As our country grapples with an “unprecedented opioid epidemic,” Congress is taking steps to take away an important tool to fight it — the Affordable Care Act (ACA). The annual cost of the epidemic is estimated to be $78.5 billion. In 2014, there were more deaths from opioid and other drug overdose than any other year; 60.9 percent of those overdoses involved an opioid. Every day, an average of 78 Americans die from opioid abuse. The coverage expansions and protections under the ACA can help lessen the epidemic and save lives.
The ACA Provides Coverage to People with Substance Use Disorders
Because of the ACA, an estimated 26 million people have health coverage through the marketplaces or Medicaid that includes substance use disorder (SUD) treatment and prevention. Additional people enrolled in new individual market or small group market plans outside the marketplace also now have SUD treatment covered because most individual and small employer insurance plans can no longer exclude SUD treatment. And, as Ohio Governor John Kasich recently noted, the Medicaid expansion is getting SUD treatment services to people in need.
In addition, coverage expansions under the ACA help people afford regular access to care, including mental health services and treatment of underlying conditions that can help to prevent SUD or allow for early identification and treatment. However, a repeal of the ACA would more than double the uninsured rate and, in the three states with the highest drug overdose deaths—Kentucky, New Hampshire, and West Virginia—a repeal would about triple the uninsured rate. Repealing the ACA will remove coverage for SUD treatment and prevention from millions of Americans, leaving a gap in care when it is most needed.
Private Insurance and Essential Health Benefits
The ACA closed significant gaps in coverage in the individual and small employer insurance markets, including a lack of coverage for behavioral health services and other SUD related services. This is not surprising given that about one-third of people enrolled in individual market plans prior to 2014 had no coverage for SUD treatment and small employer plans were exempt from the Mental Health Parity and Addiction Equity Act (MHPAEA). They therefore could exclude SUD treatment or provide stricter limits on SUD services than on other medical services. The ACA reduced these gaps by requiring all new plans in the individual and small employer markets to include a set of Essential Health Benefits (EHB), including SUD services. People covered by the Medicaid expansion must also receive the EHB, including SUD services.
As part of the EHB, new health insurance plans in the individual and small employer markets must cover SUD treatment, prevention, and harm reduction. Under the ACA and its implementing regulations, individual and small group plans must comply with the MHPAEA. As a result, SUD services cannot have limits less favorable than those imposed on medical and surgical benefits. While there is state variation in the specific services and treatments that are required to be covered, all state EHB rules require some inpatient and outpatient behavioral health services and SUD treatment and there are national standards for preventive services and a national floor for prescription drugs.
The preventive services include alcohol and drug assessments for adolescents aged 11-21 years. A recommendation for drug use screening that could require coverage of drug use screening for adults, including pregnant women, is currently under review and may be required as early as 2018. There are three categories of drugs related to SUD that must be covered, including drugs to treat opioid use disorder (OUD), alcoholism, and opioid harm reduction. The regulations implementing the EHB base the prescription drug requirements on the categorization system used by Medicare Part D. Under this system, plans must cover at least one drug from the opioid dependence treatment category (includes Buprenorphine, Buprenorphine/Naloxone, and Naltrexone [note 1]) and at least one drug from the alcohol deterrents/anti-craving category (includes Acamprosate, Disulfiram, and Naltrexone). Plans must also cover Naloxone, which is in a class without any other drugs. Naloxone is an opioid reversal agent, known also as a harm reduction medication, that is used to reverse an opioid overdose.
Medicaid is the single largest source of coverage and funding for behavioral health services in the country and the ACA has increased access to treatment for opioid use disorder in the Medicaid program in several ways.
First, the ACA requires that states that expand Medicaid to adults up to 138 percent of the poverty level cover SUD treatment for those enrollees. Thus, in the states that expanded Medicaid, 1.2 million people with SUDs, including OUDs, that were previously uninsured have gained access to coverage that includes SUD treatment (note 2). The proportion of substance use or mental health disorder hospitalizations that were uninsured dropped from 20 percent to 5 percent between 2010 and 2015 in Medicaid expansion states. This is particularly significant because Medicaid programs have been found to provide more comprehensive treatment and care to persons with SUD than private insurance. For example, by 2013-2014, Medicaid programs in 31 states and the District of Columbia covered all of the medications that can be used in combination with psychosocial treatment for treatment of OUD — methadone, buprenorphine, and one of the two forms of naltrexone (oral and extended-release injectable).
Second, as noted above, the EHB extended the MHPAEA to the Medicaid expansion population, paving the way for ensuring that treatment for SUDs, including OUD, is comparable to the level of services provided for medical care. CMS’ implementing regulations applied parity to Medicaid managed care and to long-term care services for substance use disorders.
Third, the ACA offers funding to state Medicaid programs to promote delivery reforms that integrate and coordinate care for individuals with SUD. The Medicaid health home model, for example, is an optional program states can adopt under the ACA to provide additional services to persons with certain chronic conditions, including SUD. Three states—Maryland, Rhode Island, and Vermont—have used the health home model to address OUD and have implemented these programs to increase care coordination, case management, integrate OUD treatment with medical and behavioral health services, and connect enrollees to other services in the community. CMS has also launched an initiative to encourage states to develop innovative service delivery Section 1115 demonstration projects to address SUD that also promote care coordination, integrated care, and comprehensive strategies that provide a “full continuum of care” for persons with SUD. The ACA’s Medicaid expansion also represents the first widespread opportunity to coordinate SUD treatment for individuals involved in the justice system, and several states including Connecticut and Rhode Island have developed initiatives to do so.
Finally, the ACA authorized and funded numerous payment and service delivery reforms that have enabled states to address SUD in their Medicaid programs. CMS’ Innovation Accelerator Program has provided states with resources and technical assistance to address SUD treatment. The State Innovation Models Initiative enables states to design and test multi-payer delivery and payment reform models. And states have launched new initiatives to address SUD and other behavioral health issues through CMS’ Health Care Innovations Awards.
Moving Forward on Addressing the Opioid Epidemic
There is strong bipartisan consensus on the need to address the opioid epidemic through education, prevention, and treatment. Congress took steps last year to address the opioid epidemic by passing the Comprehensive Addiction and Recovery Act of 2016 and the 21st Century Cures Act. In addition, state lawmakers around the country are passing laws to address the epidemic.
Repealing the ACA will undermine these efforts. Millions of people will lose health coverage, including comprehensive behavioral health and SUD benefits through Medicaid. People remaining covered in the individual and small group markets will lose benefits for SUD related services such as behavioral health services, preventive screenings, and prescription drugs. Progress being made to improve SUD care through ACA delivery system reforms will be halted. Addressing the ongoing opioid epidemic will require an intense, multi-faceted approach, and maintaining access to treatment and improved service delivery for millions of Americans is critical to success.
Methadone, which is used for opioid dependence treatment is classified by the USP as a long-acting opioid-analgesic along with other drugs that are used to treat pain. Plans may cover methadone but can also exclude methadone and cover other drugs from the classification.
Data specific to the number of people with OUDs that have received coverage through the Medicaid expansion is not available. In 2015, about 10 percent of people aged 12 an older with an SUD, 2.0 million people, had an SUD related to the use of prescription pain relievers (Figure 27).