Susan Weinstein, Co-Executive Director
Families for Depression Awareness
Republicans in the U.S. House of Representatives welcomed the first week of Mental Health Month by approving the American Health Care Act, the latest iteration of a bill to “repeal and replace” the Affordable Care Act (aka “Obamacare”).
The bill relies on a new tax credit to help people buy insurance and eliminates premium subsidies, Medicaid expansion, and certain taxes on companies and high-income taxpayers. It also nullifies the individual mandate by removing the penalty for not having health insurance. It is difficult to know the impact of these changes because the House voted before receiving an analysis from the nonpartisan Congressional Budget Office.
The tax credit would amount to $2,000 to $4,000 per individual, depending on a person’s age and income level. The impact of this credit would vary widely, depending on age and geography.
It is apparent, though, that this bill, if approved by the Senate (which is unlikely, in its present form) and signed by the President (which is likely, regardless of form), will significantly impact the ability of lower-income people and people with disabilities to access health care. Some of the most pronounced differences will occur in the Medicaid program, capping federal government payments, allowing state governments flexibility in how they administer health insurance rules, and ending funding for the Medicaid expansion program, which allowed states to cover very poor people and those slightly less poor. Forty-two percent of Medicaid spending is for care of people with disabilities, including mental health conditions.
Another provision of concern would erode Affordable Care Act’s protections for people with pre-existing conditions, including mental health conditions. Instead of guaranteeing equality of coverage, the AHCA would permit states to apply for a waiver which, if approved (which seems to be a given, according to reports from the Administration), would allow insurers to set rates that relied on an individual’s previous and current state of health, and how those factor into projections as to future health and costs of care.
The AHCA envisions use of “high-risk pools” for those with pre-existing conditions and allocated $8 billion over five years to support them. Experience with such high-risk pools has not inspired confidence that such insurance would be self-sustaining or affordable for people with health conditions (e.g., Kentucky’s KY Access). Also, there is no apparent basis for the amount of money assigned and it is widely thought to be inadequate to meet the need.
The bill does require insurance companies to continue covering people – even those with pre-existing conditions – as long as their insurance doesn’t lapse for more than 63 days. This means that people need to maintain coverage regardless of their circumstances; otherwise, they can be charged nearly one-third more for their premiums for one year. Again, though, this could be adversely affected by a state-requested waiver. Even employer-sponsored insurance could be affected by such waivers, as they could choose to offer plans that have benefit limits.
The potential elimination of the Essential Health Benefits (EHBs) poses a concern for a great many people, both those with and those without mental health conditions. The ACA requires that health care plans provide coverage for certain health services, including care for mental health and substance use disorders. Other EHBs include maternity and newborn care, emergency services, prescription drugs, hospitalization, and more. The AHCA contemplates that states could eliminate these requirements through waiver requests.
A New York Times article identified winners and losers under this plan.
- high-income earners
- upper-middle-class people and young middle-class people without pre-existing health conditions
- people who wish to forego insurance or want less comprehensive coverage
- large employers (who will not have to offer affordable coverage to workers).
- poor people
- older Americans
- people with pre-existing conditions
- state governments (because the cost of Medicaid will shift from the federal government to the states)
- hospitals (especially those in areas where many poor people signed up for Medicaid).*
The House version adopted last week brought together unlikely allies – hospitals, consumer groups, health systems, community health plans, doctors, and health insurers – in opposition to the bill.
People without insurance tend not to get preventive care and often delay seeking care until a disease or illness has progressed, which usually means it is more difficult and more expensive to treat. “Health insurance makes a difference in whether and when people get necessary medical care, where they get their care, and ultimately, how healthy they are. Uninsured adults are far more likely than those with insurance to postpone health care or forgo it altogether. The consequences can be severe, particularly when preventable conditions or chronic diseases go undetected.” Further, people without insurance often have access to care only through the emergency department, creating financial losses for hospitals. (See Kaiser Family Foundation, “Key Facts about the Uninsured Population.”)
We look forward to the President fulfilling his campaign promise of “insurance for everybody,” but only when we can rest assured that quality, appropriate, affordable care is available to people with pre-existing conditions; people who are lower-income; and people with mental health conditions and substance use disorders.
One more thing: mental health parity! Remember, parity only applies when mental health benefits are offered in an insurance plan, not requiring that mental health benefits be offered. Elimination of mental health as an essential health benefit means that parity would be irrelevant under many plans.
Editor’s note: We have omitted discussion of the projected impact on Planned Parenthood and on women covered by insurance plans that cover abortion services, as well as the effect on medical device companies, indoor tanning companies, and others subject to a tax under the ACA. They are not within the scope of this post.
For further reading
- Kaiser Family Foundation, “Summary of the American Health Care Act” (download .pdf)
- National Council on Behavioral Health, “House Passes AHCA, Puts Mental Health and Addiction Care in Jeopardy”
- Kaiser Health News, “Thinking About the Senate: How Their Version of Repeal and Replace Could Be Different”
- Congressional Budget Office, American Health Care Act (prior version of bill; review of passed version not yet released)
- Jeffrey Harman, PhD, on Care for Your Mind, “Repealing the ACA Could Cause a Mental Health Care Crisis”
Mental Health Parity on Care for Your Mind
- Doesn’t Health Insurance Have to Cover Mental Health Care? What the Mental Health Parity Laws Really Mean, Part 1
- Doesn’t Insurance Have to Cover Mental Health Care? What the Mental Health Parity Laws Really Mean, Part 2
- Final Parity Ruling and Obamacare
- Disparity, Not Parity, Describes Mental Health Status and Access in America Today
- How will you be affected by the AHCA should it become law?