Once again, the Trump administration’s efforts to undermine the Affordable Care Act (ACA) are threatening to reverse progress made toward addressing the nation’s opioid woes.
Last week, the administration announced it would not defend the ACA against a lawsuit filed by conservative states, and the Justice Department filed a brief asking a federal court in Texas to throw out the individual mandate to buy insurance, along with popular provisions preventing insurers from denying or charging more for coverage based on pre-existing medical conditions, including opioid use disorders.
About 130 million Americans who are too young to qualify for Medicare have a pre-existing condition, including an estimated 1.9 million living with an opioid use disorder. Despite efforts by Congress public health leaders to expand access to treatment in response to an epidemic of deadly overdoses, only a fraction of people living with an opioid disorder receive treatment for the disease.
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The Trump administration’s decision not to defend a law on the federal books is rare and clearly politically motivated, even as polls show that the ACA’s pre-existing conditions provision is popular among voters. Republicans in Congress threw out the individual mandate penalty with their recent tax overhaul, giving Texas and 19 other states the green light to file a lawsuit claiming that the ACA is unconstitutional.
The Affordable Care Act required insurance plans to start covering specific types of addiction treatment and prevents insurers from denying coverage because a patient has received treatment for opioid dependence in the past. That means both people who are seeking treatment for opioid disorders and those who have successfully completed treatment could be denied health coverage if the White House and its allies are successful in their campaign to dismantle key parts of the ACA.
Only 21 percent of people covered by private insurance and living with opioid dependence received treatment in 2016, according to a recent survey by the Kaiser Family Foundation. People living with opioid disorders and covered by the Medicaid program, which was greatly expanded across the country under the Affordable Act, were twice as likely to receive treatment.
Several factors can explain this treatment gap, including the sheer cost of treating opioid disorders, which may require special medications or taking time off work for inpatient treatment. Kevin Fiscella, an opioid addiction specialist and professor of public health at the University of Rochester, said private insurance plans have appreciable deductibles, co-payments or co-insurance that can create “financial barriers” to addiction treatment.
Despite ACA requirements, a 2016 study found that the costs patients pay out-of-pocket for drug treatment can vary depending on how insurance providers comply with state rules. Out-of-pocket costs are often lower for those covered by Medicaid, according to Fiscella.
“Engaging more people in treatment will require reducing cost-related barriers to treatment,” Fiscella said in an email to Truthout in April. “I don’t think current policy has yet come to grips with this simple fact.”
The social stigma around living with an addiction and seeking help from a doctor may also prevent people living with opioid use disorders from seeking care. The ACA requires insurers to screen for substance use disorders, and if they began rejecting coverage for people who have a history of opioid misuse, this powerful stigma could be easily reinforced.
Advocates have worked for years to expand health coverage for substance abuse and mental health problems, which often go hand-in-hand and have long been surrounded by stigma. Altha Stewart, president of the American Psychiatric Association, said the Trump administration’s decision not to defend the ACA’s patient protections is “very short-sighted” considering that the nation is “in the midst of an opioid epidemic and a 30 percent rise in suicide rates.”In some cases, treating opioid addiction can take years and several attempts, and insurers are already wary of covering people living with opioid use disorders. Many insurers already place authorization requirements and other restrictions on buprenorphine and other addiction medications, and a 2016 survey found that 56 percent of doctors said their patients had trouble accessing medication for opioid disorders despite having insurance coverage.
“We call upon the administration to reverse this decision and defend the rights of our patients,” Stewart said in a statement last week.
The Trump administration has worked tirelessly to undermine the ACA since Republicans in Congress failed to repeal it last year. The White House has also said that addressing the opioid overdose epidemic is also a priority, but much of its efforts have focused on prevention and law enforcement rather than providing people with the medical treatment they need.
If the courts decide to throw out the ACA’s provisions for pre-existing medical conditions, the Trump administration would come under serious pressure to replace them with new protections for people with opioid disorders and many other conditions.