What will ACA replacement mean for mental health?

Uncertainty surrounding President Donald Trump’s often repeated campaign promise to dismantle the Affordable Care Act has changed the way Republicans talk about it: Instead of “repeal,” the emphasis is now on “repair.”

Even so, mental health advocates are worried that any fix to the 2010 federal health care law might mean the loss of historic protections requiring health plans to cover mental health and substance use disorder treatment and services. Before ACA made these services “essential benefits,” individual and small group market policies rarely covered them.

“The Affordable Care Act, put in extreme terms, is a life-or-death issue for people with mental illness,” said Ken Norton, LICSW, executive director of the New Hampshire chapter of the National Alliance on Mental Illness. “It was years of advocacy to get above the discriminatory insurance practices that had such a profound impact on people’s lives.”

More than 20 million Americans gained health insurance coverage through ACA, which created a minimum level of protections for those enrolling on the individual market and offered more covered benefits with more sharing of health care costs across a larger population.

At least a half dozen Republican proposals have emerged in Congress to replace ACA, with a general consensus around keeping a popular provision that banned denial of coverage based on pre-existing conditions and another that provided coverage for dependents up until age 26.

Most Congressional leaders, however, are seeking to give states more flexibility in determining the options for essential benefits and how those are defined.

GOP proposals include the Patient Freedom Act introduced Jan. 23 by Sen. Susan Collins (R-Maine) and Sen. Bill Cassidy (R-Louisiana).

Modeled after a 2015 proposal with the same name, it would let states either keep using the ACA or instead divert federal subsidies to either fund their own state exchange programs or create health savings accounts for people who were previously uninsured.

The Cassidy-Collins bill would repeal the individual mandate that imposes a tax penalty on those who failed to obtain health insurance and also repeal the employer mandate that requires employers of 50 or more workers to offer health insurance to at least 95 percent of their full-time employees and their dependents.

Mental health and substance use disorder services must be included in coverage under the Cassidy-Collins bill. But it’s unclear what actuarial value standards would apply.

“You could have that coverage, but there could be a lot of limits on the services or it could be very high cost sharing requirements on them unless they explicitly regulate that and put some standards in place,” said economist Linda J. Blumberg, Ph.D, a senior fellow in the Health Policy Center at the Urban Institute.

Collins’ office did not respond to requests for an interview. A moderate among Senate Republicans, she received praise in the press both nationally and in her home state for a proposal seen as building a bridge for ACA replacement efforts.

But John E. McDonough, DrPH, MPA, a professor of practice in the Department of Health Policy & Management at Harvard T. H. Chan School of Public Health who worked on writing the ACA, said the Cassidy-Collins bill would merely “kick the can” to states without ensuring real protections for consumers.

“The bill is an example of a Republican Congressional majority that has been unable, after six years of attacking the ACA, of articulating a clear alternative vision for how Americans should have a guarantee of access to quality and affordable health coverage,” McDonough wrote in an email.

One big problem with the ACA is that insurance remains very expensive. Those who earn too much to qualify for subsidies still struggle to pay premiums and have high deductibles.

In her remarks in the Congressional Record, Collins noted that premiums for the individual market in Maine this year soared by an average of 22 percent as plan options have become more limited.

Blumberg said too much of the conversation about repairing the ACA has focused only on lowering premiums. The easiest way to lower premiums is to limit benefits or increase the costs consumers must pay out of their own pocket, she added.

“If you only think about lowering premiums there’s a lot you can do pretty quickly, but it can be really damaging in terms of impeding access to care for people who need it,” she said.

Insurers, who receive forms and rate filing instructions for 2018 in March, will want clarity from Congress and the Trump Administration as soon as possible. But the timetable for a replacement looks like it will drag on through the end of the year or into 2018. Senate Republicans who have a 52-48 margin need 60 votes under budget reconciliation rules to repeal ACA tax penalties or any provisions involving Medicaid. They will be looking to get enough Democrats on board.

“Republicans are walking back from repealing the Affordable Care Act, and I hope will be ready soon for a mature discussion about improving health care,” Sen. Sheldon Whitehouse, (D-Rhode Island) said in a statement his office released to New England Psychologist. The two-term Democratic Senator is among 23 Senate Democrats plus two independents up for reelection in 2018.

“Republicans in Congress have a lot of this work going on in their home states, so when the ‘Repeal Obamacare’ political fever passes, I believe we can do good bipartisan work together.”

Whitehouse authored the bipartisan Comprehensive Addiction and Recovery Act (CARA), which President Barack Obama signed into law last year to expand prevention and treatment efforts to address the opioid epidemic.

“Half a billion dollars is on its way to states to help with treating mental health and substance abuse. There should be no going back on this issue, not with 239 overdose fatalities last year just in Rhode Island,” Whitehouse said.