Vice President for Health Policy
Senate Republicans reportedly may try to add funds to address the opioid epidemic to their emerging bill to repeal the Affordable Care Act (ACA). As we explained when the House took a similar approach in its own ACA repeal bill, no one should fall for it — a one-time investment or even a multi-year commitment of funds wouldn’t come close to offsetting the enormous damage that the underlying House bill would do to millions of people who would lose access to treatment.
The House-passed bill, most of which Senate Republicans are expected to include in their own bill, would increase the number of people without health insurance by 23 million by 2026, according to Congressional Budget Office (CBO) estimates, and it would eliminate access to behavioral health treatment for mental illness and substance use disorders (SUDs) for several million people. The House bill effectively ends the ACA’s Medicaid expansion, which has dramatically improved access to treatment; caps and cuts federal Medicaid funding for seniors, people with disabilities, and families with children; and lets states waive requirements that health plans in the individual and small group markets cover “essential health benefits” including 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, making additional Medicaid cuts, and removing nationwide requirements that private plans cover substance use treatment and mental health care, 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 a SUD, including 222,000 with an opioid disorder, would lose some or all of their insurance coverage if the ACA’s coverage provisions are repealed.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 generally didn’t qualify for Medicaid unless they also had a qualifying mental or physical health condition. Now, low-income people with SUDs qualify for Medicaid based on their income. The results have been dramatic. After expanding Medicaid, Kentucky saw a 700 percent increase in Medicaid beneficiaries using substance use treatment services. States that expanded Medicaid have seen very large increases in the use of medication-assisted treatment for opioid addiction compared to states that did not. 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 the nation’s overall behavioral health spending by 2.7 percent or $7.3 billion in 2020, because more people would have coverage. The resources that Senate Republicans would provide in their bill almost certainly wouldn’t come close to filling the gap left by a Medicaid expansion repeal and other harmful provisions.
What’s more, there’s a big difference between giving states a lump sum of money and providing people with insurance coverage, which allows them to seek care when they need it — including care for mental illness and physical health problems that often accompany behavioral health needs. Moreover, many people who need substance use treatment need it for years or even their entire lives. Replacing coverage that’s there when people need it with state grants would fall far short of getting millions of people the care they need.