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What an Obamacare Repeal Would Mean for Mental-Health Treatment

Repealing the ACA could lead to less coverage for medicines and therapy—and possibly, a return of behavioral health disorders as pre-existing conditions.
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Photo showing a doctor talking to a patient sitting on a bed in an exam room

If the Affordable Care Act is repealed, what’s going to happen to the tens of millions of Americans who need treatment for addiction, depression, and various other mental-health conditions?

It’s a pertinent question because Obamacare had lots of provisions designed to make sure the mentally ill receive proper coverage. In 2016, Health and Human Services provided $94 million in grants through the Affordable Care Act for free clinics to screen and treat their patients for substance use disorders. With the potential for an ACA repeal, the long-term survival of those programs is now in question.

“For mental-health and substance use disorder professionals, people working in the field, I think it’s a huge concern,” says David Mineta, an Obama administration-era deputy director at the Office of National Drug Control Policy. (Mineta is now CEO of a mental health-care services non-profit in California.)

Mineta’s worries are bolstered by a new report by the Department of Health and Human Services, which argues that that “our nation’s best shot at reversing the opioid epidemic and providing needed care for opioid use disorders, others [sic] substance use disorders, and mental illness depends on the continued success of the Affordable Care Act.”

The report points out a few ways Obamacare improved the lives of those with mental disorders:

Obamacare required all health insurance plans to cover mental health conditions, including substance use disorders

Before the Affordable Care Act, 18 percent of people who bought their own insurance didn’t have mental-health coverage. More than one-third didn’t have substance use disorders coverage.

Several Republican proposals for an Affordable Care Act replacement would get rid of the stipulation that plans cover mental health.

Obamacare required insurance companies to cover people with pre-existing conditions, many of which were mental-health diagnoses

Health and Human Services estimates that, before the Affordable Care Act, behavioral health disorders were the second-most common pre-existing condition that insurance companies would use to charge people more for a plan, or to deny them coverage. (High blood pressure was the most common.) Between 2010 and 2014, an additional 800,000 Americans with behavioral health disorders gained insurance.

Many Obamacare replacement plans would preserve the act’s pre-existing conditions ban so long as people don’t let their insurance lapse. But protecting those with pre-existing conditions may be difficult without also mandating that everyone buy insurance, which is one of the major objections to the Affordable Care Act and may be up for repeal. Without prescribing that the young and healthy get covered, companies may find it’s too expensive to insure everybody for the same price, regardless of the conditions they already have, as Los Angeles Times reporter Michael Hiltzick argued recently.

As a result, after the major provisions of Obamacare went into effect, more people with substance use and other mental-health disorders seemed to be able to afford medical care

Between 2010 and 2014, among the very poor, the proportion of people who said they skipped out on mental-health care because they couldn’t afford it dropped from 6 percent to 4 percent. Between the ends of 2013 and 2014, the proportion of people who were hospitalized for a mental-health disorder, but didn’t have insurance to help pay for it, fell from 22 percent to 14 percent. The effect was most dramatic in states that expanded Medicaid under Obamacare: There, the numbers dropped from 20 percent to 6 percent. Medicaid expansion is threatened under some Republican plans, but not others, as Vox reports.

Should mental-health care become unaffordable for more people, Stanford University psychiatry professor Keith Humphreys predicts they’ll put off going to their doctor until they’re further along in their illness. And if people with opioid use disorders stop seeing the doctor altogether, that can be deadly. “Treatment does reduce overdose,” Humphreys says.

As of December, Mineta was still holding out hope that an Affordable Care Act replacement won’t erode mental-health and opioid addiction coverage. “I almost think it’s a non-partisan support for these issues because they’re so local and so personal, in many ways. It affects all of us,” he says. (Surveys suggest he’s right.) “So, hopefully, that will hold these services in good stead.”