Despite the protection of funding for 2017, the outlook for fiscal 2018 is uncertain. There are worries about full funding of the numerous mental health and substance abuse initiatives for which the Cures Act authorized funding, including $500 million for opioid addiction treatment and $51.9 million to promote integration of primary and behavioral healthcare. Beyond that, the Republican drive to repeal and replace the Affordable Care Act could roll back the Medicaid expansion that has enabled millions of low-income people with mental illness and addiction problems to receive treatment.
"If the proposed cuts end up impacting the current funding for mental health, we could be in a situation where there is a sincere intention to give and an equally sincere effort to take away," said Paul Gionfriddo, CEO of Mental Health America, an advocacy group.
Rep. Tim Murphy (R-Pa.), chief sponsor of the Cures Act's mental health provisions, vowed to keep up the pressure for full funding. "Mental health and substance abuse are a massive problem and we have to treat it," he said in an interview. "It will be a challenge because of tight budgets, but we will continue to push hard."
Experts say even if the Cures Act reforms and grants are fully funded, the negative impact on the mental health system of repealing the ACA would swamp those advances. "It would be one step forward and 10 steps back," said Ron Honberg, a senior policy adviser at the National Alliance on Mental Illness.
The GOP replacement bill that narrowly passed the House in early May would effectively end the law's Medicaid expansion to low-income adults, and threaten its mandated benefits and pre-existing condition protections for privately insured people with mental health and substance abuse problems. In addition, state Medicaid managed-care programs would have the option to stop covering treatment for mental health and substance abuse. Those provisions could neuter a separate federal law requiring insurers to cover behavioral care on parity with physical care.
On top of that, the House GOP bill would cut overall Medicaid funding by $839 billion, or about 25%, over 10 years. Medicaid pays for about 25% of all mental healthcare in the U.S.
An estimated 30% of adults who have received coverage under the ACA's Medicaid expansion have a serious mental illness and/or substance abuse problems, and about 1.3 million people receive treatment for those disorders through that coverage.
Ohio Gov. John Kasich and other Republican governors have stressed that the Medicaid expansion has been key in enabling many people with opioid addiction to receive treatment. Medicaid pays for nearly half of all medication-assisted treatment for opioid addicts in Kentucky, Ohio and West Virginia, and 20% of addiction care nationally.
Murphy, who has faced criticism from mental health advocates for backing the ACA repeal-and-replace legislation, argues the House GOP bill would enhance behavioral care. The GOP bill, he noted, would offer states tens of billions of dollars through 2026 that could be used for mental health and substance abuse treatment.
That funding, he said, would do more than Medicaid expansion to encourage states to develop effective systems of care.
Rep. Joe Kennedy (D-Mass.), a strong proponent of improved coverage for mental healthcare, rejected that claim. "The additional funding doesn't come close to offsetting the damage of repealing the Affordable Care Act," he said in an interview. "Our (Republican) colleagues have gotten committed to repealing the law without acknowledging the millions of people suffering from mental illness who will be sacrificed."