Mental health, addiction coverage in jeopardy
Patients’ lives hang in balance as Congress decides Obamacare’s fate
“Some families will do what they have to do to help their loved ones. If there’s no coverage, I think we would definitely see an increase in deaths.” Amanda Fleckinger, former heroin addict
Sherri Reynolds’ son Qual has been drug-free for 16 months, thanks largely to his treatment through Medicaid under the Affordable Care Act.
Reynolds knows well what can happen when people can’t get coverage: Her 20-year-old stepson, Jarvis, suffered from mental illness and killed himself in 2010 after he couldn’t get medical treatment. Instead, he had been cycled through foster care and the juvenile justice system.
“I really hope they don’t dismantle Obamacare, and I don’t understand why they would dismantle something which is credited for saving so many lives,” Reynolds says.
As Congress works to repeal the Affordable Care Act with the support of President-elect Donald Trump, people with addiction and mental health disorders, their families and treatment providers wonder how patients would maintain their sobriety — and psyches — without insurance coverage.
The people helped the most by the ACA are the ones most likely to suffer from poor mental health and addiction. Nearly 30% of those who got coverage through Medicaid expansion have a mental disorder, such as anxiety or schizophrenia, or an addiction to substances, such as opioids or alcohol, according to the federal Substance Abuse and Mental Health Services Administration. That compares with the more than 20% of the overall population — 68 million people — who had a diagnosable mental health or substance abuse disorder in the past year, the American Psychiatric Association says.
In New Hampshire, which has the highest synthetic opioid death rate in the country, Democratic Sen. Jeanne Shaheen is reminding Trump about some of his campaign promises there.
“He pledged to take on this
crisis, not immediately make matters much worse,” Shaheen said Friday. “Repealing the Affordable Care Act without a replacement is highly reckless and will come at a high cost for people struggling with substance use disorders.”
Almost any route taken on Capitol Hill leads to an unraveling of addiction and mental health coverage for those people. Even the partial ACA repeal Congress is considering would eliminate the tax credits that reduce the premiums for about 85% of those who buy insurance on the federal and state exchanges. Most of those who get tax credits pay less than $100 a month for insurance and have very low out-ofpocket costs that make it possible for them to afford coverage.
The partial repeal also would scrap the expansion of Medicaid that gave millions of the lowestincome people in 31 states insurance. Instead, states would most likely get block grants that would require them to make cuts in what’s covered, how much is spent and how many people can get coverage. Or states might get a set amount per person, but the overall goal is cutting spending.
If the same legislation passed by Congress but vetoed by President Obama a year ago was enacted, people would still be able to keep their children on their insurance until age 26 and insurers wouldn’t be able to discriminate against people who have pre-existing conditions such as depression or cancer. It also retains the “essential health benefits,” including mental health and addiction coverage, now required for all plans sold on the exchanges.
Without the ability to pay for insurance, however, some say that carries little significance.
“Some families will do what they have to do to help their loved ones,” says Amanda Fleckinger, a former heroin addict in Edgewood, Ky., who lost her brother and boyfriend to overdoses in the past 18 months. “If there’s no coverage, I think we would definitely see an increase in deaths.”
A 2008 law that required insurers to cover mental health and addiction at the same level they do other diseases is “useless” if there’s no insurance coverage for low-income patients that has to reach parity, says Linda Rosen- berg, CEO of the National Council on Behavioral Health. She describes the current debate on Capitol Hill over the ACA’s future as “the most critical time” in her 40-year career as a social worker.
Medication-assisted treatment for addiction “has really come into its own,” she says.
Former representative Patrick Kennedy, D-R.I., author of the mental health and addiction parity law, calls the ACA “the best mental health and addiction bill ever.” It makes his law’s mandates “real for more people,” he says.
New mental health provisions in the recently enacted 21st Century Cures Act that improve access to treatment need “to be combined with strong, affordable insurance,” says psychiatrist Henry Chung of Montefiore Health System in the Bronx. Areas that would be hard hit:
New Hampshire. Repealing the ACA would cause nearly 120,000 people to lose coverage in the state, where federal data show a nearly 200% increase in overdose deaths in the past five years.
Ohio. At the Cincinnati Center for Addiction Treatment, CEO Sandra Kuehn said about 30% of Kuehn’s patients are covered for treatment because of the expansion. Overdose deaths climbed from 2,531 in 2014 to 3,050 in 2015, up more than 20%.
Kentucky. Overdose deaths here totaled 1,248 in 2015, up about 17% from 2014, according to the Kentucky Office of Drug Control Policy. Fentanyl — which is much stronger than heroin — was involved in 420 fatal overdoses in 2015, up nearly 250% from the previous year.
Chicago. Up to 30% of the 9,000 or more inmates in the Cook County Jail have a diagnosed mental illness, according to jail data.
With an ACA repeal looming, Sherri Reynolds worries about son Qual, whose slide into mental illness and addiction began after Jarvis killed himself.
Jarvis “was 20,” Reynolds says, “and for his birthday, we got him a tombstone.”
“The ACA has been a game changer for those who are in and out of Cook County Jail.” Mark Ishaug, CEO of Thresholds, a Chicago treatment provider