GOP health plan will make opioid and mental health crises worse
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Given the United States’ ongoing struggle with opioid addiction and serious mental illnesses, we need to consider what the pre-existing conditions provisions of the House-passed American Health Care Act will buy in terms of caring for these illnesses. The short answer: not much.

Not only does the bill fall hundreds of billions of dollars short in meeting patients’ needs, its other provisions will no doubt worsen the opioid epidemic and contradict the statements of the lawmakers who have pledged to address the crisis.


The legislation permits states to allow insurers to underwrite pre-existing conditions and charge higher premiums to people who have them. It also lets states waive essential health benefits that would likely result in people with pre-existing conditions not having coverage for needed healthcare. In claiming to protect people with pre-existing conditions, the House proposed to provide states with $15 billion over ten years for maternity, mental health and substance use disorder care and $8 billion over five years to reduce premiums or out-of-pocket costs for people charged more due to pre-existing conditions.


This cannot keep up with an expanding opioid epidemic, and has the potential to make a serious problem worse by cutting access to treatment. Despite progress made in expanding access to treatment, mortality is growing at 15 percent per year, heroin dependence grows at up to 11 percent per year and opioid related hospitalizations grow at about 6 percent.

This means the shortfall in the commitment to protecting those with pre-existing opioid use disorders and serious mental illnesses grows each year by billions of dollars. While we have seen bipartisan consensus that the growing opioid epidemic requires swift and deliberate action — the AHCA’s funding shortfalls means turning our back on those affected and denying millions of people critical health services.  

There are about 220,000 people with an opioid use disorder and an additional 1.2 million people with a serious mental illness that are currently covered through the Medicaid expansion and the Health Insurance Marketplaces. In addition, there are 713,000 people with an opioid use disorder with incomes below the poverty line, many of whom are uninsured.

Data collected from state Medicaid programs indicate that today it costs about $11,000 per person to treat someone with a serious mental illness or an opioid use disorder. If states apply all those funds only to people with these serious illnesses in the Affordable Care Act’s Medicaid expansion and marketplaces, that would make up 1.42 million people (785,000 in the marketplaces and 635,000 in the Medicaid expansion population).

If we make the conservative assumption that the individuals in the Medicaid expansion population only use services in two out of the next five years, the Medicaid cost would be about $14 billion. That is just under the amount set aside for 10 years, without allowing for any eligible illnesses other than serious mental illnesses and opioid use disorders. And in the AHCA, the $15 billion is supposed to cover maternity care — in addition to mental health and substance use disorders.

For the marketplaces, if we assume that premium claims for this population would be the difference between the current subsidized premium ($1,644 per year) and the new underwritten premium that is approximated by the $11,000 (or $9,356) that cost would total $7.34 billion per year. Over five years, those premium surcharges sum to $36.7 billion or four and a half times the $8 billion set aside for the pre-existing condition subsidies.

Together these costs far exceed the funds identified to serve these populations — even assuming every dollar were spent only on such services and coverage for such individuals rather than all those who qualify. Thus, the new money added to the AHCA would fall far short of making up for the bill’s reduced coverage of people with the most serious mental and addictive conditions.

Now, consider the circumstances for people with maternity care needs where an insurance rider typically costs $5,000 per year, diabetes costs that account for 20 percent of all health spending, or heart disease and cancers that can incur annual costs in the tens of thousands of dollars — all of which are underwriting targets.

The Affordable Care Act created insurance pools that meant we (the insured) were all in it together. Taxpayers and enrollees shared the costs of caring for sick people. The AHCA fundamentally disrupts that pool and the neighborly impulse to cost-share care. The numbers show clearly that the vaunted $8 billion over five years is a mere pittance compared to what will be needed. The AHCA sets up our sickest low income neighbors for a massive insurance coverage take-away.

Richard G. Frank,PhD, isprofessor of health economics at Harvard University. He was the assistant secretary of planning and evaluation in the Department of Health and Human Services from 2014 to 2016.

The views expressed by contributors are their own and are not the views of The Hill.