1999) emphasized the importance of systemat-
ically addressing unmet need for mental health care nationally; similar
1990b). Policy formulation, however, would benefit from recent data on the
distribution of unmet need for alcohol, drug, and mental health (ADM) care
across diverse types of insurance coverage.
For example, persons with psychiatric disorders are more likely than
others to become uninsured (Sturm and Wells 2000), but it is unclear whether
the uninsured have greater unmet need for ADM care than insured groups.
One study suggests that the uninsured may have similar ADM need but lower
access to mental health care than persons with Medicaid (Norquist and Wells
1991). Further, despite public concerns about access or quality of managed
care for ADM conditions, it is unclear whether persons in more intensively
managed plans face greater unmet need (Hall et al. 1997; Mechanic and
McAlpine 1999). Most prior studies comparing ADM care among private plan
types were based on regional samples or specific plans and were conducted
greater access to mental health care in staff model Health Maintenance
Organizations (HMOs) relative to fee-for-service; while studies of depressed
patients suggest similar access but lower quality of care for some prepaid
patients compared to fee-for-service patients (Manning et al. 1987; Diehr et al.
1984; Sturm et al. 1995; Wells et al. 1996). Young et al. (2001) found similarly
the U.S. population with no insurance or public or private insurance.
This paper provides profiles of access to, unmet need for, and quality of
ADM care for a national sample of adults with telephones who have public,
private, or no insurance. We hypothesized that there would be lower access to
and higher unmet need for ADM care among the uninsured relative to
Medicaid or the privately insured, and similar access to ADM across private
plans. We were uncertain about expectations for quality of care given limited
Funded by The Robert Wood Johnson Foundation, Healthcare for Communities Grant No.
for Psychiatric Disorders Grant No. MHO 1170-04.
Address correspondence to Kenneth B. Wells, M.D., M.P.H., RAND, 1700 Main Street, Santa
Monica, CA 90407-2138. Dr.Wells is also with the UCLA Neuropsychiatric Institute and Hospital,
M.AudreyBurnam, Ph.D., arewithRAND.AlexanderS. Young,M.D.,M.S.H.S.,iswiththeUCLA
Neuropsychiatric Institute and Hospital, University of California, Los Angeles, and the Depart-
ment of Veterans Affairs, VISN 22, Mental Illness Research, Education and Clinical Center
(MIRECC), West Los Angeles Veterans Healthcare Center, Los Angeles.
1056 HSR: Health Services Research 37:4 (August 2002)
We analyzed data from Healthcare for Communities (HCC), which reinter-
the Community Tracking Study (Kemper, Blumenthal, Corrigan et al., 1996).
For HCC, 14,985 respondents were selected to oversample persons with high
psychological distress, specialty ADM use, and family income below the federal
poverty level. We obtained 9,585 eligible responses (64 percent response) and
weighted data for the sampling design and nonresponse to represent the
noninstitutionalized U.S. population (Sturm et al. 1999).
We categorize main insurance plan as uninsured, Medicaid, Medicare, or
unmanaged, partially managed, and fully managed private plans. Plans with
gatekeeping and preauthorization for specialty care plus a closed provider
panel were considered fully managed, those with some of these features were
considered partially managed, and plans without these features were unman-
We used survey items to assess age, family income, sex, marital status,
ethnicity (white, black, Hispanic, other), and education.
Clinical need is defined as probable 12-month psychiatric disorder
or substance abuse. Psychiatric disorder was assessed by major depressive,
dysthymic, or generalized anxiety disorder on the Composite International
Diagnostic Interview, Short Form (CIDI-SF); probable panic disorder by a
positive CIDI item and a role limitation on the SF-12; and probable severe
mental disorder by a positive CIDI lifetime mania item or report of an
inpatient stay for psychosis or a doctor’s diagnosis of schizophrenia
(Kessler et al. 1998; Ware, Kosinski, and Keller 1995; World Health
Organization 1995). Substance abuse was assessed by alcohol abuse on the
AUDIT (World Health Organization 1995) or illicit substance use as
reported on items adapted from the CIDI-SF (Kessler et al. 1998).
Perceived need was based on responses to two items asking individuals if
they ‘‘needed help for emotional or mental health problems, such as
feeling sad, blue, anxious, or nervous’’ or ‘‘needed help for alcohol or
drug problems.’’ Mental health-related quality of life was assessed by the
MCS-12, the global mental scale of the SF-12 (Ware, Kosinski, and Keller
1995). Medical comorbidity was assessed by a count among 17 common
chronic medical conditions.
Alcohol, Drug Abuse, and Mental Health Care1057
Access to care in the last 12 months was measured by self-report of any
outpatient mental health specialty visit and any visit to a general medical
provider that included either counseling, suggestions to cut down on drinking
or avoid recurrences, or a specialty referral. We also developed an indicator of
emergency room or outpatient visit for ADM problems.
Persons with perceived ADM need, but no ADM care, were classified as
having unmet need, while those reporting delays in care or receiving less care
than needed are classified as having delayed care.
Among persons with clinical or perceived need, we assessed satisfaction
care, care for emotional or mental health problems, and care for substance
abuse problems. Many did not answer items about satisfaction with substance
abuse care, and we analyze only complete responses.
To distinguish active treatment from visits with assessments only, we
developed an indicator of having inpatient, day-treatment, or residential ADM
care, use of prescribed psychotropic medication daily for a month or more, or
‘‘potentially therapeutic’’ outpatient care, that is, four or more ADM visits or
loss, ways to relax, taking responsibility for substance abuse problems, avoiding
recurrences, or participating in enjoyable activities).
To describeplan groups, we regressed each health and demographic indicator
on insurance status. For main analyses, we regressed each of the 10 ADM care
indicators on insurance status. Analyses of unmet need were limited to
respondents with perceived ADM need. Analyses of satisfaction and active
treatment were limited to persons with clinical or perceived need. To
determine whether plan differences were due to confounding with individual
characteristics, we conducted parallel analyses controlling for covariates. We
used logistic regression for dichotomous dependent variables and linear
regression for continuous variables. We tested the overall effect of plan type
using an F test for the set of plan coefficients. With 10 ADM care indicators, we
focus on describing patterns of ADM care when the overall plan effect is
significant at p < .005, a criterion met for all analyses. We describe results for
Medicare as a unique population and focus on six pair-wise plan comparisons
from the regression coefficients. We contrast fully managed with unmanaged
1058HSR: Health Services Research 37:4 (August 2002)
and partially managed plans, using an exploratory criterion of p < .10 due to
lack of empirical precedent. We compare the uninsured with Medicaid and
each private plan type. For these comparisons, one-tailed tests are appropriate
and results are in a consistent direction, so a formal Bonferroni correction of
p < .004 is too conservative (Miller 1981). Thus, we focus on results significant
at p < .01. To illustrate results, we generated means and percentages (either
unadjusted or adjusted for covariates) and calculated standard errorsusing the
parameters of the regression models. Some variables (especially income) had
missing data, and we used a multiple imputation method (Little and Rubin
1987; Rubin 1987; Schafer 1997). All analyses are adjusted for the clustered
sampling(SUDAAN Software1997; YatesandGrundy1953) andarenationally
weighted. Thisappendix is availableat http://www.blackwell-synergy.com or at
Demographic factors differ by plan type, but private groups are similar
persons in other plans. Minorities are overrepresented among the uninsured
probable psychiatric disorder varies widely and is highest for those with
Medicaid and lowest for those with Medicare. The uninsured have the highest
thandopersonswithMedicaid(e.g.,foranyADMcare,T ¼ 6.78,p < .001),and
significantlyloweraccessto anyADM careand generalmedicalADM carethan
persons with fully or partially managed private plans (e.g., for any ADM care,
T ¼ 4.84, p < .001 for fully managed plans). Among private plans, fully
ADM care compared to unmanaged plans (Ts are 3.16 and 3.12 respectively,
each p < .002) and partially managed plans (Ts are 2.37, p ¼ .02 and 2.13,
p ¼ .05,respectively).Inaddition,useofspecialtyADMcaretendstobehigher
for fully managed than unmanaged plans (t ¼ 1.69, p ¼ .10) (Table 2). Use of
specialty ADM care is highest for Medicaid and the lowest for Medicare.
Among those with perceived need, unmet need and delays in care are
greatest for the uninsured and those on Medicaid and lowest for those on
Medicare. The uninsured have significantly more unmet need than each
private plan group (e.g., comparison to fully managed plan has T ¼ 4.81,
Alcohol, Drug Abuse, and Mental Health Care1059
Characteristics of Adults by Plan Type
N ¼ 1,170
N ¼ 1,054
N ¼ 2,294
N ¼ 2,672
N ¼ 1,278
N ¼ 620
Mean Family Income (k)
% < High School
% High School
% Some College
% College Graduate
% Probable Mental Disorder
% Substance Abuse Problem
Mean # Chronic Conditions
% Perceived Need Mental Health
% Perceived Need Substance Abuse
Sample varied by characteristic due to missing data. Data are nationally weighted and unadjusted (no covariates).
?X X ¼ Mean or percent; SE ¼ Standard error; Entries are predicted values based on regression coefficients.
1060HSR: Health Services Research 37:4 (August 2002)
Use of ADM Care, Satisfaction with ADM Care, and Active ADM Treatment by Plan Type
Plan Type Group
Full Sample (N ¼ ¼ 9,088)
N ¼ 1,170
N ¼ 1,054
N ¼ 2,294
N ¼ 2,672
N ¼ 1,278
N ¼ 620
% ADM Care
% Primary ADM Care
% Specialty ADM Care
If Perceived Need (N ¼ ¼ 1,518)
N ¼ 235
N ¼ 160
N ¼ 385
N ¼ 492
N ¼ 68
N ¼ 178
% NO ADM Care
% Less/Delayed ADM Care
If Perceived or Actual Need (N ¼ ¼ 2,829)
N ¼ 470
N ¼ 298
N ¼ 703
N ¼ 844
N ¼ 177
N ¼ 327
General Health Care
Mental Health Care
% Active Treatment
Sample varies by characteristic due to missing data.
** ¼ < 0:005.
Data are nationally weighted.
?X X ¼ Mean or percent; SE ¼ Standard error; Entries are predicted values based on regression coefficients.
Alcohol, Drug Abuse, and Mental Health Care1061
p < .001). Differences in unmet need and delays in care between uninsured
and Medicaid plans and among private plan types are not consistently
statistically significant. Among those with clinical or perceived need, rates of
active treatment are significantly higher for Medicaid and fully managed care
plans relative to the uninsured (Ts are 5.88 and 4.85 respectively, each
p < .001). Active treatment given ADM need is somewhat more likely in fully
managed than partially managed plans (T ¼ 2.46, p ¼ .02). Satisfaction with
each type of care is lowest among the uninsured, who have significantly lower
satisfaction of each type compared to Medicaid (each p < .001) and private
plans. Results are qualitatively similar in adjusted models but a few individual
comparisons fall in significance to p ¼ 0.10.
Our findings indicate consistently lower access to and satisfaction with ADM
Medicaid and privately insured groups. These findings reinforce the need for
ADM need. Recent federal programs to expand insurance coverage mainly
target children and are variably implemented within and across states
(Edmunds and Coye 1998a; 1998b). Further, Medicaid recipients had high
rates of perceived unmet need and only moderate rates of receiving active
treatment given need; so coverage expansion without addressing supply or
public education policy may be insufficient. Among private plans, we observed
for fully managed compared to partially or unmanaged plans and for higher
rates of active treatment given ADM need for fully, compared to partially,
managed plans. This pattern may be due to the more fully developed provider
public opinion about lower access or quality in more fully managed plans.
Further research is needed on differences in ADM care as a function of
management intensity. Descriptively, we observed a pattern among Medicare
recipients with low use of ADM services and only moderate rates of active
treatment given need, yet very low perceived unmet need and relatively high
satisfaction with ADM care. This profile implies there may be some important
quality gaps among the elderly but little leverage for change. This suggests that
there is an important role for public education programs about ADM care for
1062HSR: Health Services Research 37:4 (August 2002)
The findings are based on self-reports over a long recall period; this may
based on recalling specific provider actions within visits. We found that this
approach leads to higher estimates of ADM care than in studies that rely on
respondents to directly designate primary care visits as due to mental health
problems (Regier et al. 1993; Kessler et al. 1994). The visits we assessed do not
necessarily reflect effective ADM care, a concern commonly voiced about
general medical visits (Mechanic et al. 1999; Young et al. 2001). However, even
brief counseling reduces alcohol use and may be considered ADM care
among poorer populations. We did not have data on carve-out ADM specialty
management, another coverage domain that might affect access or quality
inahousehold sample. Thesurveyhad moderateresponseand wasa follow-up
of a prior survey with moderate response, which could bias results despite
In summary, we found low access to ADM care for the uninsured;
addition, access and quality of care may be higher rather than lower in fully
managed plans compared to those less managed, emphasizing the importance
of monitoring access and quality nationally across plan types. Public plans have
more counterbalancing patterns: high access and satisfaction but substantial
unmet need among Medicaid recipients; and moderate rates of active
treatment given need, but low perceived unmet need and high satisfaction
among Medicare recipients. These findings suggest a need for supply-side
interventions within Medicaid and enrollee education within Medicare. Yet
across plans, many individuals had unmet need for ADM care, reinforcing the
Surgeon General’s conclusion that broad policy and practice changes are
needed to improve ADM care access and quality.
We would like to thank Fuan Yue Kung, M.S., for his programming support,
and Lingqi Tang, Ph.D., and Ruth Klap, Ph.D., for their statistical advice and
database management support.
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