The voices of Urban Institute's researchers and staff
January 31, 2017

Repealing the ACA could worsen the opioid epidemic

A version of this post was originally published on Health Affairs.

As our country grapples with an “unprecedented opioid epidemic,” Congress is working to take away an important tool to fight it—the Affordable Care Act (ACA). The estimated annual cost of the epidemic is $78.5 billion. In 2014, there were more deaths from opioid and other drug overdose than in any other year; 60.9 percent of those overdoses involved an opioid. Every day, an average of 78 Americans die from opioid abuse. The coverage expansions and protections under the ACA can help lessen the epidemic and save lives.

The ACA provides coverage to people with substance use disorders

Because of the ACA, an estimated 26 million people have health coverage through the Marketplaces or Medicaid that includes substance use disorder (SUD) treatment and prevention. Additional people enrolled in new individual market or small-group market plans outside the Marketplace also now have SUD treatment covered because most individual and small-employer insurance plans can no longer exclude SUD treatment. And, as Ohio governor John Kasich recently noted, the Medicaid expansion is getting SUD treatment services to people in need.

In addition, coverage expansions under the ACA help people afford regular access to care, including mental health services and treatment of underlying conditions that can help prevent SUD or allow for early identification and treatment. But a repeal of the ACA would more than double the nation’s uninsurance rate and, in the three states with the highest drug overdose deaths (Kentucky, New Hampshire, and West Virginia), a repeal would about triple the uninsurance rate. Repealing the ACA will remove coverage for SUD treatment and prevention from millions of Americans, leaving a gap in care when it is most needed.

Private insurance and essential health benefits

The ACA closed significant gaps in coverage in the individual and small-employer insurance markets, including a lack of coverage for behavioral health services and other SUD-related services. This is not surprising given that about one-third of people enrolled in individual market plans before 2014 had no coverage for SUD treatment, and small-employer plans were exempt from the Mental Health Parity and Addiction Equity Act (MHPAEA). They therefore could exclude SUD treatment or provide stricter limits on SUD services than on other medical services. The ACA reduced these gaps by requiring all-new plans in the individual and small-employer markets to include Essential Health Benefits (EHB), including SUD services. People covered by the Medicaid expansion must also receive the EHB, including SUD services.

As part of the EHB, new health insurance plans in the individual and small-employer markets must cover SUD treatment, prevention, and harm reduction. Under the ACA and its implementing regulations, individual and small-group plans must comply with the MHPAEA. As a result, SUD services cannot have limits less favorable than those imposed on medical and surgical benefits. While states vary in the services and treatments they are required to cover, all state EHB rules require some inpatient and outpatient behavioral health services and SUD treatment, and there are national standards for preventive services and a national floor for prescription drugs.

Medicaid coverage

Medicaid is the largest source of coverage and funding for behavioral health services in the country, and the ACA has increased access to treatment for opioid use disorder (OUD) in the Medicaid program in several ways.

First, the ACA requires states that expand Medicaid to adults up to 138 percent of the federal poverty level to cover SUD treatment for those enrollees. In the states that expanded Medicaid, 1.2 million people with SUDs, including OUDs, who were previously uninsured, have gained access to coverage that includes SUD treatment.

The proportion of substance use or mental health disorder hospitalizations that were uninsured dropped from 20 percent to 5 percent between 2010 and 2015 in Medicaid expansion states. This is significant because Medicaid programs have been found to provide more comprehensive treatment and care to people with SUD than private insurance. For example, by 2013–14, Medicaid programs in 31 states and the District of Columbia covered all medications that can be used in combination with psychosocial treatment for treatment of OUD—methadone, buprenorphine, and one of the two forms of naltrexone (oral and extended-release injectable).

Second, the EHB extended the MHPAEA to the Medicaid expansion population, paving the way for ensuring that treatment for SUDs, including OUDs, is comparable to the level of services provided for medical care.

Third, the ACA offers funding to state Medicaid programs to promote delivery reforms that integrate and coordinate care for people with SUDs. The Medicaid health home model, for example, is an optional program states can adopt under the ACA to provide additional services to people with certain chronic conditions, including SUDs. Maryland, Rhode Island, and Vermont have used the health home model to address OUDs and have implemented these programs to increase care coordination improve case management, integrate OUD treatment with medical and behavioral health services, and connect enrollees to other community services. The Centers for Medicare and Medicaid Services (CMS) has also launched an initiative to encourage states to develop innovative service deliveries to address SUDs that also promote care coordination, integrated care, and comprehensive strategies that provide a “full continuum of care” for people with SUDs. The ACA’s Medicaid expansion also represents the first widespread opportunity to coordinate SUD treatment for people involved in the justice system, and several states, including Connecticut and Rhode Island, have developed initiatives to do so.

Finally, the ACA authorized and funded numerous payment and service delivery reforms that have enabled states to address SUDs in their Medicaid programs. CMS’s Innovation Accelerator Program has provided states with resources and technical assistance to address SUD treatment. The State Innovation Models Initiative enables states to design and test multipayer delivery and payment reform models. And states have launched new initiatives to address SUD and other behavioral health issues through CMS’s Health Care Innovations Awards.

Moving forward on addressing the opioid epidemic

There is strong bipartisan consensus on the need to address the opioid epidemic through education, prevention, and treatment. Congress took steps last year to address the opioid epidemic by passing the Comprehensive Addiction and Recovery Act of 2016 and the 21st Century Cures Act. In addition, state lawmakers around the country are passing laws to address the epidemic.

Repealing the ACA will undermine these efforts. Millions of people will lose health coverage, including comprehensive behavioral health and SUD benefits through Medicaid. People remaining covered in the individual and small-group markets will lose benefits for SUD-related services, such as behavioral health services, preventive screenings, and prescription drugs. Progress toward improving SUD care through ACA delivery system reforms will be halted. Addressing the opioid epidemic will require an intense, multifaceted approach, and maintaining access to treatment and improved service delivery for millions of Americans is critical to success.

Copyright ©2017 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

Photo via Shutterstock.

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