What an ACA Repeal Means for Mental Health

The ACHA was introduced as an alternative to the Affordable Care Act, a piece of legislation that Republicans have campaigned against for seven years. While the bill was pulled on March 24, 2017, there’s no doubt that repealing the ACA will be the subject of new legislation. Listed are five potential consequences for mental health had the bill become law. Despite mixed public opinion regarding the state of health care in the United States, the Trump administration has announced no immediate plans for a replacement bill.  We will continue posting updates to this article as Congress makes amendments to the bill.

1. Disproportionately handing costs to individuals with pre-existing conditions

The amended AHCA drops regulations on insurance companies regarding individuals they accept into their plans. This directly affects anyone with a diagnosed mental illness on file.

According to Professor Jonathan Gruber at the Massachusetts Institute of Technology, health care is essentially a three-legged stool consisting of: 1. a universal mandate, 2. coverage for individuals with pre-existing conditions, and 3. tax subsidies to help with premiums. Without healthy individuals paying their fair share of premiums, premiums are bound to increase to unaffordable prices.

So what does this have to do with mental health? Mental illnesses are considered pre-existing conditions, including bipolar disorder, substance abuse, psychotic disorders to name a few. Studies show that mental health-centered inpatient and outpatient visits  have increased due to the ACA making healthcare more affordable for individuals with mental, neurological, and substance abuse conditions. Studies also say that visits to the emergency rooms because of mental illness have decreased. By increasing premiums for individuals with mental illnesses, the ACA-replacement essentially prevents individuals from being insured and seeking preventative mental health care.

2. Listing Mental Health As An Essential Service for Insurance Plans

According to the Department of Health and Human Services, prior to the Affordable Care Act, one-third of those covered in the individual market had no coverage for substance use disorders and about a fifth did not have coverage for mental health services.

The ACA was one of the largest expansions of coverage for mental health and substance use disorders. Both categories were now listed on the “Ten Essential Benefits” List. This meant that services and elements of care that were previously non-refundable were required to be covered by insurance plans.

In addition, the ASPE (the office of the Assistant Secretary for Planning and Evaluation), states that the ACA indirectly expanded federal parity protections to apply in the individual and small group markets. Federal parity protections mandated that there should not be annual lifetime or dollar limits for mental health and substance abuse disorders.

The 10 essential health benefits continues to apply today. However, it’s existence was debated by the Trump administration. The thought was that eliminating these essential benefits would allow insurance plans to be more individualized and thereby lower costs. While the benefits currently have not been affected, it is an area of interest that should be closely watched when the administration discusses health care again.

3. Integrating Physical and Mental Health Services

One of the strides the ACA made was to closely link physical and mental health service by way of health homes. Medicaid defines health homes as a comprehensive system of care coordination for those with chronic illnesses and comorbid conditions.

The ACA stipulates a 90% match in federal funds for two years for any state that utilized health homes. This was a huge incentive for states participating in Medicaid to invest in these optional benefit.

How does this help individuals with mental illness? The integration of these services aids those with both chronic and mental illnesses by reducing the overall cost of treatment.  A health home serves as an integrated hub of care where all services can be found in one location. The ailments of the mind and body are not looked at separately, but from is termed a “whole person” approach.

4. Increased Access For Individuals without Housing or Financial Security

Another one of the ACA’s accomplishments was the dramatic expansion of Medicaid to cover some of America’s poorest uninsured which includes those without housing or financial security. But how does this expansion relate to mental health care?

Medicaid is a social healthcare program that covers individuals who cannot afford private insurance. Traditionally, it covers low-income and disabled individuals. As of June 2016, Medicaid eligibility in California applied to individuals who were 133% of the Federal Poverty Level of FPL. While not all states chose to expand Medicaid, California was among one of those that opted for expansion with MediCal (California’s version of Medicaid).

The relationship between substance abuse, mental illness and the prevalence of both among lower socioeconomic classes and homeless populations is a complex one.  The National Coalition for the Homeless cites substance abuse as both a cause and result of homelessness.   Individuals who struggle with substance abuse may often mask underlying mental health symptoms. However, paying for treatment to combat these issues may be out of the question when basic needs such as safety, housing and food come first. The expansion of Medicaid by way of the ACA does not force people to chose between their health needs and survival needs. Rather, it offers a much needed pathway to affordable care.

5. Halting funding for mental health based grants and research

While not a major highlight of the Affordable Care Act, one of its most promising provisions included funding research grants for public health initiatives. This ranged from research on postpartum depression to studies within categories tangential to mental health (such as long-term case and community-based prevention). Specifically, section 5306 called for the allocation of mental health education and training grants, along with individuals with disability training, during the fiscal years 2010-2015. Grants are awarded to higher education institutions. The ACA allocated funds for these initiatives accordingly, and while the replacement bill does not explicitly mention a repeal of this program, it does not renew it either. In not renewing the research grants, the ACA-replacement essentially stops years of research and progress.

This post was written by Deepika Dilip and Naveena Sunkara. Please send any questions or concerns to content@subconscious.org.

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