'Repeal and Replace' Could Make Addiction Treatment Unattainable for Most Americans

The situation with healthcare reform is dire. It is estimated that as many as 18 million people could lose their health insurance if the Affordable Care Act is repealed. People struggling with substance use or addiction will be hit hard. If high risk health pools, which exist to provide insurance for people who are considered un-insurable, are re-established, it is almost certain that most addicts will find themselves unable to afford the kind of treatment they need. Even people who have been in recovery for decades could find themselves with limited access to healthcare, because addiction is considered a pre-existing condition.

The President’s address to Congress and the nation this week did little to reassure millions of Americans about his promise to “repeal and replace” the Affordable Care Act. The changes proposed by Republicans will likely not make insurance either more affordable or more accessible.

Pre-Existing Conditions

One vital part of the Affordable Care Act was that it eliminated “pre-existing conditions.” A pre-existing condition was defined as any past or current healthcare problem that you received medical treatment for. That sounds benign, but prior to the ACA it was used by insurance companies to deny coverage. If you have had cancer in the past, for example, you were a “high risk” candidate and could be denied coverage. If you are clinically obese (and in some cases, even overweight), like one-third of Americans, you can be denied health insurance. Any history of substance abuse treatment, or even a diagnosis in your medical records, would automatically be reason to deny insurance coverage. State high-risk pools, which tend to be prohibitively expensive and provide limited benefits with high deductibles, would be your only remaining option for health care.

Additionally, people with pre-existing conditions can get permanently locked out of the regular insurance system. For example, if you have insurance through your job and you are struggling with an addiction, you can get treatment through your plan. Your benefits may cover detox, residential care, outpatient services, a psychotherapist, a pain control specialist, and possibly even acupuncture or massage. That’s how we expect insurance to work. It’s supposed to be there to help you when you need it. But, if you lose your job and you do not buy COBRA (a continuation of benefits) or find a new job with insurance that kicks in within 90 days, you will only be able to purchase insurance through a state high-risk health pool. If the insurance is too expensive in that pool and your coverage lapses, it is impossible to get back into the regular system. The result is that people get locked into jobs they don’t want, cannot start their own businesses because they and their family depend on the health insurance provided by the employer, or simply cannot afford coverage.

Coverage Caps

Before the Affordable Care Act, there were lifetime limits on the amount of money an insurance company had to spend to keep a person healthy or alive. The Affordable Care Act did away with those limits. For example, if you have a child with a rare medical disorder, you could potentially blow through a coverage cap before your child turns five! Or suppose you were in a fire and needed reconstructive surgery over the course of years, or you’re young and you beat cancer at an early age. All of these types of problems could leave a person without access to health insurance.

Further, insurance plans have negotiated lower rates for services than an individual might receive. If you’re dealing with a hospital or large medical group and you pay cash, you’ll generally pay more for services than if you had insurance.

The Participation Mandate

How could all these people who have pre-existing conditions or exceeded coverage caps be paid for under the Affordable Care Act? The ACA required everyone to have health insurance or pay a penalty. So young and healthy people have to pay into the system even though they may not need it, not just draw on it once they are injured or ill. The plan works very much like Social Security: the money we currently pay into Social Security isn’t sitting there in an individually marked account waiting for us to use it. It provides the money for people who receive Social Security checks today. Without the participation mandate or moving to a single payer system, the cost of premiums will be too much for most people to afford.

Health Care Savings Accounts

The President and Republican leaders suggest replacing the Affordable Care Act with health savings accounts. HSAs are savings accounts into which you deposit pre-tax dollars. Those funds can then be used to pay for medical expenses.

But they don’t work. Most Americans can’t set aside enough money to fund a true medical emergency or serious illness because the cost of medical care is prohibitive. Healthcare is already a leading cause of bankruptcy in America. Average family income in the US is a little over $73,000 a year. At this salary, if a family deposited $5,000 a year, they would have no problem covering a broken leg, which without surgical treatment can cost about $2500. Cancer, however, can cost anywhere from $20,000 to over $100,000 for the first round of treatment. One year of methadone maintenance runs just under $5000. Residential drug treatment, outpatient, sober living, psychotherapy, and other evidence-based treatments, without insurance, will be beyond the reach of the average American family.

Activism Provides Hope

Congress is listening to the outcry from around the nation about saving our health insurance. The people who have perhaps the finest health insurance plan in the nation are poised to remove our insurance from us. But activism is working. Continue going to town halls and writing and calling your representatives. Demand that we retain our healthcare. At the same time, lobby your state to take action on the state level. With the IRS stating that it will not enforce the participation mandate, we have to be proactive to ensure that those who need medical care will receive it.