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By Alex Ruoff
Millions of Americans who suffer from mental health and substance abuse issues could be left without insurance under House Republicans’ plan for repealing the Affordable Care Act, behavioral health groups and researchers told Bloomberg BNA recently.
Behavioral health groups are lobbying House Republicans as they put the final touches on their ACA repeal bill this week, asking lawmakers to preserve Medicaid expansion funds. Many industry groups remain uncertain about the future of federal Medicaid funding and Republicans’ plan for ACA requirements that insurers cover mental health and addiction treatment.
As many as 4 million Americans with serious mental health disorders or who are addicted to drugs, including 222,000 addicted to opioids, would lose some or all their insurance coverage if the ACA’s Medicaid expansion provisions are rolled back, public health researchers estimate. Researchers don’t know how many would retain their coverage under Republicans’ latest proposal to freeze Medicaid expansion funds.
Behavioral health groups want to preserve Medicaid expansion funds and the ACA’s requirement that insurers cover mental health and addiction treatment. It’s unclear how Republican proposals for high-risk pools and as much as $100 billion in state innovation grants to replace Medicaid coverage could offset the loss of coverage from changes to Medicaid.
“All of this is really complicated because there’s so many moving parts,” Chuck Ingoglia, senior vice president for the National Council for Behavioral Health, told Bloomberg BNA March 3. “I would still say there is certainly cause for alarm.”
Democrats warn that the House ACA replacement plan would disproportionately cost people with serious mental illnesses their insurance coverage, setting back efforts to get insurers to cover mental health and addiction disorders the same as physical ailments.
The ACA required all small group and individual health insurance plans to cover some mental health and substance-use disorder services the same as medical and surgical benefits. The often-overlooked provisions extended existing federal parity laws to group plans and aimed to give coverage to an estimated 11.8 million uninsured Americans with mental health disorders as well as the millions more who had insurance that didn’t cover mental health services.
Republican lawmakers have not specifically called for lifting parity provisions and have supported expanding federal support for mental health and addiction services recently. Two Republican-controlled congressional committees championed a bill signed into law by President Barack Obama in December that authorized millions of dollars in grants to improve state mental health services as well as $1 billion to combat the opioid epidemic ( 237 HCDR, 12/9/16 ).
However, conservatives are mulling changes to how the federal government funds state Medicaid programs, which are public insurance for the poor, and federal benefits rules that could stall or roll back progress made under the ACA to improve the lives of people living with mental health disorders, according to one House Democrat who has long sought to expand federal mental health parity laws.
“None of my Republican colleagues are saying anything about how they’re going to protect these same services they championed six weeks ago,” Rep. Joe Kennedy III (D-Mass.) told Bloomberg BNA recently, referring to passage of the 21st Century Cures Act.
Obama’s health law also established new benefit rules, known as essential health benefits, that required insurers to cover mental health and addiction services, as well as preventive and wellness care. Conservative lawmakers have said they want to leave it up to individual states to define these benefit rules for insurers.
But requiring insurers to cover mental health services has also been a boon for supporters of federal parity requirements, Ingoglia told Bloomberg BNA. Before the ACA, insurers that didn’t want to cover mental health services with the same lifetime limits, treatment limitations and financial requirements (including copays) as medical and surgical services could simply not offer coverage for mental health services.
“If you don’t have the benefit, it makes parity moot,” Ingoglia said.
Rolling back some essential health benefits could make health insurance plans cheaper, Republican lawmakers have said. Insurance plans that have less coverage are generally less expensive but leave beneficiaries on the hook for uncovered services.
Behavioral health groups are worried that mental health and addiction services will be seen as low-hanging fruit for lawmakers eager to cut benefits, Ingoglia said.
Medicaid expansion was particularly beneficial to people with mental health and addiction issues, according to the National Council for Behavioral Health.
Roughly 29 percent of the estimated 11 million people who received health insurance coverage through the expansion of various state Medicaid programs under the ACA either have a mental health disorder like clinical depression, anxiety or schizophrenia or a substance use disorder or both, according to the council. Several states, like Kentucky, used their Medicaid programs to specifically expand access to medication-assisted treatment for drug addiction.
Repealing the ACA and its behavioral health provisions could leave 1.2 million people with serious mental health disorders and 2.8 million people with a substance use disorder without some or all their insurance coverage, according to Richard Frank, a professor of health economics at Harvard Medical School.
It’s difficult to determine how many of these people would retain their coverage under Republican proposals for age-based tax credits to help people purchase insurance, Frank told Bloomberg BNA March 6.
Repealing the ACA without any replacement would increase the number of uninsured people by 32 million and double premiums by 2026, the nonpartisan Congressional Budget Office said in a January report. About 18 million would be uninsured and premiums would rise as much as 25 percent in the first year alone, the report said.
Under Obamacare, the uninsured rate fell to 8.9 percent in the first half of 2016, down from 16 percent in 2010 after 20 million people gained coverage, according to the Department of Health and Human Services.
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