Trends and disparities in alcohol screening and brief counseling following the U.S. Affordable Care Act

Abstract

Background: U.S. health reforms increased primary care access for underserved groups and provided support for alcohol screening and brief counseling (ASBC) in primary care. We examined temporal trends and changing disparities in ASBC from 2013 to 2019. Methods: A sample of adults ages 18-64 who had consumed alcohol and received primary care in the past year (N = 150,332) was drawn from the 2013-2019 U.S. National Surveys on Drug Use and Health. ASBC outcomes included alcohol quantity screening, problem assessment, brief counseling, and provision of treatment information. We compared adjusted prevalence of ASBC across time by insurance type and by race and ethnicity for three alcohol severity groups (no heavy drinking (HD) or alcohol use disorder (AUD); HD without AUD; and AUD). Covariates included demographics, drinking pattern, health conditions, drug use disorder, and healthcare visits. Results: Adjusted prevalence of ASBC outcomes (excepting quantity assessment) remained low across years. Prevalence of problem assessment was <10.1 % and brief counseling <4.0 % in the HD-only group; and 16.4-17.3 % and 14.9-15.6 %, respectively, in the AUD group. Significant increases by alcohol severity level were modest (<8.6 percentage points for quantity assessment; <2.0 points for other outcomes). White adults showed increases in all ASBC outcomes, followed by the privately-insured showing increased quantity and problem assessment. Insurance- and race-based disparities increased over time. White-Black disparities in quantity assessment increased nearly four-fold among individuals who drink heavily and almost three-fold among those who did not drink heavily. Conclusions: Evidence-based alcohol preventive care was increasingly inequitable. Interventions to increase ASBC generally and particularly for underserved groups are warranted.