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John E. McDonough
May 26, 2023
May 23, 2023
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For several years, Republicans and Democrats alike have been concerned about the crisis of opioid and heroin addiction in the United States. It is hard to find anyone who rejects the notion of a serious problem that demands at least a partial governmental response. Across the nation, governors and legislatures are hard at work seeking solutions and avoiding partisan bickering. Numerous current and former presidential candidates in the 2016 campaign cycle got favorable attention explaining how the crisis has affected their families and friends in personal ways.
The question is whether there is any meaningful difference between Republicans and Democrats when it comes to substance abuse (and, for that matter, behavioral health—the merger of substance abuse and mental health).
The answer is yes, and the difference comes down to the Affordable Care Act (ACA).
The difference is that Republican lawmakers and governors, almost to a person, are publicly committed to near total repeal of the ACA, including the dramatic and historic gains that the law has achieved to improve the lives of those afflicted by substance abuse and mental health. Perhaps the most important of these gains involves the ACA’s Title I, which lists, in section 1302, 10 “essential health benefits” that all individual and small group health insurance policies must have begun covering as of January 1, 2014. Item E on the list reads: “mental health and substance use disorder services, including behavioral health treatment.”
Moreover, Title I guarantees the right of Americans to obtain individual health insurance without regard for their preexisting conditions, a previously important obstacle to health insurance for those with histories of substance abuse and/or mental illness. The law also prevents insurers and employers from imposing lifetime or annual financial limits on health insurance benefits, a significant issue for those with serious behavioral health disorders requiring extensive treatment. Finally, the ACA guarantees coverage of evidence-based clinical preventive services—with zero cost sharing—which include depression screening for adults and behavioral assessments for children.
Since 2012, several Republican members of Congress as well as conservative think tanks have advanced proposals to indicate how they would replace the ACA following its repeal. A student and I analyzed and categorized these plans.1,2 Seven out of the 8 proposals would completely eliminate any federal minimum standards for what needs to be covered by health insurance, including item E. The responsibility to define what is meant by health insurance would be returned to the discretion of states. Most of these replacement plans would also negate the ACA’s prohibition on lifetime and annual limits. All these plans would either eliminate the protections against preexisting condition exclusions in health insurance policies or allow such protections only in the case of individuals who maintain “continuous coverage” of their health insurance. All but one of the Republican/conservative think tank replacement plans would remove the ACA’s mandated coverage of evidence-based clinical preventive services such as depression screening for adults and behavioral assessments for children. These proposals would devastate the inroads we are making in treating mental illness and substance abuse in the United States.
Equally important is the intention of most Republican office holders to repeal the ACA’s Title II, which has already expanded Medicaid in 31 states to provide comprehensive health benefits, including substance abuse and mental health services, for 12.2 million low-income Americans (as of October 2015)3 who would otherwise be uninsured.
The most widely reported media accounts of the opioid crisis involve middle- or upper-class Americans who have descended into substance abuse hell because of inappropriate access to painkillers. Nevertheless, the broad population of substance abusers in the United States is heavily tilted in the low-income direction. Even many affluent victims of this crisis can find themselves needing Medicaid when addiction ruins their lives and livelihoods. The linkage among poverty, mental health, and substance abuse is well documented.4
In January of 2016, the Congressional Budget Office projected that if legislation sent to the president’s desk that month by almost exclusively Republican majorities in the Senate and House were to become law (it was vetoed by President Obama), an estimated 22 million Americans would lose their current health insurance coverage by 2022. If it had passed, tens of millions of Americans would lose access to substance abuse and mental health services.
Late last year, the New Hampshire Medical Society asked all 2016 presidential candidates for their policy positions on the opioid crisis; the society posted the responses from Democrats Hillary Clinton and Bernie Sanders and from Republicans Chris Christie, John Kasich, and Jeb Bush on February 6 (https://www.nhms.org/presidential-candidates-heroin-and-opioid-crisis). None of the other candidates responded. The candidates who replied had a plethora of ideas, including drug courts, police and first responder training, closing pill mills, increasing access to naloxone, expanding community-based programs, and more. No statement from any Republican candidate addressed the impact of lost health insurance coverage on those in need of treatment and services.
All of the above also applies to mental health, the other side of the behavioral health coin. Virtually all Democrats and Republicans, when considering the issue of gun violence, agree that improving our nation’s mental health system is an important component that must be addressed, regardless of one’s position on gun ownership. Yet, none of the Republican candidates seem willing to acknowledge that the zeal to repeal the ACA runs headlong into their stated support to improve mental health services.
According to the US Department of Health and Human Services,5 by 2020, the ACA together with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) will have expanded behavioral health coverage to 62.5 million Americans. Because of both laws, 32.1 million individuals will have obtained access to substance abuse benefits for the first time, and 30.4 million individuals will have received expanded mental health coverage.
Among the many ironies involving the ACA is that very few Americans have any idea that it represents perhaps the nation’s greatest advance in the treatment of substance abuse and mental health. It is difficult to name another federal statute in the nation’s history with such substantial and far-reaching impact. As Republicans present their vision of dismantling the ACA to the greatest extent possible, few Americans currently appreciate the depth of the losses this would incur for those in need of humane and compassionate coverage and care. But for those who depend on such lifesaving services, many would soon find out how major such changes can be.
On whichever side of the political aisle one sits, respect and concern for those who have been afflicted by the substance abuse and mental illness scourges (1 out of every 4 Americans, not counting family members, friends, and coworkers) must be articulated and with more than empty words. Without a clearly stated and defensible alternative, we must uphold the hard-won protections for behavioral health in the ACA. The lives of many of our loved ones depend on it.
Author(s): John E. McDonough
Read on Wiley Online Library
Volume 94, Issue 2 (pages 242–245) DOI: 10.1111/1468-0009.12187 Published in 2016
John E. McDonough, DrPH, MPA, is a professor of public health practice at the Harvard University TH Chan School of Public Health in the Department of Health Policy and Management. Between 2008 and 2010, he served as a senior adviser on national health reform to the US Senate Committee on Health, Education, Labor, and Pensions, where he worked on the writing and passage of the Affordable Care Act. Between 2003 and 2008, he was executive director of Health Care For All, a Massachusetts consumer health advocacy organization, where he played a leading role in the passage of the 2006 Massachusetts health reform law. From 1985 to 1997, he was a member of the Massachusetts House of Representatives where he cochaired the Joint Committee on Health Care. His articles have appeared in the New England Journal of Medicine, Health Affairs and other journals. He has written several books including Inside National Health Reform in 2011 and Experiencing Politics: A Legislator’s Stories of Government and Health Care in 2000, both by the University of California Press and the Milbank Fund. He holds a doctorate in public health from the University of Michigan and a master’s in public administration from the Kennedy School of Government at Harvard University.
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