On March 6, 2017, Republican leadership in the House of Representatives presented the American Health Care Act (AHCA), their answer to the effort to “repeal and replace” the Affordable Care Act (ACA), also known as “Obamacare.”
Unfortunately, the replacement bill makes major changes to the expansion of Medicaid under former President Barack Obama and removes many of the provisions that ensured coverage for mental health treatment, including addiction treatment.
Part of Obamacare’s main mission was to provide mental health parity — meaning insurance coverage for mental health issues would be comparable to coverage for physical health issues — and ensure that mental health conditions would be considered “essential care” by Medicaid and Medicare.
This paved the way for addiction treatment services to be covered.
Medicaid now covers more than 70 million people and is “the largest source of funding for behavioral health treatment, like addiction recovery and substance abuse prevention,” according to the Washington Post.
On the campaign trail, President Donald Trump made opioid addiction and treatment a key part of his message. In New Hampshire, a state devastated by the opioid crisis, he said, “People are getting hooked, and we’re going to take care of those people.”
At his inaugural address, he reiterated his promise: “Drugs … have stolen too many lives and robbed our country of so much unrealized potential.”
Trump also made preserving Medicaid, Medicare and Social Security one of his main talking points. He said in his presidential announcement that he planned to “save Medicare, Medicaid and Social Security without cuts.”
Most recently, during his speech to a joint session of Congress, Trump promised to “expand treatment for those who have become so badly addicted.”
Rolling Back Medicaid Expansion
The AHCA, which the Republican-led majority has proposed, makes two major changes to the way Medicaid is administered. They both affect addiction treatment coverage.
First, under the ACHA, the expansion of Medicaid that 31 states plus the District of Columbia undertook as a result of the ACA would be rolled back. This change would affect the 1.3 million people who have received drug treatment under the expansion, according to a joint study by Harvard University and New York University.
This signals a change for many states that expanded Medicaid and that also have extraordinarily high numbers of drug-related overdose deaths. Kentucky and West Virginia both expanded Medicaid under Obamacare, and the 15 counties with the highest incidence of opioid overdoses were in those two states, according to the New England Journal of Medicine.
In January 2017, Ohio Gov. John Kasich commented, “Thank God we expanded Medicaid because that Medicaid money is helping to rehab people.”
A 2016 study by the Robert Wood Johnson Foundation stated, “Medicaid is the most powerful vehicle available to states to fund coverage of prevention and treatment for their residents at risk for or actively battling opioid addiction.”
Mental Health Services No Longer Essential
Secondly, a change to Medicaid in the AHCA also removes mental and behavioral health treatment from the list of essential services that are to be covered under the program.
During a congressional panel meeting, Republicans confirmed that mental and behavioral health services would be removed from the essential services list. This prompted Rep. Joe Kennedy, D-Mass., and Rep. Peter Welch, D-Vt., to introduce an amendment during the meeting to include mandates for addiction and mental health coverage.
The amendment did not pass after a party-line vote from Republicans.
The consensus among the scientific community is that the GOP proposal would strip away essential coverage for drug addiction just as the number of deaths from drug overdose is skyrocketing across the country.
Leaving It up to States
As an alternative to funding mental health services nationwide, the GOP leadership has suggested that the decision of whether or not to cover addiction treatment services and substance abuse prevention will be up to the states.
House Speaker Paul Ryan has championed a cap on Medicaid spending, so it will be up to the states to make up the shortfall.
“The states then have a choice: They can continue to take on those responsibilities and pay for it out of their own budgets, or, if they are under pressure, they have to scale back,” Richard G. Frank, a professor of Health Economics at Harvard University, told CNN.
State budgets are already under immense pressure as it is. Virginia Gov. Terry McAuliffe, speaking to All Things Considered on National Public Radio, said, “It will strap our state budget. It will reduce benefits. It will limit choices. And when people think of Medicaid, you know, they think it’s poor, minority families.”
A number of state senators and governors, especially those from the states hardest hit by the opioid epidemic, have spoken out against the AHCA’s changes.
Four Republican senators, Cory Gardner of Colorado, Rob Portman of Ohio, Lisa Murkowski of Alaska and Shelley Moore Capito of West Virginia, sent a letter to Senate Majority Leader Mitch McConnell to encourage protection of Medicaid in providing drug treatment services.
The senators asked that the health care plan “provide stability and certainty” for Americans who rely on Medicaid for these services.
Currently, Medicaid pays for 49.5 percent of medication-assisted treatment in Ohio, 44.7 percent in West Virginia and 44 percent in Kentucky. Trump secured the most electoral votes in these states in the 2016 election, and all three are top states for opioid overdose deaths, according to the Centers for Disease Control and Prevention.
Reactions from Researchers
Researchers from many major universities have commented on the negative impact the AHCA will have on those who struggle with drug addiction.
“Taken as a whole, [the AHCA] is a major retreat from the effort to save lives in the opiate epidemic,” Joshua Sharfstein, associate dean at Johns Hopkins Bloomberg School of Public Health, told the Washington Post.
Deaths from opioids, including heroin, have skyrocketed in recent years. The CDC released a study in late 2016 finding that 25 percent of all drug overdoses were heroin-related in 2015. In 1999, that number was only 6 percent.
Relatedly, more than 33,000 people died of opioid overdoses in 2015 — a record number — according to the CDC. By that toll, opioids now kill more people than car accidents. The number of heroin deaths exceeded the number of gun-related murders in 2015.
In an interview on National Public Radio, cancer surgeon Atul Gawande, who practices at Brigham and Women’s Hospital in Boston, commented that the stakes for patients in this situation are “extremely high.”
Director of the Opioid Policy Research Collaborative at Brandeis University, Dr. Andrew Kolodny, told CNN that the AHCA is a “step in the wrong direction at a time when America’s most urgent public health crisis is an addictive disorder.”
