One of President Trump’s major campaign promises was a repeal of the Affordable Care Act, also known as Obamacare. Currently, the law regulates coverage by health insurers, mandates health insurance coverage to all Americans and provides care through federal- and state-run exchanges and employer-provided benefits.
More than 22.5 million people received health insurance through federal marketplace, state-run exchanges and Medicaid expansion implemented by the ACA. Another 150 million receive insurance through their employer.
Treatment for substance use disorders is currently covered under the ACA, as are co-occurring disorders. Neither can be cited as a pre-existing condition, which means insurers can’t deny coverage based on presence of a substance use or mental health disorder. If the ACA is repealed, several provisions of the law for substance use disorders and mental health treatment will be interrupted.
In November 2014, the final regulations for the ACA were released. They included provisions for the coverage of mental health and substance use disorder treatment. According to these regulations, the conditions were to receive equal footing with medical health care, known as parity.
In 2008, Congress had passed the Mental Health Parity and Addiction Equality Act, requiring parity in private insurers. The 2014 rules extended that parity to federal and state-run health care exchanges and Medicaid.
This signaled a sea change in the way these disorders were handled by insurance companies.
Federal and state-funded expanded Medicaid programs were instrumental in bringing coverage to millions of Americans living under the poverty line. The increase in coverage made substance use disorder treatment and mental health care available to millions who hadn’t had access to treatment for cost reasons.
According to the Substance Abuse and Mental Health Services Administration, 30 percent of those who received coverage under the Medicaid expansion were individuals with mental health challenges.
With the extension of parity and the expansion of Medicaid, 32 million people were able to access substance use disorder treatment under their health care programs for the first time.
While the ACA requires insurance to cover most of the costs associated with substance use disorder treatment, patients still pay some costs out of pocket. An estimated 40 percent of Americans with a substance use disorder didn’t seek treatment because they believed they could not afford the out-of-pocket costs.
Insurance companies are mandated to help shoulder the costs of rehab treatment, but each company decides how much to pay for and which services to cover. Prices for substance use disorder treatment vary from center to center, ranging from $500 per week to $100,000 per month. Insurance companies may cover some or all of the costs, depending on the type of treatment available and whether or not a rehab center is considered an in-network provider.
Insurance companies will not be mandated to cover rehab treatment once the ACA is repealed. While it’s obvious Congress intends to dismantle the law — a budget resolution instructing House and Senate committees to start drafting legislation for repeal was passed on Jan. 11, 2017 — what they plan to replace it with is still unclear.
While Congress works on their replacement plan, there may be a lag time of up to a few years, during which time mental health coverage and substance use disorder coverage could be unclear. Several tenets of the ACA that help individuals with addiction obtain affordable treatment would disappear with repeal.
If the ACA is repealed, individuals in the 31 states, plus the District of Columbia, that chose to expand Medicaid under the ACA would lose coverage. These include the lowest-income individuals in the United States — those living under the poverty line making less than $25,000 per year.
This is especially harmful to those seeking addiction treatment, since the poorest individuals in the country have a high risk for substance abuse. The current opioid epidemic is most prevalent in states where the median income is the lowest in the country, including West Virginia, Louisiana, Tennessee and Kentucky.
The ACA provided an extension of parity to federal and state-run health care exchanges, as well as Medicaid. This means mental health conditions and substance use disorders were to be treated the same as other chronic medical issues under the law.
Without these regulations, insurance companies can choose to treat mental health and substance abuse differently from other medical issues, either increasing the out-of-pocket maximum allotment or refusing to cover them at all. Linda Rosenberg, CEO of the National Council on Behavioral Health, told USA Today that the 2008 parity law is “useless” if there’s no coverage under Medicaid for low-income patients.
Mental health and substance use disorder services are essential benefits and fall under the pre-existing conditions clause of the health care law. This clause states that no insurer can deny coverage or drop coverage because of a health problem that existed before the new insurance took effect.
Up until Jan. 1, 2014, insurers could deny or drop coverage based on pre-existing conditions such as cancer, diabetes, asthma and pregnancy. Under the ACA, individuals with those conditions cannot be denied coverage. Once those provisions are repealed, insurance companies can drop or deny coverage based on addiction or co-occurring disorders such as anxiety, depression or PTSD.
The Surgeon General’s report “Facing Addiction in America,” released November 2016, points to preventative care as one of the main ways to mitigate the current drug epidemic. The report states that “the traditional separation of substance use disorders and mental health services from mainstream care has created obstacles to successful care coordination.” Increased insurance coverage is named as one of the most important methods of reducing the occurrence of substance use disorders.
The ACA provides some mandated coverage of preventative care related to substance abuse and co-occurring disorders, including:
Each condition is common among people with substance use disorders. Without these provisions covered by the ACA, insurance companies can choose not to cover these services, or increase the co-pay required to receive them.
Currently, the ACA requires insurance companies to cover the children or dependents of the insured up until age 26, regardless of where they get their insurance. This ensures that addicted children get treatment while they are covered under their parents’ health care plans.
This provisions especially benefits college-age young adults. College is a time for experimenting, sometimes with drugs and alcohol, and addiction can take hold during these formative years.
According to the 2015 Monitoring the Future survey, more than one-third of college students reported binge drinking in the past two weeks in 2015, and 45 percent of college students admitted to having used illicit drugs.
The increase in prescription drug abuse has increased exponentially on college campuses. Between 1993 and 2005, opioid use increased by 343 percent, and stimulant use increased by 93 percent, according to the Clinton Foundation.
Without the dependent care provision of the ACA, children of insured individuals may lose insurance coverage and be unable to receive treatment for drug or alcohol addiction.
Under the ACA, the amount of money you can spend on covered services within a plan’s year is limited. After the out-of-pocket limit is reached, insurance pays 100 percent of medical costs. For 2017, the out-of-pocket maximum is $7,150 for an individual and $14,300 for a family.
Without these protections under the ACA, insurance companies could raise or lower this out-of-pocket max. If they choose not to cover a specific service, such as substance use disorder treatment, individuals will be responsible for the full cost. Or, an insurance company can choose to cover a smaller percentage of treatment, so individuals will be required to pay a larger share of the costs.
Substance use disorders affect people throughout their lives. Recovery doesn’t mean the disorder goes away; it just means the individual is learning to manage their substance use disorder. This means that treatment is ongoing and aftercare is important.
With the ACA, insurance companies are no longer allowed to place time limits on coverage of essential services, including substance use disorder treatment. If an individual with a substance use disorder relapses and requires mental health or rehabilitation treatment more than once, they can get it.
Without this provision, insurance companies can place limits on the dollar amount a person requests for treatment for essential services, including rehab treatment and mental health services, such as counseling and medications.