How Repealing Obamacare Could Make Addiction Treatment Unaffordable for Millions

Denise Mariano fought for two years to get her insurer to cover her son’s treatment for opioid addiction, draining her retirement savings and all three children’s college funds to pay out-of-pocket as she battled her insurer’s denials.

That struggle ended several years ago when Michael, her eldest, enrolled in an individual health plan on the new Affordable Care Act marketplace in California. Like many who become addicted to opioids, he had begun with prescription pain pills and progressed to heroin, which is often cheaper and more readily accessible. His plan covered most of the cost of a 28-day stay at an inpatient treatment facility, which offered better-quality care than what Mariano and her husband had paid for on their own. “It was the beginning of his recovery,” she says. “It’s probably one of the reasons he’s alive.”

Michael, now 25 and working for his family’s plumbing business in Morristown, N.J., has been in recovery for four years. His mother worries that other families won’t get the break that hers finally got, if Republicans succeed in their efforts to repeal and replace the Affordable Care Act. She also worries that Michael may have trouble getting care in the future under a system where mental health services may no longer count as a required benefit, and where his past addiction could be labeled a pre-existing condition.

“Addiction is a complex and often, a life-long medical condition that requires health care like any other medical condition,” says Mariano, who volunteers for the Partnership for Drug-Free Kids, a non-profit organization that supports families struggling with a child's substance use.

Opioid overdoses killed 91 Americans a day in 2015, according to the Centers for Disease Control and Prevention. The epidemic has become one of the sticking points in senators’ efforts to pass the Better Care Reconciliation Act, as their Obamacare replacement bill is called. A number of Republican senators have spoken out against the bill, saying they won't vote for it in its current form. On the far right, Kentucky's Rand Paul has criticized it for not taking a big enough axe to Obamacare, while more moderate Republicans such as West Virginia's Shelley Moore Capito and Maine's Susan Collins have expressed concerns over the bill's Medicaid cuts.

Medicaid plays a key role in paying for addiction treatment. In addition to jeopardizing care for pre-existing conditions in general and mental health care in particular, the bill would cut an estimated $772 billion from Medicaid over the next decade, according to the non-partisan Congressional Budget Office (CBO).

Medicaid Cuts Would Reduce Treatment Options

From 2015 to 2016, Medicaid spending on prescriptions to treat opioid use disorder grew by 30%, according to a recent report by the Urban Institute. States with some of the highest overdose death rates in 2015—including Kentucky, Massachusetts, Ohio, Rhode Island, and West Virginia—have seen particularly fast growth in Medicaid spending for opioid addiction treatment, the report found.

Yet Republican senators from these hard-hit states aren't united in their opposition to proposed Medicaid cuts. While Capito, Collins, and their colleague Rob Portman of Ohio have voiced concerns over the harm the cuts would do to their constituents, Senators Rand Paul and Mitch McConnell of Kentucky have been notably "silent on the subject," says Andrew Kessler, principal at Slingshot Solutions, a behavioral health care and policy consultancy firm. McConnell is the Senate's Majority Leader, charged with wrangling the 50 votes Republicans need to pass the legislation, assuming no Democrats vote yes and Vice President Mike Pence casts the tie-breaking 51st vote.

The Better Care Reconciliation Act would do more than reduce federal funding for Medicaid and roll back the expansion of the program under Obamacare that extended coverage to some 11 million lower-income adults; it would fundamentally restructure the program, switching Medicaid from an uncapped benefit to one where spending is held to a strict formula. The CBO has projected that federal Medicaid spending in 2036 would be 35% less than under current law. If states receive fewer Medicaid dollars from the federal government, they’ll be forced to make difficult choices about who continues to get care, and at what level.

Addiction services could be first on the chopping block, Kessler says. Medicaid serves many vulnerable populations whose care it would be politically risky to cut, including lower-income and disabled children, disabled adults and elderly people in nursing homes. Addicts make an easier target in a society that too often looks at addiction as a moral failing as opposed to a medical condition, Kessler says.

Mental Health Services Could be Dropped From Some Plans

Beyond the Medicaid cuts, other provisions in the bill could further compromise addiction treatment. The Affordable Care Act named mental health and substance use disorder services as one of 10 “essential health benefits” that most health plans nationwide must cover. Yet the Senate bill would allow states to apply for waivers to define their own essential health benefits. Proponents of these waivers say they will bring flexibility to states and increase choice for consumers.

If a state drops high-cost coverage such as maternity or mental health care from its list of essential health benefits, then consumers who don’t need those services may spend less for a policy than they would today. Yet those who do need them will have to pay more, as that care would in some cases become “extremely expensive” on the individual insurance market in waivers states, the CBO projects. Carriers could choose to offer those services as an additional, pricey rider on their basic policies, similar to the way many did before Obamacare.

What’s more, the Better Care Reconciliation Act could open the door for discrimination against pre-existing conditions. While the bill would nominally retain one of Obamacare’s most popular provisions and require insurers to cover any applicant regardless of health status, and to not charge sick people any more than healthy people, it could still undermine coverage for consumers in states that obtain waivers to change their essential health benefits. If plans aren’t required to cover substance use disorders, for example, then someone who needed treatment for one would be out of luck. In other words, a heroin addict would still be able to buy a policy, but if that policy didn’t cover addiction treatment—or only did so at a prohibitive cost—then it wouldn’t do him or her much good.

Senate Republicans currently seem well shy of the 50 votes needed to pass the bill, according to media reports. Lawmakers will likely put forth a new iteration of the bill in the coming week, with the goal of brining it before the full Senate for a vote before the scheduled August recess. If it passes, President Donald Trump is expected to sign the bill into law.

In an effort to garner support for the bill before Congress’ July 4 vacation, Senate leaders added an additional $45 billion to the bill for opioid addiction, Politico reported, an amount that Ohio Gov. John Kasich likened to “spitting in the ocean.”

As it stands, it’s not easy for families to find and finance quality, timely treatment for their loved ones facing addiction. The Senate’s bill would make it that much harder, critics say. If it becomes law, “we’re going to lose lives,” Mariano says, “there’s no doubt about it.”

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