Friday, February 24, 2017

Repealing Obamacare (ACA) may exacerbate the opioid epidemic in rural America

The opioid epidemic is a serious public health issue in the U.S. Opioid overdose deaths have more than quadrupled since 1999. In 2015, there were over 22,000 overdose deaths involving prescription opioids, equivalent to 62 overdoses a day. Since 2014, overdose deaths have increased by approximately 3,000 deaths a year. Nearly 13,000 people died from heroin overdoses in 2015, a 20.6% increase since 2014. Heroin overdose deaths have quadrupled since 2010. Although all states have experienced increases in nonmedical prescription opioid overdoses, states with large rural populations, like Kentucky, West Virginia, Alaska, and Oklahoma, have experienced disproportionately high increases. The widely acknowledged opioid epidemic in rural areas has been discussed in previous blog posts here, here, and here. However, the government has made strides in tackling this epidemic in recent years by passing new healthcare laws.

The Affordable Care Act (ACA) or Obamacare, combined with the 2008 Mental Health Parity and Addition Equity Act (MHPAEA), made major advances in improving and ensuring treatment for people with substance use disorders (SUDs). The ACA increased access to health insurance by expanding Medicaid eligibility, allowing children to stay on their parent’s health plans until age 26, and provided financial subsidies to help people afford health insurance. The Medicaid expansion has had an especially large effect on people with SUDs. In states that expanded Medicaid, the percentage of people with SUDs or mental health disorders who were hospitalized fell from 20% in 2013 to 5% in mid-2015. This expansion has been particularly helpful in states, like West Virginia, that have been hit hardest by the opioid epidemic. In West Virginia, which had the highest drug overdose rate in 2015, the rate of uninsured people who were hospitalized with SUDs or mental health disorders fell from 23% in 2013 to 5% in 2014.

The ACA and MHPAEA also closed gaps in health insurance coverage. These laws eliminated annual and lifetime insurance benefits limit on behavioral health services and ending discrimination based on pre-existing conditions. Moreover, before these laws health plans often didn’t include substance abuse treatment or had very strict limits on what they covered and for how long, so the benefits were rarely used. Roughly a third of individually sold private health insurance plans didn’t cover SUDs treatment before the ACA. The ACA required all health insurance plans in the individual and small-group markets to provide essential healthbenefits (EHBs) and included SUD services as EHBs. The ACA also required individual and small group plans to comply with the MHPAEA. The MHPAEA required the majority of health insurance plans to cover mental and behavior health conditions at the same level they cover physical health conditions. However, this law will be “useless” if the ACA is repealed and there is no insurance coverage for low-income people.

States with large opioid epidemics have benefitted substantially from the ACA and MHPAEA. In Kentucky, 1,500 people received addiction treatment through Medicaid in early 2014 but by mid-2016 that number rose to around 11,000 people. In New Hampshire, over 10,000 people received addiction treatment after the ACA expanded Medicaid in that state. In Pennsylvania, 124,000 people received addiction treatment after the ACA expanded Medicaid. The ACA also provided $5.5 billion in spending on addiction and mental health treatment.If the ACA were repealed, not only would the policies promoting SUDs treatment disappear, 2.8 million people with SUDs may lose the coverage they obtained under the ACA. 220,000 of those people have opioid use disorders. 

Furthermore, the repeal of the ACA will affect rural Americans more than urban Americans. As discussed in a previous blog post, rural America experienced the highest rates of health insurance coverage gains through Obamacare. The Urban Institute's Health Reform Monitoring Survey found that coverage for rural individuals between June 2013 and March 2015 increased by 7.2%.

The ACA also provided grants to many community health centers in rural areas to begin or expand mental health and medication-assisted treatment. As mentioned in a previous blog post, Congress passed the 21st Century Cures Act in December 2016, which sets aside $1 billion in grants to help states expand drug treatment programs over the next two years. However, if the ACA is repealed and many people with SUDS lose their health insurance, they will likely lose access to the new treatment options provided by the 21st Century Cures Act.

The GOP’s current ACA replacement proposals fall short and could undo many of the gains made in treatment for people with SUDs mentioned above. The plan proposed in January 2017 imposes deep cuts to federal Medicaid funding for states which would eliminate or reduce access to insurance for millions of low-income people. The plan also replaces ACA tax credits with fixed amounts, which would make health insurance less affordable for lower and moderate income families who are the most likely to be uninsured. These changes could make insurance less affordable for millions of Americans who may lose their insurance. But even before the ACA is repealed and replaced, the Department of Health and Human Services (HHS) could weaken SUD services coverage. They could do so by not enforcing the ACA’s EHB requirements, which require insurance plans to cover SUDs services. The future of EHB requirements looks bleak since Tom Price, the newly confirmed head of HHS, has criticized them in the past.

Any "replacement" plan for the ACA must contain provisions that protect SUDs treatment. The U.S. cannot afford to ignore the opioid epidemic that is plaguing many states in America, especially among rural Americans. If the new health care plan ignores this crisis, thousands of Americans may die a year from opioid overdoses because they will no longer have any access to treatment programs through their health insurance. 

1 comment:

Kyle said...

Thank you for this timely and well-researched post. Laying bare my political leanings, I think this piece shines a bright light on the contradictions in then-candidate Trump's platform. Now that he, and the Republican-controlled Congress, must govern, these tensions have to be reconciled. I am doubtful that they can be, and since "something's gotta give" I hope that the quixotic project of dismantling the APA wanes before our national focus on opioid abuse does.

This post cites a NY Times piece that parallels a similar Mother Jones piece (here: The MoJo piece contains a pair of U.S. maps side by side which make clear the overlap between the states most affected by the opioid epidemic and those where access to insurance under the ACA has increased the most.

Stories from West Virginia continue to show up in media accounts. A pre-election story from another rural-focused blog claims that West Virginia was slated to receive as much as $10M over the next two years for opioid treatment. A pair of recent NPR pieces ( and highlight the importance of treatment programs to break the cycle of opioid abuse and how vulnerable these efforts are to a loss of ACA resources.

Returning to the political: West Virginia is one of just three states with majority-rural populations ( It is also a state with diverse political leanings: it has chosen the Republican in each of the last five presidential candidates, yet from the 1950s until 2014 both of its U.S. Senators were Democrats. Democrats have also controlled the governorship during most of the 21st century and the Democrats' control of the statehouse was uninterrupted from the 1930s until 2014. From the outside looking in, it seems that voters worried about opioid addiction in this GOP-trending, rural, coal-mining state had good reasons to embrace Candidate Trump's promises. The question is whether or not President Trump truly will "Never, ever let [them] down." If he does, they may return the favor.