Overall, the United States Department of Health and Human Services reports
that provisions of the Affordable Care Act have resulted in an estimated
20 million people gaining health insurance between the passage of the
law in 2010 and early 2016. An Urban Institute report estimates that as
many as 30 million people could lose their insurance should the ACA be
Aside from expanding Medicaid and providing subsidies to make it
more affordable to buy insurance, the ACA required insurers to cover
people with pre-existing medical condition and allowed parents to keep
their children on their policies until the age of 26.
‘Significantly more people with mental illness and substance use disorders had insurance coverage in 2014 due to the expansion of health insurance under the Affordable Care Act, but many barriers to treatment remain.’
Significantly more people with mental illness and substance use
disorders had insurance coverage in 2014 due to the expansion of health
insurance under the Affordable Care Act (ACA), but many barriers to
treatment remain, new Johns Hopkins Bloomberg School of Public Health
The findings, published in the journal Psychiatric Services
come just as Congressional leaders and the president-elect vow to
repeal the ACA. A rollback of the law, which included an expansion of
Medicaid in 31 states and the District of Columbia, would likely
eliminate the gains in insurance among this group. Medicaid expansion
under the ACA covers individuals with incomes below 138% of the
federal poverty line in participating states and the law also provides
subsidies for individuals with moderate incomes to purchase insurance
"The Affordable Care Act has been very effective in reducing the
uninsured rate in this vulnerable population where there is a real need
to get people into services," says study leader Brendan Saloner, an
assistant professor in the Department of Health Policy and Management
at the Bloomberg School. "But having insurance is just the first step.
We need to find ways to get this population treated, whether that means
prescriptions for psychotropic drugs, counseling or placements in drug
Saloner says that repealing funding for the ACA, and Medicaid
expansion in particular, would leave many people without access to
services and add a burden to state and local budgets. "Amidst a national
crisis in opioid overdoses, now is a particularly critical moment to
extend services to people with mental health and substance use
disorders," Saloner says.
For the new study, Saloner and his colleagues analyzed data from the
National Survey on Drug Use and Health, identifying 29,962 adults ages
18 to 64 with mental illness and 19,243 with substance use disorders for
two periods: 2011-2013, before the ACA was implemented, and 2014, the
first year it was in place.
While the researchers found increases in the number of people with
mental illness and substance use disorder obtaining insurance coverage,
these changes did not lead to dramatic increases in use of services to
treat these conditions. Use of mental health treatment increased by 2.2% points and the number of people in substance use treatment
did not change.
The researchers did find, however, that Medicaid payment
for substance use treatment increased by 7.7% points,
suggesting that people who had been paying out-of-pocket for services
were uninsurable or who had another form of insurance switched to the
newly expanded Medicaid program when it became available. Most of the
increased coverage for people with mental illness and substance use
disorders came from increased access to Medicaid for poor people who
previously were not eligible for the program.
Insurance isn't the only barrier to getting treatment for these
disorders. In 2014, less than half of people with mental illness in the
United States and fewer than one in 10 people with a substance use
disorder received treatment, the researchers found.
"We got more people covered, but we didn't make dramatic progress in
closing the under-treatment gap," Saloner says. "We need to find ways
to take the next step and ensure people are seeing the providers who can
Among the barriers to treatment are that psychiatrists have the
lowest Medicaid acceptance rate of any medical specialty, Saloner says.
He says that while newly insured people may visit a primary care
provider, those physicians may be better equipped to manage diseases
like diabetes and hypertension than depression and drug addiction.
Primary care providers may fail to refer their patients for appropriate
treatment for mental illness and substance use disorders.
there continues to be a shortage of evidence-based treatment options for
drug addiction in many communities, a problem that has been made worse
in the context of the crippling opioid crisis in the United States. The
recently passed 21st Century Cares Act that provides funding for opioid
use disorder though building an addiction treatment workforce won't
happen overnight, he says.
Federal law requires that insurance coverage for mental health and
addiction treatment be offered on an equal basis with coverage for other
medical care. Saloner says that before the recent election, many were
hoping that one way to get closer to that goal would be to expand
Medicaid to more states. After the November election, that seems
"2017 is not likely to be a year when additional states opt to
expand their Medicaid programs," Saloner says. "Instead, it could be a
year of massive retraction. Loss of insurance would surely be a step
backward for people with mental illness and substance use disorders."