What the Senate's Obamacare Replacement Would Mean for Mental-Health Treatment

The Better Care Reconciliation Act would make mental-health care more expensive for many Americans.
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A 24-year-old man talks with his therapist.

A 24-year-old man talks with his therapist.

When Obamacare repeal was but a twinkle in Republicans' eyes, Pacific Standard wrote about how the disappearance of the Affordable Care Act might affect Americans who need mental-health care, including addiction treatment. At the time, we didn't yet know what the ACA's replacement would look like. Now we do. The Senate released its Better Care Reconciliation Act last week, and Majority Leader Mitch McConnell aims to hold a vote on it next week.

Below, we take a look at what the latest Obamacare replacement would mean, if passed, for Americans who use mental-health services.

What Obamacare did: Required all health insurance plans to cover mental-health conditions.

What the Senate health-care plan does: Exempts plans from covering mental health after 2019.

The Affordable Care Act established what it called the "10 essential benefits," which were services that every health insurance plan in America was required to cover. These services included mental-health care, substance use disorder treatment, pharmacy benefits, and prenatal care.

The Better Care Reconciliation Act exempts Medicaid from covering the 10 essential benefits after December 31st, 2019. In addition, states may request a waiver from the essential benefits for other plans sold in the state. Folks dependent on these types of plans may then end up paying for their mental-health treatment out of pocket.

What Obamacare did: Required health insurance companies to cover people with pre-existing conditions, many of which were mental-health conditions.

What the Senate health-care plan does: Companies must still cover all applicants, but those with pre-existing conditions may end up paying more.

Before Obamacare, behavioral health disorders were the second-most common reason for insurance companies to refuse to cover people or to charge them more for coverage, according to a Department of Health and Human Services estimate. (The most common pre-existing condition was high blood pressure.) So for mental-health advocates, it was a point of worry that the House of Representatives' Obamacare replacement plan, the American Health Care Act, allowed states to charge people with pre-existing conditions more if they let their health insurance lapse.

In contrast, the Better Care Reconciliation Act stipulates that companies must cover all applicants. However, some experts think that people with pre-existing conditions might still end up paying more for insurance under the BCRA because the 10 essential benefits are no longer required—so those who want mental-health coverage must pony up for special plans that meet their needs. Such plans may be extra pricey because younger, healthier people may not buy them and thus wouldn't be in those pools, helping to spread out the risk.

What Obamacare did: Offered states the option to loosen Medicaid eligibility requirements so more lower-income adults could join. Thirty-one states and the District of Columbia expanded their Medicaid programs.

What the Senate health-care plan does: Phases out federal funding for Medicaid expansion, making states less likely to keep it up on their own.

Contracting Medicaid affects a variety of Americans, not just those with mental-health needs. But it seems Medicaid expansion made mental-health care more affordable for many. For example, before the Affordable Care Act's major provisions took effect, in the states that would later expand Medicaid, about one in five Americans who were hospitalized for a substance use or other mental-health disorder didn't have insurance to pay for it. By the middle of 2015, that proportion fell to 5 percent in Medicaid-expansion states, according to the Department of Health and Human Services.

Addiction-care advocates worry about how less affordable care will affect their patients. People may forgo seeing the doctor until they're further along in their illness, which can be deadly, in the case of addiction, as Stanford University psychiatry professor Keith Humphreys told Pacific Standard earlier this year. Today, the American Society of Addiction Medicine released a statement opposing the Senate's rollback of Medicaid expansion, noting that 2.8 million Americans with substance use disorders gained health insurance for the first time under the expansion.

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