How the ACA Fights the Opioid Epidemic

Every day, on average, 78 Americans die from opioid abuse.[1] But did you know that the Affordable Care Act (ACA/Obamacare) has been the key way that states have developed tools to fight the opioid epidemic across America?

The ACA’s expansion of healthcare coverage—including benefits for prevention, treatment and harm reduction—continues to help lessen the epidemic and save lives. But the currently-stalled U.S. House ACA repeal bill and the ideas under discussion for amending that bill would significantly water down coverage requirements for substance use disorder (SUD) treatment, decreasing access to life-saving treatments and hampering states’ attempts to aggressively confront the opioid epidemic.

Epidemics involving opiates and other powerfully addictive substances (e.g., crack cocaine) are nothing new in the U.S., and it is a mistake to assume that the causes, effects, or treatment solutions for addiction are uniquely tied to a particular substance or form of the drug involved. Important commentary has been made about the more empathic public policy response to opioid addiction that emerged as addiction, overdose deaths, and removal of children from addicted parents became associated with more white and higher-income Americans. As CPPP’s first director the late Helen Farabee reminded us, too often in public policy “it’s not real until it happens to me.”

This excellent article published by Vox quoted the mayor of Ithaca, New York, on the topic of gentler treatment of white addicts, “I’m as angry about this as anybody. But just because these are now white kids dying doesn’t mean we shouldn’t care, because these are still kids dying.” The surge in access to substance use disorder treatment under the ACA’s insurance market reforms and Medicaid Expansion has encompassed treating addiction by all kinds of Americans to all kinds of drugs.

Private insurance and the Essential Health Benefits

Under the ACA, individuals with health insurance plans purchased through the individual market or the small employer market are able to receive both mental health and SUD services as part of the Essential Health Benefits (EHBs). This means that plans cover inpatient and outpatient behavioral health services and addiction treatment, including for opioid addiction. Prior to the ACA, coverage of SUD service benefits was often limited or even completely excluded from policies.

The Essential Health Benefits also require coverage of prescription drugs that include three categories of drugs related to SUD treatment: drugs to treat opioid use disorder, alcoholism, and opioid harm reduction. The regulations implementing the EHB include prescription drug requirements based 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, and at least one drug from the alcohol deterrents/anti-craving category. 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 coverage and Medicaid expansion

Medicaid is the biggest source of coverage and funding for mental health and SUD services in the country.[2]Under the ACA, access to treatment for opioid use disorder has increased through Medicaid, because 31 states have expanded coverage to adults up to 138 percent of the poverty level (e.g., an annual pre-tax income under $34,000 for a family of four). Coverage under a state’s Medicaid expansion must include EHBs, so it covers SUD treatment for participants. A 2015 national survey estimates that 1.2 million people with SUD gained access to insurance through Medicaid expansion[3]. Uninsured hospitalizations related to mental illness or SUD dropped from 20 percent to five percent between 2010 and 2015 in Medicaid expansion states.[4]

Looking ahead

Fortunately 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 (CARA) and the 21st Century Cures Act. Additionally a number of governors have taken initiative and enacted legislation to address the issue within their own states.  Any proposal to repeal the ACA without accounting for the millions of people who gained access to SUD services will undermine these efforts.

Still, today only 20 percent of adults with an opioid use disorder get the treatment they need each year, with cost and access reported as a primary barrier.[5] Addressing the ongoing opioid epidemic will require an intense, multi-faceted approach, and maintaining access to treatment and improved service delivery is critical to success.  Instead of limiting access to SUD treatment, Congress and the Administration can help by building on the success of the ACA to increase insurance eligibility and coverage for people with SUDs.

[1] Centers for disease Control and Prevention, 2015, “Opioid Overdose: Understanding the epidemic,” Centers for Disease Control and Prevention. Retrieved on Mar. 26, 2017.

[2] Deborah Bachrach, Patricia Boozang & Mindy Lipson, July 20`6, “Medicaid: States’ most powerful tool to combat the opioid crisis,” Manatt Health. Retrieved on Mar. 28, 2017.

[3] Jonaki Bose, Sara L. Hedden, Rachel N. Lipari & Eunice Park-Lee, 2016 “Key indicators for mental health and substance use in the United States: Results from the national survey on drug use and health,” Centers for Disease Control and Prevention. Retrieved Mar. 26, 2017.

[4] ASPE, Jan. 11 2017, “Continuing progress on the opioid epidemic: the role of the Affordable Care Act,” ASPE. Retrieved on Mar. 26, 2017.

[5] NORC, Dec. 2016, “Opioid use, misuse, and overdose in women” U.S. Department of Health and Human Services office for Women’s Health. Retrieved on Mar. 26, 2017.

Monica Villarreal joined the Center in 2016 as a Hogg Mental Health Policy Fellow. She has previously worked on advocacy for disability issues and has policy experience from working at Disability Rights Texas and the American institutes for Research. Villarreal is a native of Monterrey Mexico and moved to Austin in 2010 to attend school at the University of Texas at Austin where she received a bachelor’s degree in Government and Latin American Studies and a Master’s of Public Affairs from the LBJ School of Public Affairs.

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