The Senate GOP bill to repeal and replace the Affordable Care Act could reverse progress in expanding access to behavioral health and substance abuse treatment, experts say.
An analysis by the Congressional Budget Office found 22 million Americans would lose coverage under the Better Care Reconciliation Act, mostly through an estimated $772 billion, or 26%, cut to federal Medicaid spending by 2026. The CBO said 15 million fewer people would be on Medicaid by that year.
Mental health advocates fear large cuts to Medicaid because it is the single largest payer for mental health services. On top of that, it would allow states to waive the ACA's requirement that commercial insurers and Medicaid plans cover benefits such as mental health and substance abuse treatment.
Concerns about the bill's impact on treatment for mental illness and addiction have led some GOP senators and governors, including Ohio Sen. Rob Portman and Ohio Gov. John Kasich, to withhold support for the legislation.
"This is going to affect people with mental illness and addiction disproportionately," said Dr. Jeffery Lieberman, chairman of the Psychiatry Department at Columbia University College of Physicians and Surgeons.
But supporters say the bill's Medicaid changes would prompt states to redesign their Medicaid programs to cover their residents more cost-effectively.
The bill would effectively end the ACA's Medicaid expansion to low-income adults by phasing out enhanced federal funding for expansion by 2024. It also would impose a cap on the growth of federal payments to states that experts say likely would force states to cut eligibility, benefits and provider payments.
Medicaid covers more than a quarter of all spending for mental health and substance abuse services. 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.
"If the expansion goes away, and if the federal government imposes these draconian cuts, the pressure on clinics will be enormous," said Rebecca Farley David, vice president of policy and advocacy for the National Council for Behavioral Health.
According to David, Medicaid makes up anywhere from 40% to 80% of the payer mix for many of her organization's members. "Without the support of the Medicaid program, many of them cannot keep their doors open."
The uncertainty over the fate of Medicaid has caused anxiety at many behavioral healthcare facilities.
"The consequences of this for many will be life or death," said Ken Taylor, CEO of Valley Cities Behavioral Health Care, a community mental healthcare organization with eight sites in the Seattle area.
Taylor said his clinics have doubled the number of patients receiving care since 2014 to about 12,000 patients, which he said was due to the ACA's Medicaid expansion.
The Senate bill allows states to seek waivers that would grant health insurers the option not to cover benefits such as mental health and substance abuse treatment. Those changes could remove the ACA's limits on patient out-of-pocket costs, which could deter people from seeking needed care.
Behavioral health advocates see some positives in the Senate bill. It would keep in place the requirement for health plans to cover children up to age 26 who are on their family's plan. It also bars insurers from denying coverage for people with pre-existing conditions, including mental illness and substance abuse.
Under the bill, states could extend the number of days their Medicaid program covers psychiatric hospitalizations, up to 30 consecutive days in a month and up to 90 days in a year.
Federal law has long barred Medicaid programs from covering the cost of patients receiving mental health or substance abuse treatment in residential facilities with more than 16 beds. Congress changed the limits on inpatient stays when it included a provision within the 21st Century Cures Act last year allowing Medicaid to cover the costs of up to 15 days.
John Snook, executive director for the Treatment Advocacy Center, said the bill's increase in allowed Medicaid-covered treatment days is significant.
But Snook said the bill overall could deprive people with serious mental illness of access to treatment through its provision to cap Medicaid spending. That could force states to cut eligibility and/or benefits. The CBO said the cap would reduce federal Medicaid spending by 35% in 2036.
Such large cuts would further limit access to care for many, who could end up in facilities that are detrimental to their health and more expensive for taxpayers.
"We know what happens when there isn't enough capacity," Snook said. "People end up in the facilities that will take them, and too often that's a jail."