Seven years ago, if Tricia Howe wanted to get a client into substance abuse or mental health treatment, it took a herculean effort.
Howe is a substance use treatment supervisor at REACH, which provides mental health and substance abuse services to homeless and low-income people.
Before the Affordable Care Act, anyone seeking treatment would have to go to the Department of Social and Health Services, get a psychiatric evaluation, a medical evaluation and be deemed “disabled” before they would qualify for Apple Health, Washington’s insurance for low-income people.
Then, if the person was battling addiction to heroin, for instance, they would be put on a waiting list for a referral to a methadone clinic. Not treatment, just the opportunity to stand in line for it.
A substance abuse disorder alone was insufficient to receive care, and the person would have to demonstrate that their disability was unrelated to their addiction. Substance abuse was treated as a “moral issue,” Howe said.
The Medicaid expansion, which Washington embraced, extended coverage to more than 600,000 people in the state who previously couldn’t receive it and made the program income-based, meaning a person making 138 percent of the federal poverty level or less could qualify.
It could take up to a month to get a person into treatment, even if they successfully jumped through the hoops. That left a lot of time for a person to fall back into their addiction or for REACH to lose track of them if they were homeless or unstably housed.
The passage of the Affordable Care Act changed that.
The Medicaid expansion, which Washington embraced, extended coverage to more than 600,000 people in the state who previously couldn’t receive it and made the program income-based, meaning a person making 138 percent of the federal poverty level or less could qualify.
Between 30 and 50 percent of the clients at REACH that couldn’t get Medicaid before suddenly qualified, the organization estimated. The number of treatment slots expanded and people began getting care quickly, sometimes an immediate referral.
“It’s 1,000 times better than before Medicaid [expansion],” said Chloe Gale, the program director at REACH.
Today, many of the gains that came out of the Affordable Care Act, colloquially known as Obamacare, are at risk. Candidate Donald Trump ran on a platform that promised to “repeal and replace Obamacare,” although details beyond that catchphrase were scarce.
One thing he asserted consistently was that the new health care plan would be better coverage at a lower cost and every American would get health care.
“Believe me,” he said, ad infinitum.
The first bill to pass the House to replace the Affordable Care Act, the American Health Care Act, spawned from the brain of House Speaker Paul Ryan (R-Wisconsin) and supported by Trump, proved those words to be empty.
It’s impossible to know exactly what the bill, which passed the House on May 5 before stalling on its way to the Senate, would do. That’s because the Republicans forced a vote on the measure before it received a score from the Congressional Budget Office (CBO), the nonpartisan office in the government responsible for estimating the impact of legislation.
The new CBO score is expected to come out May 24, but a previous version of the bill would have kicked 24 million Americans off of health insurance between 2017 and 2026, and raised premiums on older, poorer people by almost 750 percent. Eventually care would get cheaper, but only after the poor, elderly and sick patients disappeared from the rolls.
The American Medical Association called it “critically flawed” and a group of seven hospital associations sent a letter to Congress demanding that they change the law.
Locally, Harborview Medical Center estimated that the previous bill, as formulated, would cost the hospital $627 million over a decade.
“In addition to adverse financial impact, you can only imagine the dramatic impact it will have in the health of those we serve,” said Paul Hayes, executive director of the hospital.
While the full impact is difficult to know, pieces of the plan — such as allowing insurers to charge more for people with pre-existing conditions and a plan to cap Medicaid payments — would have a devastating effect on people who are sick or would have difficulty affording care. The harm would be even more dire for women, who were routinely charged more for health care than men before the passage of the Affordable Care Act.
The costs are real.
According to an analysis by Consumer Reports, filings for personal bankruptcy plummeted after the Affordable Care Act passed. In 2010, 1,536,799 people filed for personal bankruptcy compared to 770,846 in 2016, and bankruptcy and legal experts interviewed for this piece point to the fact that fewer people racked up health care costs that they could ill afford.
It’s hard to envision a world in which those numbers stayed the same or improved if programs like Medicaid, which help the poorest, get cut. If the government had capped the Medicaid program in 2004, like they suggest under Ryan’s Plan, Medicaid dollars flowing from the federal government to states would have been cut by $17.8 billion in 2011, according to a report by the Brookings Institution, which attempted to use past spending to estimate the impact of the bill.
That’s 11 percent of total state Medicaid spending, and the costs are not spread evenly.
Thirty thousand people would lose access to substance abuse treatment, and 20,000 cancer patients would see their care disrupted. In a state where 98 percent of all long-term care dollars for the elderly are matched with Medicaid funds, the impacts on the elderly would be severe.
To maintain current levels of spending, one state would have to increase its Medicaid spending by 77 percent, and eight more would see jumps of up to 25 percent.
In a letter to Sen. Patty Murray, D-Washington, Gov. Jay Inslee and Washington Insurance Commissioner Mike Kreidler said that the state would have to come up with $1.3 billion in 2023 and $2 billion in 2028 to keep people who currently receive insurance through Apple Health on the plan.
Thirty thousand people would lose access to substance abuse treatment, and 20,000 cancer patients would see their care disrupted. In a state where 98 percent of all long-term care dollars for the elderly are matched with Medicaid funds, the impacts on the elderly would be severe.
“This ill-conceived legislation would have devastating consequences for the health and well-being of the people of our state; it would hurt our economy and cripple our state budget,” Inslee and Kreidler wrote.
Rachel Diaz, a substance abuse specialist at REACH, described a client who had insurance through the Veteran’s Administration until he lost his appeal of a dishonorable discharge and was stripped of care. The man, who struggled with substance abuse issues, was kicked off of his methadone treatments, lost his housing and began using again.
It was only when he went to prison that he was able to get health care and stabilize. Because of the Affordable Care Act, he got back onto Medicaid when he was released. His condition improved, and he was able to stay in treatment.
“This wouldn’t have happened,” Diaz said, without the Affordable Care Act.
Ultimately, the future of health care in this country rests on members of Congress in both houses, and on the government’s ability to come up with a plan without causing further instability in existing insurance markets. Sarah Kliff, a health care policy writer at Vox, reported in April that the uncertainty is spooking insurers, who aren’t sure if they will sell certain products in 2018.
Until the national situation becomes clear, health care professionals, insurance providers and governments have no choice but to wait and watch.
One thing is definite, Howe said. If access to health care reverts to a pre-Affordable Care Act condition, the costs won’t go away, they’ll just move.
“They’re saying, ‘We don’t care about poor people,’” Howe said. “Those are the people who are expendable.”
Ashley Archibald is a Staff Reporter covering local government, policy and equity. Have a story idea? She can be can reached at ashleya (at) realchangenews (dot) org. Twitter @AshleyA_RC
Read the full May 24 issue.
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