Impact of ACA Repeal and Replace Legislation on Mental Health

In December 2016 Congress delivered on a long-standing promise to overhaul the country’s mental health system by passing the 21st Century Cures Act, an achievement that Speaker Paul Ryan called “the most significant reform in a decade.”[1] The Act authorized treatment and prevention programs and created a new Assistant Secretary for mental health at the U.S. Department of Health and Human Services. Now, House Republicans could roll back coverage of millions of people with mental health and substance use disorder needs by cutting funding to Medicaid as part of the ACA repeal package.
The House’s proposed repeal legislation, the American Health Care Act (AHCA), will phase down federal funding of Medicaid Expansion which today covers an estimated 1.2 million people with serious mental illness and substance use disorders.[2] Additionally, the repeal bill removes the requirement that certain Medicaid plans cover the Essential Health Benefits (EHBs), which include mental health and addiction services, putting enrollees at risk of losing access to treatment.
The AHCA does not eliminate the EHB coverage requirement of the individual insurance market.  But in 2020 the bill will allow states to stop covering these benefits for individuals insured under the ACA’s Medicaid Expansion for adults.  Addiction-care advocates say lowering the coverage standard in this way may hurt many who are getting treated for an opioid use disorder. The five states with the highest number of opioid overdoses in 2015 – West Virginia, New Hampshire, Kentucky, Ohio and Rhode Island – all have expanded Medicaid, and the expansion has provided much-needed support for treatment in those states, often becoming the largest source of treatment.[3] Medicaid pays for 44 percent of buprenorphine-based opioid addiction treatment in Kentucky; 45 percent of it in West Virginia; and 49.5percent of it in Ohio.[4]
The House repeal bill keeps in place coverage without penalty for individuals with pre-existing conditions including mental illness with no gaps in coverage. Continuous coverage under the AHCA means that an individual may not let their coverage lapse for more than 63 days. Advocates are greatly concerned about the impact of this on persons in need of mental health and substance use disorder services, because those consumers can be particularly prone to letting health insurance lapse while in a mental health crisis.   The consequences of losing coverage could extend the crisis.
The proposed capping of Medicaid funds to states is also of great concern to the mental health and substance use disorder community. Treatment for individuals experiencing mental health or addiction issues can be costly. The repeal bill would give states a fixed allocation for each Medicaid enrollee in 4 or 5 broad categories, with the annual increase per enrollee subject to a strict inflation cap.  Each state would have great latitude to decide what behavioral health care benefits to cover. There is great worry that states would limit treatment for serious mental illness and substance use disorder under the repeal bill’s Per Capita Cap or Block Grant funding proposals.
Republican Senators Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado and Lisa Murkowski of Alaska have stated that they would withhold support for the AHCA through a letter to Senate Majority Leader Mitch McConnell. In their letter they declared that “reform should not come at the cost of disrupting access to healthcare of the most vulnerable and sickest individuals.”[5]  By penalizing the consumer with breaks in coverage and reducing the amount of financial assistance, the AHCA will leave consumers with mental illness and substance use disorders without access to critical care. In the midst of an epidemic of opioid overdoses, this is a crucial moment to extend services to people with mental health and substance use disorders, not to reduce or repeal them. This bill will cost lives and impose financial burdens on states.
[1] Brianna Ehley, March 8 2017, “Obamacare repeal seen as weakening mental health protections,” Politico. Retrieved on March 15 2017.
[2] ibid.
[3] Katie Zezlma & Christopher Ingraham, March 9 2017, “GOP Health care bill would drop addiction treatment mandate covering 13 million Americans,” The Washington Post. Retrieved on March 15 2017.
[4] ibid.
[5] Brianna Ehley, March 8 2017, “Obamacare repeal seen as weakening mental health protections,” Politico. Retrieved on March 15 2017.

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