^{Compiled by Megan J. Wolff, PhD MPH
Last updated: May 8,2017}

The rate of uninsurance among Americans has presented serious and ongoing challenges to the provision of health care and mental health services in the United States.

Prior to the passage of the Affordable Care Act in March, 2010:

• 47.5 million Americans lacked health insurance coverage. ¹
• 25% of uninsured adults had a mental health disorder or substance use disorder, or both. ²
• In the Individual Insurance Market
• 34% of those with individual market plans had no coverage for substance use disorder services.
• 18.9% had no coverage for mental health services, including outpatient therapy visits and inpatient crisis intervention and stabilization. ³
• 9% had no coverage for prescription medications. ⁴
• Federal parity law did not apply to mental health benefits in this market. Coverage for mental health and substance use disorders did not need to be comparable to that of medical and surgical care. ⁵
• In the Small Group Market
• Federal parity law did not apply to mental health or substance abuse benefits (though 95% of individuals with this class of insurance had them) in the small group market.

The Affordable Care Act was implemented in 2014 and created the following changes in the provision of mental health care and treatment for substance use disorders:

• Essential Health Benefits: Mental health and substance use disorder benefits were classified as essential health benefits, and became mandatory within all plans in all markets.

• Insurers were prohibited from applying annual and/or lifetime dollar limits to essential health benefits.
• The Department of Health and Human Services estimates that mental health disorders were among the most common pre-existing conditions for which Americans were denied coverage or charged excessively prior to implementation of the ACA.
• The number of people who gained coverage for mental health and substance use disorders due to their inclusion as essential health benefits expanded as follows:
• Individual market: 3.9 million ⁶
• Small group market: 1.2 million ⁷
• Uninsured due to preexisting conditions (all markets): 3.6 million ⁸

• Parity Protections: Federal parity protections became mandatory within all plans in all markets.
• Prior to the ACA, mental health disorders were among the most common pre-existing health conditions for which Americans might have been denied coverage or charged more for coverage. ⁹
• Building on the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA, or the federal parity law), the act required insurers that provide coverage for mental health and substance use disorder benefits to do so at a rate comparable to coverage for general medical and surgical care.
 
• The number of people who gained parity protections for mental health and substance use disorder benefits under the ACA expanded as follows:
• Individual market: 7.1 million ¹⁰
• Small group market: 23.3 million ¹¹

• Medicaid expansion extended insurance coverage to low-income adults earning up to 138% of the federal poverty line. This coverage included access to mental health services and substance use disorder treatment.
• 32 states (including the District of Columbia) extended Medicaid under the Affordable Care Act. ¹²

• 16.2 million people enrolled in Medicaid under the ACA, gaining access to care for mental health and substance use disorders. ¹³
• As of December 2016, 74 million people were enrolled in Medicaid. ¹⁴
• Medicaid is the nation’s principal insurer of the poor; Medicaid’s principal objective is to furnish medical assistance to people who cannot afford necessary health care. ¹⁵
• Medicaid accounts for nearly half of all births, covers over one-third of all children, and accounts for nearly half of all long-term care spending. ¹⁶

The ACA and the Opioid Epidemic

Research shows that health insurance coverage makes care more affordable, secure, and reliable, and that people with insurance are more likely to get timely and consistent care. ¹⁷

• In 2016, 39% of people suffering with illicit drug use disorders reported that they had no health insurance coverage and could not afford the cost of treatment ¹⁸
• Changes implemented through the Affordable Care Act have been especially important to people with substance use disorders and other behavioral health conditions.
• Parity. Prior to the ACA, an estimated 34 percent of individual market policies did not cover substance use treatment. ¹⁹
• Expansion of Health Insurance Coverage. Among low-income adults, Medicaid expansion was associated with an 18.3 percent reduction in unmet need for substance use disorder treatment services. ²⁰
• States that made an early commitment to expand Medicaid and establish insurance Marketplaces had significantly higher growth in the number of physicians with a waiver to prescribe buprenorphine for opioid use disorder treatment. ²¹
• If the ACA were repealed

President Donald Trump has promised to “repeal and replace” the Affordable Care Act, an initiative with significant implications for the provision of care for mental health and substance use disorders in the United States.

• Repeal
• Campaign promises to immediately repeal the ACA met resistance from a wide spectrum of stakeholders on a variety of grounds.
• Analysis by the Urban Institute released on December 6, 2016 estimated the following: ²⁴
• The number of uninsured people would rise from 28.9 million to 58.7 million in 2019, an increase of 29.8 million people (103%).
• 82% of the people becoming uninsured would be in working families.
• 38% would be ages 18 to 34.
• 56% would be non-Hispanic whites.
• 80% of adults becoming uninsured would not have college degrees.
• This would generate an additional $1.1 trillion in uncompensated care between 2019 and 2028, which would fall to hospitals, clinics, physicians, etc., and to state and local governments.
• Federal government spending on health care for the nonelderly would be reduced by $109 billion in 2019 and by $1.3 trillion from 2019 to 2028.
• State spending on Medicaid and CHIP would fall by $76 billion between 2019 and 2028.
• Abandonment of the individual and employer mandates in the midst of an already established plan year would cause major disruption in the insurance market.
• The number of uninsured would increase by 4.3 million immediately.
• Insurers would undergo $3 billion in financial losses.

• A January 24^th, 2017 Congressional Budget Office report reiterated that repeal alone would leave 20-30 million Americans without coverage and possibly collapse the individual insurance market. ²⁵

• Replace
• House Republican leadership introduced the American Health Care Act (AHCA) on March 6, 2017. It is currently moving through congress, and received amendments on March 20^th.
• The bill’s focal point is Medicaid spending, which it aims to reduce by $880 billion over a 10-year time frame through two main mechanisms: ²⁶
• Elimination of adult expansion of Medicaid initiated under the ACA
• Introduction of per-person spending limits

• Medicaid is the nation’s principal insurer of the poor; Medicaid’s principal objective is to furnish medical assistance to people who cannot afford necessary health care. ²⁷
• The roll-back of Medicaid services and entitlements would include personal attendant services expanded under the ACA to avoid unnecessary institutionalization, including for people with mental health disorders and intellectual disabilities. ²⁸

Legislative Updates

On Friday, March 24, House Republican leaders failed to secure enough support to pass their plan to repeal and replace the Affordable Care Act, and removed the bill from consideration.

On Thursday, May 4th, the House passed a bill consisting of the original AHCA and a series of amendments. In addition to the impacts discussed above, the new bill will do the following:

• • Permit states to waive the ACA’s essential health benefit requirements
• o This will include mental health and substance use disorders. Insurers will be able to impose annual and lifetime limits on spending or omit treatment of these disorders altogether. Such an act will significantly undermine federal parity protections.
• • Permit states to waive “community rating” rules prohibiting insurers from charging higher premiums based on pre-existing conditions.
• o While insurers will not be allowed to outright exclude individuals with pre-existing conditions, they will be allowed to charge premiums high enough to effectively do so.

Recommended Selected Analysis

Timothy Jost, “House Passes AHCA: How It Happened, What It Would Do, And Its Uncertain Senate Future,” Health Affairs Blog , May 4, 2017.

Billy Wynne, “Five Lessons From The AHCA’s Demise,” Health Affairs Blog, March 27, 2017.

Timothy Jost, “Eye on Health Reform: First Steps of Repeal, Replace, and Repair,” Health Affairs, March 2017 vol. 36 no. 3 398-399.

Barack H. Obama, J.D., “Repealing the ACA without a Replacement — The Risks to American Health Care,” NEJM, January 26, 2017; 376:297-299.

Sara Rosenbaum. “The Unfolding Medicaid Story: Congress, Governors, and the Trump Administration” Health Affairs Blog, March 20, 2017.

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References

1. Estimated based on the US Census Bureau’s 2011 American Communities Survey.
2. Garfield RL, Lave JR, Donahue JM, “Health reform and the scope of benefits for mental health and substance use disorder services.” Psychiatric Services 61:1081-1086 (2010).
3. "Essential Health Benefits: Individual Market Coverage," ASPE Issue Brief, Washington, DC: U.S. Department of Health & Human Services, 2011.
4. ibid
5. Kirsten Beronio, Rosa Po, Laura Skopec, & Sherry Glied, “Affordable Care Act Will Expand Mental Health and Substance Use Disorder Benefits and Parity Protections for 62 Million Americans,” ASPE Issue Brief, Washington, DC: U.S. Department of Health & Human Services, February 20, 2013.
6. ibid
7. ibid
8. "Health Insurance Coverage for Americans with Pre-Existing Conditions: The Impact of the Affordable Care Act,” ASPE Issue Brief, Washington, DC: U.S. Department of Health & Human Services, January 5, 2017.
9. Health Insurance Coverage for Americans with Pre-Existing Conditions: The Impact of the Affordable Care Act,” ASPE Issue Brief, Washington, DC: U.S. Department of Health & Human Services, January 5, 2017.
10. Beronio, et al. February 20, 2013.
11. ibid
12. “Centers for Medicare and Medicaid Services. Medicaid & CHIP: August 2016 Monthly Applications, Eligibility Determinations and Enrollment Report.” November 3, 2016.
13. “December 2016 Medicaid and CHIP Enrollment Data Highlights” Medicaid.gov
14. ibid
15. Sara Rosenbaum, “The Unfolding Medicaid Story: Congress, Governors, and the Trump Administration,” Health Affairs Blog, March 20, 2017.
16. ibid
17. Baicker & Finkelstein, 2011. “The Effects of Medicaid Coverage – Learning from the Oregon Experiment.” NEJM 365:683-685. Sommers et al., July 28, 2015; “Changes in Self-reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act.” JAMA, 314(4): 366-74.
18. Richard Frank, “How do we Finish the Job that the Comprehensive Addiction and Recovery Act Started?” Health Affairs Blog, September 12, 2016.
19. National Conference of State Legislators. Individual Health Insurance and States<: >
Chronologies of Change. Retrieved from http://www.ncsl.org/research/health/individual-health-insurance-in-the-states.aspx
20. Wen et al., December 2015.”Effect of Medicaid expansions on health insurance coverage and access to care among low-income adults with behavioral health conditions.” Health Serv Res, 50(6): 1787-809.
21. Wen et al., December 2013. ‘State parity laws and access to treatment for substance use disorder in the United States: implications for federal parity legislation.” JAMA Psychiatry, 70(12): 1355-62. 22. Blumberg et al., December 6, 2016. “Implications of Partial Repeal of the ACA through Reconciliation.”
23. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, December 16, 2016. Drug Overdose Death Data.
24. Blumberg LJ, Buettgens M, Holahan J., ”Implications of partial repeal of the ACA through reconciliation,” Washington, DC: Urban Institute, 2016.
25. “The Budget and Economic Outlook: 2017 to 2027,” Congressional Budget Office, January 24, 2017.
26. Sara Rosenbaum, “The American Health Care Act and Medicaid: Changing A Half-Century Federal-State Partnership” Health Affairs Blog, March 10, 2017.
27. Sara Rosenbaum, “The Unfolding Medicaid Story” March 20, 2017.
28. For a guide to the ACA enhancement of these services, see https://www.medicaid.gov/federal-policy-guidance/downloads/smd16011.pdf