The last decade saw two major federal legal advances for addiction treatment. First, in 2008, the Mental Health Parity and Addiction Equity Act outlawed discrimination by health plans against coverage of addiction and other behavioral health conditions. Second, in 2010, the Affordable Care Act (ACA) – known by supporters and detractors as ObamaCare – mandated that all health plans include addiction treatment in the definition of minimum essential benefits, ensuring access to patients irrespective of how they got health insurance.
The combination of these two laws opened the door to significant growth in the number of both residential beds and facilites in outpatient treatment programs for patients in need of addiction treatment. Then, President Trump was elected in November 2016 on a platform to repeal ObamaCare. He promised to replace it with “something terrific.” Will there really be a replacement? Will it be terrific?
Earlier this year, my partner, Rob Fuller, and I coauthored a book, From ObamaCare to TrumpCare: Why You Should Care, which attempts to answer these questions. Our goal was to be apolitical and to “call balls and strikes” on both sides. Much has happened on the ground since our book came out. In March, President Trump and House Speaker Paul Ryan set their own health reform package, the American Health Care Act (AHCA), for a vote in the House and then canceled when it became clear the votes weren’t there. In the last week of April, they revived the bill, revised it to address concerns of Freedom Caucus House conservatives, and again pulled the bill when the changes lost support from more moderate members of the House. Finally, on May 4, the third version of the bill resolved conservatives’ concerns, passing in the House of Representatives. Attention now turns to the Senate, which will attempt to pass a bill. This would then be followed by negotiation to reconcile the two versions via a bicameral vote (or committee authorization to arrive at a final bill).
With all of this drama, I found myself thinking about the contrast between the chaos swirling around votes in real life and the cool of Kevin Spacey, aka President Frank Underwood, on the Netflix series, House of Cards, whose team always seems to have legislative vote counts down to a hard science before a bill goes before Congress. The last few months have been a reminder that truth is messier than fiction, and that counting the votes on healthcare reform is a complicated business.
So now that ACA repeal efforts have progressed after stalling out twice over intramural Republican conflict, can we still make any sense of what TrumpCare (aka, RyanCare) will mean for addiction treatment? We still don’t know if the Senate will pass legislation, let alone what the reconciliation between the House and Senate will be.
Despite the uncertainty, there has been enough movement to make some predictions. As we await the Republicans’ next move, some clues to how TrumpCare may ultimately look are already available. The following are three possible events that could unfold:
Decreasing Levels of Insurance Coverage for Addiction Treatment. Although the ACA remains legislatively intact as of this writing, the situation on the ground is already shifting. On his first day in office, President Trump issued an Executive Order (EO) to “minimize the unwarranted economic and regulatory burdens” of the ACA. Confident that the ACA would be repealed, President Trump directed federal officials to “prepare to afford the States more flexibility and control to create a more free and open healthcare market.” Translation: federal officials and, in particular, Secretary of the Department of Health and Human Services, Tom Price, were directed to exercise their authority and discretion to not enforce the ACA.
All indications point toward Secretary Price and other federal officials’ intentions to be faithful to the President’s EO. As a result, while the ACA remains law, it seems clear that Secretary Price will not enforce its provisions. When it comes to addiction treatment, the “hammer” in the ACA is the penalty for health plans that fail to offer minimum essential benefits that all plans were required to include, including addiction treatment. When the Department of Health and Human Services signals to the insurance industry that it does not intend to enforce these penalties, this translates into providing plans with more discretion.
While health plans have not yet reacted to their greater flexibility on minimum essential benefits, it is a safe bet that they will walk through the door the government has opened and take advantage of greater discretion. One manifestation of this smaller government, market-driven GOP vision is greater flexibility for health plans to establish different levels of coverage. In order to avoid litigation, our expectation is that there will continue to be some coverage for addiction treatment, but that it will be narrowed in scope.
For example, health plans are expected to begin offering more types of “low cost, low benefit” (LCLB) plans. Coverage will cost less and offer lower benefit levels, with the extreme being coverage only for catastrophic events in “high deductible health plans” (HDHP).
This is consistent with the Republican vision of healthcare reform: driving pricing and spending downward by giving patients more “skin in the game” to incentivize more consumer-driven behavior, turning patients into value-oriented shoppers for cost-effective healthcare. The bottom line for addiction treatment will be a smaller pool of insurance-funded dollars and pressure on providers to offer lower cost services that patients can afford.
Reduced Enforcement of Mental Health Parity. Under the Obama Administration, the US Department of Labor tightened enforcement of the Mental Health Parity and Addiction Equity Act of 2008. The government expressed concern that health plans were moving too slowly to remove limitations that were barriers for behavioral care and discriminatory care relative to the easier availability of medical/surgical care. From the perspective of patients and providers, this served as a useful source of pressure to expand access to addiction treatment.
Under the Trump Administration, the Department of Labor, headed by Secretary Alex Acosta, appears to be positioned for a less adversarial role with employers. In general, the philosophy of reducing the regulatory burden on private companies will translate to greater flexibility not only for insurers (as described above), but also for employers and self-insured health plans.
With less enforcement of parity, expect to see the rise of more restrictive coverage criteria for addiction treatment. We anticipate reduced availability and narrower qualification standards for residential detoxification and treatment beds, and more pressure toward lower cost intensive outpatient program (IOP) services.
Focus on Increasing State-Level Opioid Abuse Prevention Efforts. While the reduction in government enforcement may signal access challenges ahead in addiction treatment, one bright spot for TrumpCare’s approach to addiction treatment is likely to be a heightened focus on addiction prevention efforts, particularly with respect to opioids.
President Trump has been vocal about being a teetotaler because of his sensitivity to the role of alcohol abuse in the untimely death of his older brother, Freddy Jr. The President’s strong personal feelings about the problem of substance use disorders dovetails with growing public recognition of the seriousness of America’s opioid epidemic and the disturbing rates of overdose–related death rates nationwide.
Bipartisan support for addiction prevention efforts may increase as a result of this alarming trend. Consistent with the Republican philosophy of shifting oversight and responsibility from Washington, D.C. to the states, TrumpCare is likely to put the onus on states to expand prevention efforts. As states look to negotiate Medicaid waivers, the Administration is likely to condition federal funds on state implementation of opioid/drug prevention programs. The focus on prevention is likely to take precedence over treatment resources.
As healthcare reform remains on the federal government’s “to do” list in coming months, the particulars of TrumpCare will continue to unfold with regard to addiction treatment, as well as the government’s overall healthcare agenda. Many details remain to be negotiated. The stakeholders in addiction treatment – patients, family members, providers and employers – need to be paying attention to the ways in which insurance coverage and access to addiction treatment are changing.