How would repeal of the Affordable Care Act affect mental health care?
Individuals with mental illness and substance use disorders could lose coverage
What does the ACA cover?
The ACA required health plans to cover Essential Health Benefits starting January 1, 2014. These include:
- medical services such as doctor visits
- emergency and urgent care services
- hospital physician and facility services
- prenatal, delivery, and postnatal care
- evaluation and treatment of mental health conditions
- services to address substance use including behavioral health treatment
- coverage of prescription medications
- rehabilitation services
- diagnostic tests and imaging
- preventive and wellness care and management of chronic diseases
- pediatric care.
As of March 2013, only 2% of existing health plans in the United States provided all of these benefits required by the ACA.7
Required coverage of mental health care and substance use disorders increases patient access to those services. Including preventive care extends the reach of mental health screening to primary care providers, who can screen for mood disorders and substance use in adults and adolescents and for autism and behavioral issues in children.8
The ACA provides further expansion and enforcement of mental health parity. In 2008, the Mental Health Parity and Addiction Equity Act was passed with the intent of providing behavioral health benefits at the same level as medical care. Although this law was beneficial in theory, it did not require insurers to cover behavioral health treatment. Rather, it only required parity if large group plans already provided behavioral health coverage; parity laws did not apply to individual or small group plans. The Essential Health Benefits of the ACA specify that insurers must provide mental health and substance use treatment. Essentially, the ACA gave the parity law teeth. The law would matter very little if low-income patients, who often suffer from mental health symptoms, have no insurance coverage.
Perhaps more concerning are the implications for those battling substance use disorders. If the ACA is repealed without appropriate replacement measures, it is unclear how those with limited income or preexisting substance use disorders would access evidence-based treatment.
Opioid use disorder affects >2 million individuals in the United States and caused 33,000 overdose deaths in 2015.9 The Opioid Initiative, established in 2015 by the U.S. Department of Health and Human Services (HHS), has worked to improve prescribing practices, increase use of naloxone to treat overdose, and expand access to medication-assisted treatment and psychosocial support. The success of this initiative relies on accessible health insurance coverage. Medication-assisted treatment and psychosocial support services would be threatened most by repeal of the ACA.9 In 2016, the HHS provided $94 million in grants, through the ACA, for free clinics to screen and treat patients for substance use disorders.10 Continued funding for these programs would be jeopardized if the ACA was repealed without replacement.
