In March, President Donald Trump announced the American Health Care Act (AHCA), more popularly known as Trumpcare. The plan was intended to both repeal and replace the Affordable Care Act (Obamacare).
The Congressional Budget Office (CBO) then released a report estimating that, if this new plan was approved, the number of uninsured Americans would increase by 24 million people. Rural America and senior citizens would be among the hardest hit by these healthcare changes.
But how would Trump’s plan affect treatment for drug and alcohol addiction? Let’s take a look.
Addiction Treatment Under Obamacare
The U.S. Department of Health and Services states, “The Affordable Care Act provides one of the largest expansions of mental health and substance use disorder coverage in a generation, by requiring that most individual and small employer health insurance plans, including all plans offered through the Health Insurance Marketplace, cover mental health and substance use disorder services.”
Under Obamacare, mental and behavioral health treatment, including for substance abuse, is considered essential. This means all plans must cover these types of treatment.
Additionally, Obamacare forbids marketplace plans from denying coverage or charging higher prices for pre-existing medical conditions, such as substance use disorder. There can also be no lifetime or yearly limit on coverage for these essential health benefits.
Obamcare also significantly expanded Medicaid, which has produced noticeable results for people with substance abuse disorders. In states that expanded Medicaid, the percentage of people with substance use disorders who were hospitalized but uninsured dropped from about 20% in 2013 to just 5% by mid-2015.
This was particularly beneficial in states hit hardest by the opioid epidemic, such as West Virginia, the state with the highest rate of drug overdose deaths in 2015. In West Virginia, the number of people hospitalized for substance abuse disorders fell from 23% in 2013 to 5% by 2015.
Obamacare emphasizes the importance of treatment for both substance abuse and mental health disorders, which often go hand in hand. It requires that treatment for these disorders is placed on the same level as treatment for physical health issues. Obama’s health care plan also provides access to health insurance for millions who would not be covered otherwise.
Changes Under Trumpcare
The current version of Trump’s healthcare plan should not significantly impact rehab treatment or mental care through private insurance. However, it will alter Medicaid, which is for low income individuals. States would also have more freedom in determining which conditions necessitate coverage.
Technically, Trumpcare does not repeal the Mental Health Parity and Addiction Equity Act, which was signed in 2008 and requires health insurance plans to provide the same coverage for mental health and substance abuse treatment that they would provide for chronic physical health problems, such as diabetes.
This means that plans can’t charge more for mental health or substance abuse treatment than they would charge for physical health treatments, and they can’t limit the number of visits to a healthcare professional who will help manage mental health concerns such as addiction or depression.
However, beginning in 2020, Trump’s healthcare bill would remove the Obamacare requirement for Medicaid to cover substance abuse-related health services, as well as other mental and behavioral health services. This would threaten the care that millions receive under the expansion of Medicaid.
Representative Joe Kennedy III (D-MA) points out, “…mental health benefits are not required now by federal law. It would be up to the states to actually impose. So when we look at those essential health benefits, whether it’s mental healthcare or…other health conditions, that is no longer essentially covered, or required to be covered, by this version of this text.”
In response, Republicans admitted that this plan would remove a requirement to offer both substance abuse and mental health coverage that’s currently used by at least 1.3 million Americans.
In fact, Harvard health economist Richard Frank estimates that about 2.8 million people who struggle with substance abuse will lose some or all of their health insurance coverage if the proposed changes are made.
If Trumpcare were to repeal and replace Obamacare, the most significant changes would be rolling back the expansion of Medicaid and limiting the “essential benefits” for which states are required to provide, including treatment for substance abuse and mental health disorders.
How Will This Impact the Opioid Epidemic?
It’s well-documented that America is in the grips of a severe opioid epidemic. Opioids include heroin, fentanyl, and prescription painkillers such as oxycodone and hydrocodone.
In 2015, drug overdose was the leading cause of death in America, resulting in 52,404 lost lives. 20,101 of these deaths were linked to prescription painkillers, while an additional 12,990 were caused by heroin. This means at least 63% of drug overdose deaths in 2015 were related to opioids, and these numbers are steadily climbing.
One of Trump’s campaign promises was to help assuage the opioid crisis, a promise that resonated strongly with working-class voters. Trump promised, “The people that are in trouble, the people that are addicted, we’re going to work with them and try and make them better. And we will make them better.”
After promises to declare the opioid epidemic a national emergency, Trump called it a “national public health emergency” in an October announcement. However, Trump did not request additional funds to fight the opioid epidemic.
Trumpcare, in fact, may worsen the epidemic that Trump pledged to fight. If passed, it’s likely that this plan would make health insurance inaccessible and unaffordable for millions of Americans who need coverage to treat both substance abuse and mental health disorders.
While President Trump claims that the changes to Medicaid simply give more freedom to the states, others believe these changes are dangerous.
Frank explains, “”The states then have a choice: They can continue to take on those responsibilities and pay for it out of their own budgets, or, if they are under pressure, they have to scale back,” Frank said. ”Historically, states have been loath to cover substance abuse treatment.”
In the New England Journal of Medicine, a group of public health researchers reported that the 15 counties with the highest death rates from opioid overdoses were located in Kentucky and West Virginia. Both of these states expanded Medicaid, and the removal of these benefits would affect “tens of thousands of rural Americans in the midst of an escalating epidemic.”
Kentucky, West Virginia, Ohio, and other states have almost 50% of medication-assisted opioid treatment covered by Medicaid. States are also beginning to increase drug addiction services to respond to the rising crisis, but these efforts “could be crushed by this [plan] if not done in a way that specifically protects the most vulnerable populations,” says Shawn Ryan, a doctor at Brightview Health in Cincinnati.
Frank further states that removing treatment services from low-income people is especially dangerous, because drug abuse is far more prevalent among those who live below the poverty line.
As access and affordability to treatment is scaled back for those who need it most, we may see an already dire crisis continue to escalate.
Impact on Treatment Providers
Trump’s repeal-and-replace plan could also have an impact on treatment providers. In many parts of the country, substance abuse treatment providers are small businesses that may not be able to remain in business if clients lose their coverage for addiction treatment.
Keith Humphreys, a drug policy expert at Stanford University, points out that both the supply and quality of treatment could suffer as a result. “Most providers are small, mono-business entities that can’t absorb costs elsewhere in their care systems. While hospitals may not go broke if people get less oncology care coverage, many [substance abuse disorder] treatment agencies will.”
Obamacare expanded Medicaid, providing health insurance coverage to millions of low-income Americans. It also made substance abuse and mental health treatment essential. However, many of these changes would be rolled back by Trumpcare, which would allow states to determine which types of treatment are essential.
This could potentially result in the loss of substance abuse treatment coverage for millions of Americans, particularly the most vulnerable populations. Mental health treatment coverage, too, would suffer, which would likely further fuel the drug addiction crisis.
In addition, as less Americans are able to afford treatment for substance abuse, many substance abuse disorder treatment and rehab agencies would likely have to shut down. If these small businesses were able to remain open, many would be forced to offer lower quality care.
Ultimately, Trumpcare would reduce access to and affordability of rehab treatment. At a time when these services desperately need to be expanded, the proposed health care plan does not bode well for America’s opioid epidemic.