In enacting the 21st Century Cures Act this past December, Congress took important steps toward promoting access to high quality care for mental and substance use disorders. The Act directs new resources to two long-standing challenges: federal opioid misuse and abuse ($1 billion over two years) and serious mental illnesses (about $200 million in 2017). These new appropriations, secured through a broad bipartisan vote, will fund critical investments in treatment capacity and quality.
But these investments will be squandered if the new Congress rolls back recent gains in the quality and level of substance use and mental health insurance coverage generated by the Affordable Care Act (ACA) of 2010. Building upon the Mental Health Parity and Addictions Equity Act, the ACA gives people suffering from these devastating illnesses the purchasing power that will allow them to use this new treatment capacity.
Repealing the ACA — and its behavioral health provisions — would have stark effects on those with behavioral health illnesses. We estimate that approximately 1,253,000 people with serious mental disorders and about 2.8 million Americans with a substance use disorder, of whom about 222,000 have an opioid disorder, would lose some or all of their insurance coverage.
One impetus for passing the Cures Act was to address an opioid treatment gap of about 420,000 people that reported money or availability of care were key impediments to obtaining substance use treatment — repealing the ACA would increase that gap by over 50% with the stroke of a pen.
The impact of repealing ACA provisions related to mental and substance use disorders would have particularly adverse effects on states that have experienced some of the most tragic increases in opioid related deaths. Many of these states — including Alaska, Kentucky, Maine, Ohio, West Virginia — have seen their adult uninsured rates drop by more than 5 percentage points since the implementation of the ACA coverage expansions in 2014.
Several states — Kentucky, Massachusetts, Maryland, Ohio and West Virginia — have addressed the opioid overdose problem by promoting use of effective Medication Assisted Treatment (MAT) in the context of their Medicaid expansions. The result is that Medicaid pays for between 35% and 50% of all MAT in those states. They would find it much more challenging to maintain these evidence-based programs in the face of a repeal of those expansions.
To put this in dollar terms, repealing the mental and substance use disorder coverage provisions of the ACA would withdraw at least $5.5 billion annually from the treatment of low income people with mental and substance use disorders. The Cures Act’s two-year, $1 billion increase in treatment capacity would not even serve as much of a bandage if it were coupled with a cut in annual treatment spending that is more than five times greater.
The Congress and the American people have come to realize that stemming the tragic toll of opioid misuse and addiction and serious mental illnesses takes funding as well as policy. The Cures Act reflects bipartisan agreement on this point.
It would be a cruel sham for Congress to take an important, but modest, step forward in investing in treatment capacity, while withdrawing funds from the enormous recent progress made in addressing the needs for care of those with mental health and addictive illnesses.
Congress should not backtrack on the promise of the Cures Act by repealing the ACA.
Richard G. Frank, Ph.D., is the Margaret T. Morris Professor of Health Economics in the Department of Health Care Policy at Harvard Medical School, and Sherry Glied, Ph.D. is Dean of the Wagner School of Public Service at NYU.
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