Vice President for Health Policy
In a last-ditch effort for Republican votes, GOP leaders have added an extra $15 billion to their bill’s $100 billion stability fund, with the $15 billion earmarked for behavioral health treatment and maternity coverage and newborn care. No one should fall for it — a one-time $15 billion investment with little direction on how to spend the funds wouldn’t come close to offsetting the enormous damage that the underlying House bill would do to millions of people who would lose these important categories of care.
That’s because the underlying House bill would increase the number of people without health insurance by 24 million by 2026, according to Congressional Budget Office (CBO) estimates, and it would have particularly harmful effects on access to treatment for mental illness and substance use disorders (SUDs). Specifically, it effectively ends the Affordable Care Act’s (ACA) Medicaid expansion, which has dramatically improved access to treatment; converts Medicaid to a per capita cap; and rolls back requirements that health plans in the individual and small-group markets cover a list of “essential health benefits” that include behavioral health care, which encompasses treatment for mental illness and SUDs.
Experts estimate that the ACA’s coverage expansions will increase total spending on behavioral health by more than $7 billion per year by 2020. By rolling back those expansions and making additional Medicaid cuts, the House bill likely reduces resources for behavioral health by that amount or more.
An estimated 1.3 million people with serious mental disorders and about 2.8 million people with SUDs, including 222,000 with an opioid disorder, would lose some or all of their insurance coverage if the ACA’s coverage provisions were repealed. The greatest impact would be from repealing the Medicaid expansion, which allowed millions of people with behavioral health care needs to become eligible for the first time.
Before the ACA, Medicaid eligibility was largely restricted to children, pregnant women, low-income seniors, and people with disabilities. For Medicaid eligibility, a SUD alone doesn’t qualify as a disabling condition, so people with SUDs also must have a mental or physical health condition that rises to the level of a disability in order to qualify for Medicaid due to disability. The results have been dramatic. After expanding Medicaid, Kentucky saw a 700 percent increase in Medicaid beneficiaries using substance use treatment services. The use of these services rose nationally as well; one study found that expanding Medicaid reduced the unmet need for substance use treatment by 18.3 percent.
The federal agency overseeing behavioral health treatment expects the ACA’s coverage expansions to increase behavioral health spending by 2.7 percent or $7.3 billion in 2020, because more people would have coverage. Meanwhile, the revised House bill offers a one-time investment of $15 billion in 2020, spread across behavioral health and care for newborns. (Maternity coverage and newborn care are also essential health benefits that plans wouldn’t have to cover under the House Republican bill.) That funding could make up for some of the bill’s cuts in 2020, but it wouldn’t come close to filling the ten-year gap that the House bill would leave.
What’s more, there’s a big difference between providing people with insurance coverage, which allows them to seek care when they need it — including care for physical health problems that often accompany behavioral health needs — and giving states a lump sum of money to spend as they see fit. For millions of people with behavioral health needs, the revised bill would replace coverage that’s there when they need it with poorly targeted state grants that fall far short of getting them the care they need.