When details of the American Health Care Act (AHCA), the Republican-led bill to repeal and replace the Affordable Care Act (ACA), were released last week, advocates for the rights of people with mental illness and addiction were alarmed.
The GOP bill would remove the requirement that Medicaid benchmark plans cover essential health benefits, which include mental health, substance use and behavioral health services. Some 1.3 million Americans currently receive these services under the ACA provision.
Mental health advocates were vocal in their opposition to the AHCA; The American Psychological Association (APA), for instance, voiced its concern about the act, calling on Congress to maintain mental health and substance use coverage.
“Any health care reform legislation considered by Congress should increase, not decrease, the number of Americans with access to affordable health care,” said APA President Antonio E. Puente, Ph.D. “While we support efforts to strengthen and stabilize our nation’s health care system and extend insurance coverage and protections, we oppose the legislation as introduced in light of the adverse impact it will have on Americans, particularly those with mental health and substance use disorders.”
The national impact of this legislation would be broad: Earlier this week, the Congressional Budget Office said that if AHCA were passed, the plan would leave 24 million Americans without health care. In Minnesota, the impact would be significant: The Minnesota Department of Human Services released a report that said that as many as 1.2 million people on Minnesota’s Medical Assistance and MinnesotaCare programs could either lose coverage altogether or have significantly reduced coverage.
Interested in a local expert’s perspective on how these proposed changes could affect Minnesotans seeking coverage for mental health and addiction concerns, I called Sue Abderholden, executive director of NAMI-Minnesota, a nonprofit dedicated to supporting adults and children with mental illness and their families. Abderholden took time to walk me through her concerns about the legislation.
MinnPost: How do you believe the AHCA would affect coverage for mental health and addiction treatment in Minnesota?
Sue Adberholden: The plan that Republicans are proposing would eliminate the essential benefit set from certain Medicaid plans, including Medicaid expansion. Mental health and substance use treatment are part of that essential package.
The Minnesota Department of Human Services has told us there were over 40,000 people in the state who received mental health treatment under Medicaid expansion. If you include chemical dependency, the number would probably be a little over 50,000 people who could lose that coverage under the GOP plan.
MP: In recent years, the state Legislature has consistently supported increased protection and benefits for people with mental illness and substance use disorders. Does this change with this new proposal?
SA: We continue to have bipartisan support for mental health treatment in Minnesota. That means that we aren’t going to completely eliminate mental health treatment for people covered under MinnesotaCare, but it is important to remember that the Republican-led plan does allow other states to eliminate that coverage. When we look at how funding for mental health treatment has been low on the list of priorities for decades, and how people with mental illness have been historically discriminated against when seeking public and private insurance coverage, this is a huge issue.
MP: So are you saying that you are more concerned about people with mental illness who live in other states than you are for people with mental illness in Minnesota?
SA: There might not be the will to protect these benefits other states like there is here. I’d be very surprised if we were going to back away from what we already have established in Minnesota: We have the support of the Legislature, the legal community, the health-care industry, the schools, the police. We don’t know for sure if they will reduce coverage in the state, but we hope they won’t.
MP: You don’t think lawmakers are going to deconstruct what they’ve worked so hard to create?
SA: I doubt it. We are in the process of building our mental health system in this state. We have an investment. We’ve been doing this for several years. The one concern is that we were expecting to be billing Medicaid more as we built more crisis homes and crisis teams and treatment programs for kids. We were also looking at expenditures for addiction treatment to expand. But now these proposed changes mean that we could be capped at 2016 dollars. How are we supposed to continue building the state’s mental health system if the dollars are not going to be there?
Because Minnesota has been very innovative in all sorts of ways when it comes to boosting mental health care, including building behavioral health homes, health care homes, getting waivers, the impact may be less severe in this state than it might be in others. But our prior support for mental health care also means that we don’t really have the fat to cut out of our budgets that some other states might have.
MP: Are there pending mental health programs that could suffer under these proposed cuts?
SA: We were looking at adding housing supports for people on Medicaid. How can we pay for that when we’re stuck with 2016 dollars? If this ends up being the case, this project would have to be put on the shelf. This is the kind of stuff that absolutely scares people in the mental health field.
MP: Can you tell me more about where this fear comes from?
SA: More than others, the mental health community understands what happens when you cap dollars. There is not much difference between capping dollars and a block grant. We know that block grants have never worked as reliable funding sources. We have struggled for years to get the mental health system we’ve got simply because we have been funded using block grants, and every recession that funding got cut.
MP: Why was that?
SA: It’s easier to cut programs through block grants because you can’t say how many people got served, who got the payments. Under Medicaid, we’re required to say, “We are paying these specific providers.” With Medicaid, we know where those dollars are going and whom they are supporting.
And we can’t forget that there are a lot of questions still up in the air. What will our state do with the loss of Medicaid dollars? How will that pan out? Will they tighten, eliminate or increase provider payments and eligibility?
MP: We haven’t really talked about the proposed cuts to benefits for substance use treatment. What’s your take on the possible impact of this change?
SA: The opioid crisis is a serious, issue on many levels. After the ACA, we were seeing more people seeking treatment than ever before, more people reaching out for help for addiction, and that’s very important. Just like with mental illness, in addiction, early intervention is the best approach. If we lose coverage for addiction treatment, that’s going to be a real problem. If the Republicans succeed in eliminating Medicaid expansion, many people who really need addiction treatment won’t be able to access this kind of care. In this country, we need all the help we can get to address this crisis.
MP: Do you have suggestions about what people who are worried about these proposed changes can do to make a difference?
SA: First of all, I don’t want people to be scared. I do want them to get active, to call their congresspeople and say that they don’t want to lose the coverage they have now.
When people contact their member of congress, they need to let them know that they are on Medicaid or have an insurance plan through the exchange. That’s really important information to get out there. Politicians are keeping track of these numbers. We know from experience that mental health is a bipartisan issue. It affects Republicans and Democrats alike. People need to make sure that they let people in power know that this is a very important issue for them.
MP: What do you plan to be doing in the coming days?
SA: I’m going to really be watching what happens. It’s important to remember that none of these changes are going to happen tomorrow, even if this plan passes. That said, some people are saying that proponents of this legislation want it to be fast-tracked, so it can be signed on March 23, the same day as the ACA was signed.
But there is a high chance that this all may backfire. It doesn’t look good to take away so many people’s health care. And the timing of this plan is not good. With the baby boomers all aging right now, we are about to experience a silver tsunami. This is the worst time possible to be cutting essential health-care benefits.