Republicans in the Senate are currently deciding whether to repeal major portions of the Affordable Care Act (ACA) without providing a replacement. If they are successful, the collapse of the ACA would harm women by decreasing access to breast and cervical cancer screening, and upend protections for patients with pre-existing conditions such as children with congenital diseases and adult patients with diabetes.
When it comes to repealing the ACA, however, the most at-risk group of individuals may be those with mental illness.
The massively destabilizing effects of ACA repeal and the rapidly shifting Republican replacement plans make it difficult to accurately predict exactly how mental health care would change in the wake of ACA repeal. The best prediction comes from evaluating how coverage for mental illness changed with the protections established under the ACA.
The ACA promoted the delivery of mental health and substance abuse services in two major ways. First, the ACA expanded Medicaid, which is the primary source of funding for funding mental health care coverage. This expansion turned out to be an effective means of improving access to care for low-income individuals and families. Second, the ACA introduced legislation prohibiting discriminatory coverage practices by private insurers. Prior to the ACA, insurance companies regularly did not cover mental health conditions at the same level as other medical illnesses, and in some cases did not cover them at all. By addressing these issues, the ACA represents a two-pronged approach to improve access to mental health and substance abuse care for both Medicaid-enrolled and privately-insured individuals.
It is undeniable that repealing the ACA would cut access to mental health and substance abuse services. The question then is whether these issues are worth addressing, or if they can be safely ignored.
Despite still carrying a damaging stigma, mental health is not a fringe concern. Rather, it is one of the most important determinants of happiness, productivity, and survival. A recent study showed that in America, mental illness is a stronger predictor of misery than physical illness, poverty, or employment. Depression is the leading cause of disability for Americans aged 15-44. The opioid epidemic is the leading cause of death in Americans under the age of 50. Given that every year one in five Americans will suffer from mental illness, it is difficult to argue that these diseases do not demand our attention and resources.
The opioid abuse epidemic currently sweeping across America exemplifies the importance of treating mental illness, and portends the damage that will occur if access to care is curtailed. Despite being identified by former Surgeon General Vivek Murthy as one of the most important public health issues in America, we are not winning the war against opioid overdose. Rather, as time passes, we are losing more and more quickly. Approximately 60,000 Americans died of opioid overdose last year alone (compared to approximately 40,000 deaths due to car crashes), and the toll in 2017 is expected to climb even higher.
Supporters of ACA repeal have argued that replacement bills would adequately address the opioid epidemic through direct funding for opioid abuse treatment. However, regardless of whether $2 billion or $50 billion is allotted to make up for gaps in coverage, this piecemeal approach is completely inadequate. Part of the difficulty in solving the opioid epidemic is the need for systemic solutions that address the underpinnings of mental health and substance abuse. Depression, for example, has been shown to be an important driver of the opioid epidemic. By cutting coverage for psychiatric conditions and failing to appreciate the gravity of the opioid epidemic, the current Republican strategy would leave millions of Americans without any options for treatment.
Regardless of whether we decide that it is worthwhile to treat mental illness, it is not going away. Just as high blood pressure is managed to avoid long-term complications such as stroke, mental illness is treated in part to avoid acute exacerbations such as psychosis and suicidality. We can either address these issues through funding evidence-based methods to treat patients with effective longitudinal care, or we can try to ignore them and thereby pay the price in the form of emergency room visits, lost productivity, and premature death. We desperately need forward-thinking solutions to address one of the most pressing issues that America currently faces. From a medical, economic, and moral standpoint, it is completely indefensible to deprive Americans of access to life-saving treatment for these deadly diseases.