How would repeal of the Affordable Care Act affect mental health care?

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Individuals with mental illness and substance use disorders could lose coverage



With the changing political landscape in Washington, there has been much talk about health care in the United States. The Affordable Care Act (ACA) is at risk for repeal or, at least, substantial change. As the debate heats up, many psychiatric clinicians wonder what repeal could mean for mental health care and treatment of substance use disorders.

To examine this issue, we need to understand what the ACA has accomplished so far. The Patient Protection and Affordable Care Act—known as “Obamacare”—was enacted on March 23, 2010. From 2010 to 2014, various provisions were implemented; more provisions are slated for completion by 2017 if the law remains in place. These provisions are at the heart of how those with mental illness or substance use disorders could be affected by repeal of the ACA.

Since the ACA’s implementation, an estimated 20 million Americans have gained health insurance.1 The ACA includes several provisions that made this number possible, such as the expansion of Medicaid in some states. In addition to plans offered through the Health Insurance Marketplace, private insurers are required to provide insurance to some who previously fell into non-coverage gaps.1 Young adults can remain on a parent’s plan until age 26, which is significant to mental health care because many psychiatric disorders emerge in young adulthood, and this age group is vulnerable to developing substance use disorders.

The ACA also requires private insurance plans to cover those with preexisting health conditions. This has been crucial for persons with mental illness because before the ACA, mental health disorders were the second most common preexisting condition that precipitated either an increase in the cost of a plan or coverage denial.2

These provisions have helped ensure coverage for the approximately 20% of adults in the United States who have a mental illness.3 Before the ACA, 18% of individuals who purchased their own insurance did not have mental health coverage, and more than one-third of insurers did not cover substance use disorders.4 According to the CDC, the uninsured rate for those with serious mental health disorders fell from 28.1% in 2012 to 19.5% in 2015.5 Likewise, the number of adults with mental illness who could not afford needed care decreased during the same years.5 A University of Minnesota study found that persons with mental illness are disproportionately represented among the uninsured.6 Before the ACA, 18% of individual health plans did not cover prescriptions, including those indicated for psychiatric illness.7 Simply put, the ACA has allowed people to seek assessment and treatment for mental health, whereas it would not have been as accessible before the legislation.

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