Repealing the Affordable Care Act (ACA) could undo the gains of the Cures Act, which gave $200 million to serious mental disorders and $1 billion to opioid use disorder treatment over the next two fiscal years, and go even further, taking billions away from treatment for substance use disorders (SUDs) and mental illnesses in years to come. The ACA, which builds upon the Mental Health Parity and Addiction Equity Act, gave many people health insurance who didn’t have it before, either through Medicaid expansion or subsidies of marketplace plans. Without the protections of the ACA, insurance companies could also single out people with pre-existing conditions to deny coverage. Rolling back the ACA will mean many people with mental illness and SUDs will end up in prison and jail instead of treatment, wrote Richard G. Frank, Ph.D., and Sherry Glied, Ph.D., in The Hill Jan. 11. Frank was formerly the assistant secretary for planning and evaluation in the Department of Health and Human Services, where he shepherded many initiatives through the regulatory process.

One of the reasons for passing the Cures Act was to start to close an opioid treatment gap in which about 420,000 people said finances or lack of availability of treatment were the reasons they couldn’t get it. Repealing the ACA would, Frank and Glied write, “increase that gap by over 50% with the stroke of a pen.”

Repealing just the mental and substance use disorder coverage provisions of the ACA would cut at least $5.5 billion a year from the treatment of people with mental and substance use disorders, leaving the Cures Act’s $500 million in 2017 and 2018 little more than a bandage, they write.

“The Congress and the American people have come to realize that stemming the tragic toll of opioid misuse and addiction and serious mental illnesses takes funding as well as policy,” they write. “It would be a cruel sham for Congress to take an important, but modest, step forward in investing in treatment capacity, while withdrawing funds from the enormous recent progress made in addressing the needs for care of those with mental health and addictive illnesses.”

Ultimately, people with the greatest need would end up in prison or jail, instead of getting treatment, they write. “Without the foundation of that ongoing financial support, those in the eye of the opioid storm and those who live in society’s shadows due to serious mental illnesses will continue to die of untreated illness, and their communities will continue to pay for the jails, prisons and homeless shelters that serve as our de-facto service system for many with these conditions,” Frank and Glied write. “Repealing the ACA — and its behavioral health provisions — would have stark effects on those with behavioral health illnesses,” they continue. “We estimate that approximately 1,253,000 people with serious mental disorders and about 2.8 million Americans with a substance use disorder, of whom about 222,000 have an opioid disorder, would lose some or all of their insurance coverage.”

And all four plans under discussion in Congress do not even mention Medicaid expansion. Five states that did expand Medicaid under the ACA would be particularly hurt when it comes to opioid use disorders.

Medicaid expansion in West Virginia

Also last week, Sen. Joe Manchin (D-West Virginia), along with other organizations from the state, announced the research by Harvard and New York University conducted by Frank and Glied that shows repealing the ACA would cut $5.5 billion per year from treatment and prevention of opioid use disorders. The removal of this funding would lead to increased deaths, homelessness and incarcerations and would adversely affect states with opioid challenges, according to Senator Manchin, whose state did take advantage of the Medicaid expansion provisions of the ACA. “Repealing the Affordable Care Act without a replacement will not only cause 184,000 West Virginians to lose their coverage, but would also cause those struggling with addiction to lose their treatment,” Senator Manchin said. “In West Virginia, half of the people in treatment would lose their coverage that was made possible through the Affordable Care Act. With our state leading the nation in drug overdose deaths, West Virginians cannot afford to have this critical funding ripped from them without a replacement ready. In order to beat this scourge on our society, we must use every tool and resource at our disposal and that includes the funding and consumer protections for individuals suffering from substance abuse disorders established by this law. While I recognize the serious flaws with the ACA, I will do everything in my power to protect the individuals, families, and communities in West Virginia who are struggling and ensure that they have the resources they need to combat this epidemic.”

Any cut of federal funding for SUD treatment “could literally kill members of my community,” said Judge William S. Thompson, circuit judge in the 25th Judicial Circuit (Boone and Lincoln counties). “We need to be expanding treatment dollars, not cutting them.”

Recovery Point West Virginia operates four residential recovery centers, and almost all patients are on Medicaid. ACA repeal would jeopardize health care coverage for the 250 individuals there now, said J. Matt Boggs, executive director. “Currently, 98% of Recovery Point clients are enrolled in Medicaid through the ACA expansion and have access to essential behavioral health and physical health services in our community,” he said.

Five new medication-assisted treatment (MAT) facilities have opened with funding through the ACA last year, said Louise Reese, chief executive officer of the West Virginia Primary Care Association. Young adults and pregnant mothers are among the patients getting this treatment, said Reese, adding that the new programs are providing MAT to about 700 patients, and already have long waiting lists. “West Virginia needs significant resources to reduce this serious epidemic and medication-assisted treatment is one of several important strategies to reduce addiction,” she said.

The Children’s Home Society of West Virginia cares for over 14,000 children and families annually, said Chief Operations Officer Mary White. “The expansion of Medicaid in West Virginia has benefited West Virginia’s most vulnerable children and families,” she said. Many of these families have been left homeless, and the number of children in foster care has been greatly increased — all because of the opioid epidemic, she said. “West Virginia’s Medicaid expansion has provided the additional resources to allow West Virginia child welfare providers to better care for and meet emergent needs,” White said.

Mark Drennan, executive director of the West Virginia Behavioral Healthcare Providers Association, said that Medicaid expansion under the ACA allowed his members to increase the number of patients to about 30,000 last year. “Prior to the ACA we served approximately 9,000 annually,” he said.

CBO report

Also last week, the Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) estimated the budgetary effects of H.R. 3762, the Restoring Americans’ Healthcare Freedom Reconciliation Act of 2015, which would repeal portions of the ACA. The law would have eliminated the ACA's mandate and subsidies but left market reforms in place. Now, the CBO has estimated the changes in coverage or premiums that would result from leaving market reforms in place while repealing penalties and subsidies. The report was prepared at the request of Senate Democrats.

In brief, the CBO and JCT estimate that enacting that legislation would affect insurance coverage and premiums primarily in these ways:

  • The number of people who are uninsured would increase by 18 million in the first new plan year following enactment of the bill. Later, after the elimination of the ACA’s expansion of Medicaid eligibility and of subsidies for insurance purchased through the ACA marketplaces, that number would increase to 27 million, and then to 32 million in 2026.
  • Premiums in the nongroup market (for individual policies purchased through the marketplaces or directly from insurers) would increase by 20 percent to 25 percent — relative to projections under current law — in the first new plan year following enactment. The increase would reach about 50 percent in the year following the elimination of the Medicaid expansion and the marketplace subsidies, and premiums would about double by 2026.

For the CBO report, go to https://www.cbo.gov/publication/52371.

Bottom Line…

Repealing the ACA, a process that Congress has begun and that was a key campaign promise of President Trump, would take treatment away from patients with opioid use disorders, and especially harm Medicaid expansion.