The Hill Op-Ed — Keep Obamacare to keep progress on treating opioid disorders and mental illnesses

From the House Democratic Leader's Press Office

The Hill Op-Ed

Keep Obamacare to keep progress on treating opioid disorders and mental illnesses

By: Richard G. Frank and Sherry A. Glied

January 11, 2017

In enacting the 21st Century Cures Act this past December, Congress took important steps toward promoting access to high quality care for mental and substance use disorders. The Act directs new resources to two long-standing challenges: federal opioid misuse and abuse ($1 billion over 2 years) and serious mental illnesses (about $200 million in 2017). These new appropriations, secured through a broad bipartisan vote, will fund critical investments in treatment capacity and quality.

But these investments will be squandered if the new Congress rolls back recent gains in the quality and level of substance use and mental health insurance coverage generated by the Affordable Care Act (ACA) of 2010. Building upon the Mental Health Parity and Addictions Equity Act, the ACA gives people suffering from these devastating illnesses the purchasing power that will allow them to use this new treatment capacity. Without the foundation of that ongoing financial support, those in the eye of the opioid storm and those who live in society's shadows due to serious mental illnesses will continue to die of untreated illness, and their communities will continue to pay for the jails, prisons and homeless shelters that serve as our de-facto service system for many with these conditions.

Repealing the ACA - and its behavioral health provisions-- would have stark effects on those with behavioral health illnesses. We estimate that approximately 1,253,000 people with serious mental disorders and about 2.8 million Americans with a substance use disorder, of whom about 222,000 have an opioid disorder, would lose some or all of their insurance coverage. One impetus for passing the Cures Act was to address an opioid treatment gap of about 420,000 people that reported money or availability of care were key impediments to obtaining substance use treatment - repealing the ACA would increase that gap by over 50% with the stroke of a pen.

The impact of repealing ACA provisions related to mental and substance use disorders would have particularly adverse effects on states that have experienced some of the most tragic increases in opioid related deaths. Many of these States - including Alaska, Kentucky, Maine, Ohio, West Virginia - have seen their adult uninsured rates drop by more than 5 percentage points since the implementation of the ACA coverage expansions in 2014. Several - Kentucky, Massachusetts, Maryland, Ohio and West Virginia-- have addressed the opioid overdose problem by promoting use of effective Medication Assisted Treatment (MAT) in the context of their Medicaid expansions. The result is that Medicaid pays for between 35% and 50% of all MAT in those states. They would find it much more challenging to maintain these evidence-based programs in the face of a repeal of those expansions.

To put this in dollar terms, repealing the mental and substance use disorder coverage provisions of the ACA would withdraw at least $5.5 billion annually from the treatment of low income people with mental and substance use disorders. The Cures Act's two-year, $1 billion increase in treatment capacity would not even serve as much of a bandage if it were coupled with a cut in annual treatment spending that is more than five times greater.

The Congress and the American people have come to realize that stemming the tragic toll of opioid misuse and addiction and serious mental illnesses takes funding as well as policy. The Cures Act reflects bipartisan agreement on this point. It would be a cruel sham for Congress to take an important, but modest, step forward in investing in treatment capacity, while withdrawing funds from the enormous recent progress made in addressing the needs for care of those with mental health and addictive illnesses.

Congress should not backtrack on the promise of the Cures Act by repealing the ACA.

Richard Frank is a Professor of Health Economics at Harvard Medical School. Sherry Glied is Dean of the Wagner School of Public Service at NYU.

In addition, in data analysis done by the Harvard Medical School, the numbers show, of the states hit particularly hard by the opioid epidemic:

* West Virginia

o ACA repeal threatens 45% of the state's funds for evidence-based Medication Assisted Treatment using buprenorphine to help West Virginians battling opioid addiction.

o West Virginia filled more opioid prescriptions than there are people with 1,049 opioid prescriptions per 1000 population.

o West Virginia covers more than 214,000 people with serious mental illnesses, other mental illnesses and substance use disorders (SUDs) through Medicaid expansion and the Health Insurance Marketplaces. This includes 204,000 people with a serious mental illness, other mental illnesses and substance use disorders who are covered through Medicaid expansion.

o Had the highest drug overdose mortality rate in the nation with 41.5 deaths per 100,000 people (2015 CDC data).

* Tennessee

o Filled more opioid prescriptions than there are people with 1,161 prescriptions per 1000 population.

o In Tennessee, 78,000 people with mental illnesses and substance use disorders gained coverage through the Marketplace. Of these, more than 8,000 or 10.2% had a serious mental illness.

o Had a mortality rate from drug overdoses of 22.2 per 100,000 people.

* Pennsylvania

o ACA repeal threatens 30% of the state's funds for evidence-based Medication Assisted Treatment using buprenorphine to help Pennsylvanians battling opioid addiction.

o In Pennsylvania more than 180,000 people with serious mental illnesses, other mental illnesses and substance use disorders have gained coverage due to the Medicaid expansion and the Marketplaces.

o Had 3,264 drug overdose deaths and a mortality rate of 26.3 people per 100,000 population

o Pennsylvania filled 795 opioid prescriptions per 1000 people.

* Ohio

o ACA repeal threatens 50% of the state's funds for evidence-based Medication Assisted Treatment using buprenorphine to help Ohioans battling opioid addiction.

o Ohio covers more than 220,000 people with serious mental illnesses, other mental illnesses and substance use disorders (SUDs) through the Medicaid expansion and the Health Insurance Marketplaces. This includes 14,000 people with a serious mental illness and nearly 30,000 with a substance use disorder who are covered through the Marketplaces.

o Ohio filled 829 opioid prescriptions per 1000 people.

o Had 3,310 drug overdose deaths (2015 CDC data) and a mortality rate of 29.9 people per 100,000 people.

* Nevada

o Nevada covers more than 50,000 people with serious mental illnesses, other mental illnesses and substance use disorders through Medicaid expansion or the Health Insurance Marketplaces. This includes 6,400 with a serious mental illness and nearly 13,000 with a substance use disorder who are covered through the Marketplaces.

o Nevada filled 816 opioid prescriptions per 1000 people.

* Maine

o Maine covers close to 20,000 people with serious mental illnesses, other mental illnesses and substance use disorders through the Health Insurance Marketplaces. This includes more than 8,000 with a substance use disorder who are covered through the Marketplaces.

* Arizona

o Arizona covers close to 79,000 people with serious mental illnesses, other mental illnesses and substance use disorders through the Medicaid expansion and the Health Insurance Marketplaces. This includes 7,177 people with a serious mental illness and nearly 22,000 with a substance use disorder who are covered through the Marketplaces.

* Alaska

o ACA repeal threatens nearly 35% of the state's funds for evidence-based Medication Assisted Treatment using buprenorphine to help Alaskans battling opioid addiction.