On March 24, many people covered by Obamacare breathed easily for the first time in months, as the highly divisive American Health Care Act (AHCA) was pulled from the House floor due to its general unpopularity amongst Democrats and many moderate Republicans.
One of Trump’s most prominent critiques during the presidential election was of the Affordable Care Act (ACA), more commonly known as Obamacare, prompting his insistence on a more privatized, conservative healthcare system. Changes such as threats to reproductive healthcare and overall higher premiums, amongst a myriad of other reforms, galvanized protests ranging from local demonstrations to the Obama-backed Organizing for Action’s large online petition. One lesser-known movement was the work of the American Psychological Association (APA) and practicing clinicians across the country who expressed their concerns about the dangerous implications of repealing Obamacare, considering millions of people in need of therapy and counseling services are funded through this current program. As more information is released about Paul Ryan’s determination to keep pushing a reform, it is increasingly important to understand the ways in which the ACA bolstered mental health services for millions of Americans and the possibly devastating results conservative healthcare policies could have on psychological care.
A December 2016 letter to Paul Ryan and Mitch McConnell from the APA, speaking on behalf of over 100,000 members, included several key points as to why repealing the ACA was particularly dangerous towards providing “comprehensive mental health, behavioral health, and substance use services.” The letter first explains how the Mental Health Parity and Addiction Equity Act of 2008 (but put into effect in 2014) helped offer psychological care to “over 60 million Americans” who were previously uncovered. Assistant Professor of Community Health Andrea Acevedo explained that “…the 2008 parity law prevented health plans and health insurance issuers that provide mental health and substance use disorder benefits from having less favorable benefit limitations on those benefits than on medical or surgical benefits. This applied to group health plans only, like which you may get from your employer, but not those for which the individual gets health insurance for themselves directly. The ACA extended parity to individual health plans.”
Many healthcare companies favor insuring physical healthcare at better rates than mental healthcare, considering how costly mental health services can be. A 2013 study by HealthAffairs.org found mental disorder treatment to be one of the most expensive conditions to treat, with annual spending totaling $201 billion. Despite these statistics, the ACA included equal parity to ensure that as many people as possible could have access to crucial mental health resources, such as clinical therapy and addiction recovery services. These actions seemed to work. Another HealthAffairs study included an analysis of data from the National Survey on Drug Use and Health which found “…that mental health treatment rates increased significantly among people with serious psychological distress in 2014, when ACA-driven Medicaid expansion and private insurance exchanges were initiated.” Psychology Professor Dr. Alexander Queen, who is also a practicing clinical psychologist, likewise noticed a significant increase in patient numbers while working in community mental health after ACA increased coverage to people, especially those with Medicaid and Medicare.
On a more macro-level, covering more people indirectly granted previously underserved populations various types of mental health services. Acevedo pointed out that 47.5 million Americans lacked any type of health insurance before the ACA and yet an estimated 25 percent of adults had a mental illness, experienced addiction, or both. Covering more people implicitly allowed those foregoing therapeutic treatments to consider them now that they were once again affordable. With the ACA and parity acts combined, people had a chance to consider therapy now that they were covered and were certain of its affordability, as health insurance companies were no longer allowed to favor physical treatments. These extremely valuable systems would have been jettisoned if the repeal of Obamacare had proceeded as planned.
On top of equal parity laws, the ACA ensures that preexisting psychological conditions can no longer justify denying people coverage. Various mental health diagnoses were considered preexisting conditions under the previous healthcare system, such as bipolar disorder, schizophrenia, and depression. According to Dr. Queen, people with these diagnoses “could not purchase private insurance” prior to the ACA.
The Freedom Caucus, a highly conservative faction of the Republican Party, targeted the issue of preexisting conditions in Trump’s healthcare plan. The group was created by many members of the Tea Party and centered itself around pushing its party even further to the right. Many members, for example, were some of the key players in the movement to defund Planned Parenthood.
This specific attack on preexisting conditions, though harmful for anyone with a diagnosed mental illness, particularly highlights the AHCA’s focus on isolating marginalized communities who were more easily able to gain access to psychological care under Obamacare.
The Affordable Care Act, of course, is nowhere near perfect. A study by the Henry J. Kaiser Family Foundation found that non-elderly people who are Latinx, Black, American Indian, and Alaska Natives were still more likely to remain uninsured than White people despite increases in enrollment rates across all populations of people of color. Professor Acevedo explained that part of this issue was due to a Supreme Court ruling which made Medicaid expansion optional for states, leading to several Southern states with large populations of people of color opting out of this legislation. But despite these shortcomings, people using Medicaid for their mental and behavioral care services still certainly saw improvements under the ACA in terms of accessibility.
Another Henry J. Kaiser Family Foundation report explained that “Medicaid coverage has expanded considerably with the passage of the Affordable Care Act and other policy changes, reaching more adults with behavioral health needs. States may now expand Medicaid eligibility to include almost all adults at or below 138 percent of the federal poverty level (FPL), or $27,821 for a family of three in 2016, and receive enhanced federal funding to finance the cost of this expansion.” Acevedo also noted that the ACA could be expanded to better serve Medicaid users by “[making it] more universal…[For] instance Medicaid expansion could be included for all states or changing to a single payer plan. For many people, the premiums are still too high for them to afford them, and sometimes the deductibles are high as well.” Meanwhile, Republicans in support of the AHCA and its future iterations are planning to significantly cut enhanced federal funding to Medicaid, resulting in an uncertain future for many people who have benefited from various types of therapy.
A specific example of this reform was the AHCA proposal to eliminate Medicaid coverage of opioid addiction recovery treatment. Of the over two million estimated Americans suffering from a prescription opioid or heroin addiction, 3 out of 10 are covered by Medicaid according to the Henry J. Kaiser Family Foundation. Medicaid expansion, an integral part of the ACA, would have quickly been reduced under the AHCA. States would again be allowed to voluntarily cover these treatments. Considering their generally high prices, behavioral health programs would have likely seen considerable reductions in funding, leaving millions of Americans without an insured way to overcome their addictions.
So while the life of the AHCA was prematurely curtailed, conservative sentiments expressed by many Republicans make another proposed bill in the near future probable. The neglect of mental health care in these plans is likely to persist through reduced funds in mental healthcare, because of high costs targeting Medicaid and other marginalized groups first. There are, thankfully, some options for those who may lose Medicaid benefits from a future version of the AHCA.
“First, look into community mental health centers. Often these agencies will accept Medicaid, or can offer low-cost therapy,” advised Dr. Queen. “Seeking services at a training clinic, such as those affiliated with a graduate program where graduate students provide services under supervision, can also be a great way to get good treatment for a low fee.” For others who may not be as directly affected by such legislation, it remains important to be aware of healthcare changes and resist discriminatory practices against covering comprehensive psychological care. Healthcare policy can often seem mystifying and inaccessible, but taking the time to understand and push back on bills like the AHCA could protect countless people from losing access to crucial psychological care.