More Challenges Emerge in the Effort to Enact AHCA

By: Paul Gionfriddo, president and CEO

As the past few days and weeks have unfolded, it is becoming increasingly clear how the American Health Care Act of 2017 (AHCA) as currently drafted will have mostly unintended, mostly negative consequences for people with behavioral health conditions. We believe that these consequences easily could and should be mitigated.

At a very high level, the Congressional Budget Office (CBO) scoring analysis suggests that millions of Americans with mental health and substance use conditions will have less access to the treatment they need.

This could include up to five million people by 2026 who were covered by Medicaid expansion, based on reliable estimates of the number of people with behavioral health conditions included within the expansion population.

This will be mitigated to some extent by individuals living below the poverty level who will now be eligible for tax credits to purchase insurance in both expansion and non-expansion states. But let’s be honest. The CBO estimates that the number of newly insured will be no more than one million, and people with behavioral health concerns will represent only a fraction of those.

We continue to see these elements as essential to the health and well-being of people with behavioral health conditions:

• Maintaining behavioral health benefits at parity with other benefits;
• Maintaining guaranteed, continuous, and affordable insurance coverage for people with pre-existing and chronic conditions;
• Maintaining a healthy Medicaid program for people with chronic conditions; and
• Giving states more flexibility within Medicaid to cover earlier interventions.

The AHCA as it stands today will adversely affect these essential elements.

While the intent of AHCA was not to repeal behavioral health parity, as was made clear in the Energy and Commerce Committee colloquy between Rep. Murphy and Committee Counsel during the mark-up, according to the CBO the law will lead to broader availability of “plans that cover a lower share of health care costs,” and “that individuals’ cost-sharing payments, including deductibles, in the nongroup market would tend to be higher than those anticipated under current law.”

That’s clear. If plans cover less and prices go up, the concept of “parity” won’t mean tomorrow the same thing as it does today. Plus, if the Essential Health Benefits are fully repealed in the future as they are in the Medicaid program through the AHCA, then many insurance products might not contain behavioral health benefits at all.

While the AHCA does not repeal protections for individuals with pre-existing conditions, it does include a continuous coverage penalty. That’s inconsistent with our position that people are harmed by making it harder for them to maintain continuous insurance coverage.

And finally, Medicaid is cut – big-time – through a major shifting of costs to states.

So, what should be done to fix these flaws?

Here are three recommendations that flow naturally from what sponsors intended in crafting the AHCA. 

First, let’s make sure that the dollars that remain are used for their intended purpose. For example, giving $8 billion in new short-term Medicaid funding to non-expansion states could help get more people with behavioral health needs the care and services they need, but only if states are obligated to use these dollars for that purpose, and not just to balance their budgets. 

Second, let’s recognize the importance of early intervention across the board. The only reason insurance costs in the nongroup market will go down is because the AHCA is incentivizing younger, healthier people to purchase insurance. The Medicaid program should offer similar incentives to states to enroll eligible individuals at the earliest stages of their illnesses and move them along pathways to recovery well before Stage 4. And Congress shouldn’t be trying to save money by eliminating prevention funding, yet again, as the AHCA does.

Third, states – who will receive billions of dollars less from the AHCA than they would from existing law – must be given greater much greater flexibility through AHCA to use their Medicaid dollars for social support services for their future Medicaid populations. But the AHCA could go a step farther. It could incorporate everything we’ve learned from past successful waivers – which, by definition, all saved money while improving care, services, and supports – and build them into the new Medicaid program rules.  

Otherwise, everyone loses.  

Congress has a long way to go to make this AHCA right, and if it is going to move forward it should get there as soon as it can.