A key but understated issue in the 2016 elections was the heartbreaking and widespread epidemic of opioid addiction and mental health crisis in the United States. Both candidates vowed to help the victims and families affected by opioid addiction and mental health issues, but, as can be deduced from a recent report from the Assistant Secretary for Planning and Evaluation (ASPE) at the US Department of Health and Human Services, the one candidate who had a viable plan for actually helping did not win. The major takeaway of this report? The authors said it best: “our nation’s best shot at reversing the opioid epidemic and providing needed care for opioid use disorders, other substance use disorders, and mental illness depends on the continued success of the Affordable Care Act (ACA).”
As a quick primer, the ACA is a far-reaching law that seeks to revolutionize the quality of care provided in the United States and improve the accessibility and affordability of this health care. Part of the improvement in the quality of care meant that health insurance plans were required to provide a higher level of minimum essential coverage (MEC), which includes substance abuse treatment and mental health services. In comparison, before the ACA, an estimated 34% of individual market policies did not cover substance abuse treatment and 18% did not cover mental health services. Part of the improvement in accessibility and affordability were the Marketplace exchanges, where individuals could buy private health insurance, and the expansion of Medicaid for most non-elderly adults with incomes at or below 138% of the federal poverty line (FPL). Medicaid enrollees who were newly eligible due to the ACA expansion would be subsidized by the federal government. As of January 2017, 19 states (primarily Republican run ones) decided to not adopt the expansion of Medicaid. Also worthy of note, the ACA does not allow insurance issuers to deny anyone coverage due to pre-existing conditions or to charge someone a higher rate due to pre-existing conditions, such as a history of substance abuse or mental health issues. Over 20 million Americans gained coverage as a result of the ACA, with coverage beginning as early as January 1, 2014. And, of course, the new administration and the Republican Party want to repeal the law.
Perhaps unsurprisingly, the ACA saw the uninsured rate dramatically decrease for hospitalizations due to substance use or mental health disorders. Significantly, the findings were most pronounced in states that expanded Medicaid. Table 1 shows that, when comparing the share of hospitalizations due to substance abuse or mental health disorders in which the patient is uninsured right before the ACA took effect to a year later, the share dropped by 8 percentage points for all states and by 14 percentage points in states that expanded Medicaid. Note that, as can be seen in the full report, utilization of such hospitalizations did not drop toward the end of 2013 (which might indicate people knew they had health insurance coming and therefore waited to get help) – if anything, it rose slightly. In states most affected by the opioid epidemic, the trend is even more dramatic. For example, in West Virginia, the state with the highest drug overdose death rate in 2015, the share dropped 18 percentage points (23% to 5%) in this time period. An even more impressive example is Ohio: after the expansion of Medicaid, 75% of enrollees with an opioid use disorder reported improved overall access to care, 83% reported improved access to prescription medications, and 59% reported improved access to mental health care. This all points to the fact that, due to the ACA, Americans suffering from substance abuse or mental health issues finally had health insurance that gave them access to treatment.
Table 1: Share of hospitalizations due to substance use or mental health disorders in which the patient is uninsured
| All States | Medicaid Expansion States | ||
| 2013 Q4 | 2014 Q4 | 2013 Q4 | 2014 Q4 |
| 22% | 14% | 20% | 6% |
While there is undoubtedly more work to do in combatting the opioid epidemic, the ACA was a big step in the right direction, and repealing it would undo this progress. Furthermore, the states that would be the most affected by a repealing of the ACA are also states most affected by the opioid epidemic. According to the Urban Institute, the uninsured rate in West Virginia, New Hampshire, Kentucky, and Massachusetts would more than triple if the ACA were repealed, and, according to the CDC, these states rank 1st, 2nd 3rd, and 7th, respectively, in drug overdose death rates in 2015. The seven other states with drug overdose deaths above 22 deaths per 100,000 people, uninsured rates would increase by 79-170%.
Unfortunately, perhaps because substance abuse and mental health are difficult issues that cannot be solved overnight, and also perhaps because the beginning of the ACA coincided with the rise of the opioid epidemic, having insurance did not lower the death rates, and it is not clear if it slowed it down. Table 2 shows the drug overdose death rates from 2013 through 2015 for the top ten states by drug overdose death rates in 2015 from the CDC.
Drug Overdose Death Rates, 2013-2015
| State | 2013 | 2014 | 2015 |
| West Virginia | 32.2 | 35.5 | 41.5 |
| New Hampshire | 15.1 | 26.2 | 34.3 |
| Kentucky | 23.7 | 24.7 | 29.9 |
| Ohio | 20.8 | 24.6 | 29.9 |
| Rhode Island | 22.4 | 23.4 | 28.2 |
| Pennsylvania | 19.4 | 21.9 | 26.3 |
| Massachusetts | 16.0 | 19.0 | 25.7 |
| New Mexico | 22.6 | 27.3 | 25.3 |
| Utah | 22.1 | 22.4 | 23.4 |
| Tennessee | 18.1 | 19.5 | 22.2 |
However, the uninsured rate decreasing is still important, primarily because over time it offers an opportunity for people suffering from substance abuse or mental health issues to receive help before it becomes an emergency at a lower economic and social cost to the general public. According to a Kaiser Family Foundation report, individuals without insurance for a full year in 2013 only paid for about 70% of their total health care costs, leaving other sources (primarily Medicaid, at 25% of uncompensated costs or $13.5 billion in 2013) to fill the uncompensated gap with public dollars. Furthermore, while an uninsured person’s health costs were on average about half of the health costs of an insured person, their place of service was disproportionately in a hospital (60%), where the cost of health care is more expensive in comparison to an office-based place of service. This may reflect that the uninsured are also not receiving necessary preventive health care services. In other words, when the uninsured seek help it’s most likely an expensive emergency and taxpayers will still subsidize the bill (like they do on the ACA), and the burden of the cost prevents the uninsured from seeking help earlier, which, in the case of opioid addiction or mental health issues, could save families the tragedy and heartache as well as the general public a host of unexpected or hidden consequences.
Let me end by bringing it back to California, my home state, to emphasize that it’s not just states ravaged by the opioid epidemic that have benefited from the ACA for substance abuse and mental health treatment. California ranks 43rd out of the 50 states in terms of the drug overdose death rate in 2015. At the end of 2013, the share of hospitalizations due to substance use or mental health disorders in which the patient is uninsured was 25%. At the end of 2014, the share was 5.6%, and the share has dropped every quarter with data in the ASPE report. While California has its own state exchange, the expansion of MediCal was paid for by the federal government, so any repeal of the ACA would affect us, too.
In summary, if the government is serious about stopping the substance abuse and mental health crises in the United States, they would decide to not repeal the ACA. I am not hopeful that they will see the light, but it would be the right thing to do.
For the full ASPE report, see: https://aspe.hhs.gov/sites/default/files/pdf/255456/ACAOpioid.pdf
Theory in Practice 