Repeal of the ACA: Effects on Substance Abuse Epidemic

February 16th, 2017 by Alexandra Podolny

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by CHHS Research Assistants Christie Chung and Charles Hilberg

Substance abuse and addiction is a serious public health problem that impacts communities on multiple levels. It is estimated that at least 40 million Americans age 12 and over meet the clinical criteria for addiction that involves substance abuse, a tally that surpasses the number of individuals inflicted with heart disease, diabetes, or cancer.  Even larger, 80 million people are estimated to be at risk for substance abuse.  These numbers, not including those suffering more broadly from mental health conditions, have been quantified to cost the U.S. Government $468 billion annually. From January to June last year, there were 920 overdose-related deaths in Maryland alone—an increase of approximately 34.7% from the same period in 2015. In reaction to the alarming spike in overdose-related deaths, former Maryland Secretary of Health and Mental Hygiene, Van T. Mitchell, stated that, “Maryland, like many states across the nation, has been in the midst of an opioid epidemic.”

Many institutions, including the National Institute of Drug Abuse, categorize substance addiction as a complex mental disease and emphasize its corrosive effect on nearly all aspects of life, including interpersonal relationships, financials, and personal health/well-being. Ultimately, in light of the substantial body of research that recognizes the strong connection between mental illness and drug abuse, medical treatment needs to be able to address both the substance abuse and any underlying mental health symptoms in order to afford the best chances at sustained sobriety and good health. A substantial portion of individuals who require treatment for substance abuse or mental illness rely on the Affordable Care Act (ACA). According to the Substance Abuse and Mental Health Services Administration (SAMHSA), approximately 30% of those receiving coverage under the ACA “have a mental disorder, such as anxiety or schizophrenia, or an addiction to substances, such as opioids…”. With current congressional leadership vowing to appeal the Affordable Care Act (ACA), it is important to consider how such a change would impact those suffering from mental health and addiction.

The ACA, as it was enacted, “include[s] mental health as an ‘essential benefit’” which requires insurers to cover mental health care at the same level as other medical care for those under ACA plans. Additionally, health plans are obligated to cover preventative services such as “depression screening for adults and behavioral assessments for children, at no additional cost.”  The ACA also includes rules for carrying out the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Centrally, MHPAEA requirements are geared towards ensuring that the co-pay, deductibles, and treatment options for mental health and substance use disorders are “no more restrictive” than the limitations applied to other medical benefits. For health care reform to be effective for mental health and addiction treatment, it must ensure both the required coverage as well as the access to the coverage for low income individuals.

While there is much uncertainty about what a health plan would look like following a repeal, congressional leaders who worked on the 2008 bill aimed at providing better health care support for mental disorders and substance abuse have expressed fear that a ACA repeal would make the 2008 bill “meaningless.”  Some plans from Congress for an ACA repeal include cuts to Medicaid expansion, which is the source of coverage under the ACA for a large group of those in need of mental health or addiction treatment. Another plan which would detrimentally affect the health of those with mental health and substance use disorders, if adopted, is a proposal outlined by Senators Bill Cassidy and Susan Collins from Louisiana and Maine, respectively. The Cassidy-Collins bill, which gives the states the following three options: keep the ACA, receive the federal funding to create individual “Health Savings Accounts”, or reject federal funding, would result in differential access to treatment across state lines. A repeal of the ACA, whether in full or partial, would critically jeopardize the well-being of those in need of mental health or addiction treatment.

A comprehensive replacement plan has not been offered by the congressional leadership pushing for ACA repeal; however, early last month, Congress took a major preliminary step towards dismantlement of the ACA. Passed by both the House and Senate, a new budget resolution allows for repeal of certain ACA provisions with only a majority vote as opposed to the 60-vote supermajority that is usually required. Ultimately, whatever reform measure gets adopted, if it does not include both mandatory coverage of mental health and substance use disorders and subsidized treatment for low income individuals, many of those in need of mental health care and addiction treatment will find themselves unable to access the care they need.

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