ACA Repeal Threatens Insurance Status of Patients with Mental Illness, Substance Use Disorder

New findings suggest that significantly more individuals with mental illness and substance use disorder had health insurance in 2014 than they did before the implementation of the Affordable Care Act (ACA). Despite gains in coverage, treatment barriers still exist.

Under the ACA, states may expand Medicaid programs to enroll those with incomes below 138% of the federal poverty level, and patients also receive subsidies to purchase insurance. The impending repeal of the health law would likely remove Medicaid expansion and reverse gains in coverage made by these individuals, according to a study published by Psychiatric Services.

"The Affordable Care Act has been very effective in reducing the uninsured rate in this vulnerable population where there is a real need to get people into services," said study leader Brendan Saloner, PhD. "But having insurance is just the first step. We need to find ways to get this population treated, whether that means prescriptions for psychotropic drugs, counseling or placements in drug treatment programs."

Repealing ACA funding and Medicaid expansion would leave patients without insurance, and may disproportionately affect individuals with mental illnesses or substance misuse disorders.

"Amidst a national crisis in opioid overdoses, now is a particularly critical moment to extend services to people with mental health and substance use disorders," Dr Saloner said.

Approximately 20 million individuals gained health insurance through ACA marketplaces since the law was passed, but up to 30 million may lose their coverage if the health law is repealed.

In the study, the investigators evaluated data from the National Survey on Drug Use and Health. Included in the analysis were 29,962 adults with mental illness, and 19,243 adults with substance use disorders between 2011 and 2014.

The researchers found that the numbers of individuals with insurance increased. However, this significant increase did not translate to an uptake in treatment services. Mental health treatment only increased by 2.2%, while treatment for substance use disorder was not seen to rise, according to the study.

The investigators did find that Medicaid payment for substance use disorder treatment jumped 7.7%, which suggests that patients with the condition were paying out-of-pocket or had another form of insurance before enrolling in Medicaid.

Gains in coverage for patients with mental illness and substance use disorders came from increased access to Medicaid for those who did not qualify before the ACA, according to the study.

Insurance is not the only treatment barrier individuals with these conditions face. Less than 50% of patients with mental illness and less than 10% of patients with substance use disorder received treatment, the authors wrote.

"We got more people covered, but we didn't make dramatic progress in closing the under-treatment gap," Dr Saloner said. "We need to find ways to take the next step and ensure people are seeing the providers who can help them."

A common barrier is that psychiatrists have a low rate of Medicaid acceptance. While newly-insured patients can access a primary care physician, those healthcare providers may not be able to treat mental illness and substance use disorder adequately, according to the study.

Another barrier is that there are few treatment options for patients with substance use disorder. Many states have implemented tactics to fight the opioid epidemic, but a key to reducing substance use is sufficient treatments.

Federal law requires that coverage for these conditions be comparable to treatment for other conditions, such as diabetes or heart disease. Many individuals were hoping that more states expanding Medicaid in the coming years would be an important factor in improving care for mental illness and substance use disorder, but repealing the ACA would have the opposite effect, according to the study.

"2017 is not likely to be a year when additional states opt to expand their Medicaid programs," Dr Saloner concluded. "Instead, it could be a year of massive retraction. Loss of insurance would surely be a step backward for people with mental illness and substance use disorders."