An act of mercy. That is how Paul Ryan described the Obamacare repeal and replace plan put out by House Republican leadership this past week. An act of mercy, he said. I shudder to think of Speaker Ryan’s concept of vengeance if the American Health Care Act is what he deems merciful. What sort of sequestered and shriveled mercy lies within the heart of a man who celebrates a health care plan that would strip 24 million people of their health insurance? How perverse and strained must the quality of said mercy be to attach itself to an act that robs the poor of their health care subsidies and then gifts the top 0.1 percent nearly $200,000 a year in tax breaks? Where are the old and the infirm supposed to turn when the Medicaid they were once entitled to is arbitrarily rationed and doled out to a select few in insufficient portions?
I don’t know the answers to such questions, but the necessity for us to ask them of those who claim to speak for us in Congress is a sadness I had hoped we had moved beyond. And, at a time when the scourge of substance abuse is coming at us so thick and so fast that we’re creating opiate addicted corpses faster than our morgues and funeral homes can process them, the introduction of a bill like the American Health Care Act is little more than a death sentence for many of the millions of us who live with substance use disorders.
America’s health care system as it stood under President Obama was far from perfect. The Affordable Care Act was a byzantine and needlessly complex law that was formed out of Democratic leadership’s desire to make the ACA all things to all people and all lobbies. However, despite being rife with flaws, Obamacare was very successful in expanding health care to those who were unable to obtain it, and in creating a regulatory framework that prohibited health insurers from discriminating against their clients based on race, sex, age or health status, while mandating that they cover a wider array of services. Among the segments of the American public who gained access to health coverage and services from the ACA’s provisions, few could lay claim to a larger benefit than people living with mental health issues and substance use disorders.
Thanks to the ACA, health insurers were no longer allowed to deny or charge more for coverage to people living with mental illness or a substance use disorder. At the same time, the Obama administration and Democrats in Congress made certain that mental health and substance use disorder services were mandated as essential health benefits in the ACA, which meant that all plans sold on the health insurance marketplace had to include behavioral health and substance abuse treatment. When paired with the broadened parity protections that were included in the ACA, these essential health benefits not only mandated that insurers provide mental health and substance abuse services, but that they do so at the same level as medical/surgical benefits. And all of that is without mentioning perhaps the most impactful provision of the ACA for people living with substance use disorders in Medicaid expansion.
It is hard to overstate just how crucial Medicaid expansion has been in fighting the opioid epidemic in America. A staggering 29 percent of all Americans who received health care as the result of Medicaid expansion had either a mental disorder or a substance use disorder or both simultaneously. This meant that in states that expanded Medicaid, 1.29 million low-income Americans with substance use disorders were able to obtain coverage that was not available to people living in non-Medicaid expansion states. Many of the states hardest hit by the opioid epidemic, like Kentucky, Ohio, West Virginia and Massachusetts, used Medicaid expansion to strengthen their implementation of Medication Assisted Treatment (MAT) like buprenorphine and methadone, with Medicaid paying for between 35 percent and 50 percent of MAT in those states.
All in all, the repeal of the Affordable Care Act is estimated to cut at least $5.5 billion from substance use disorder and mental health treatment per year, with the bulk of that—$4.5 billion—being taken from low income individuals who received their coverage through Medicaid expansion. Now, if the House GOP’s ACA replacement plan maintained the patient protections, coverage mandates and Medicaid expansion provision of its predecessor, none of this would be an issue. Unfortunately, the entire raison d’être of the American Health Care Act is the reduction of federal spending on health care and the gashing of social safety nets like Medicaid that cannot help but compound the suffering of those struggling with substance use disorders and mental health issues.
During a meeting of the House Energy and Commerce Committee last Wednesday, Rep. Joe Kennedy III (D-MA) specifically raised the issue of mental health and substance abuse coverage under the American Health Care Act, asking a lawyer speaking on behalf of the Republicans on the committee if the legislation would eliminate the requirement that Medicaid plans provide mental health and substance abuse coverage. When he was told that the ACA coverage requirements were to be scrapped under the American Health Care Act, Kennedy turned his sights on Speaker Ryan and the House Republican leadership, castigating them for their gross hypocrisy and impenitence in divorcing millions of Americans in need from their health care.
“There is no mercy in a system that makes health care a luxury,” Rep. Kennedy said. “There is no mercy in a country that turns their back on those most in need of protection: the elderly, the poor, the sick, and the suffering. There is no mercy in a cold shoulder to the mentally ill...This is not an act of mercy. It is an act of malice.”
Those of us living with substance use disorders and mental health issues surely do not have a monopoly on sickness and suffering, nor are we the only ones whose lives will be jeopardized by the willful negligence of the American Health Care Act and the politicians who support it. However, I do not think it is hyperbole to say that we, perhaps more than any other substrata of society, will be some of the most callously cast aside by this vile excuse for a health care bill because we are the ones who fall through the cracks best and who are the most convenient to ignore. The Affordable Care Act did its best to provide millions of us with the quality health care we need to cope with our substance use disorders, but could not stem the rising tide of opioid addiction in America. If we allow the American Health Care Act to take that health care away from those with substance use disorders, there is no act of mercy large enough to prevent the public health catastrophe that will follow.
Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.
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