By Ashley M. Casey
Staff Writer
Within hours of taking the oath Jan. 20, President Donald Trump signed his first executive order to begin dismantling predecessor Barack Obama’s signature piece of legislation: the Affordable Care Act.
While Trump’s executive order largely deals with easing economic and regulatory burdens of the ACA, the executive order does not specify which ACA provisions will go, and Trump’s administration has not proposed a replacement option. In the meantime, consumers of mental health services are bracing themselves for parts or all of “Obamacare” to be repealed.
“Disinvestment in mental health, alongside with the already existing challenges of accessing affordable treatment, will place far too many people at risk for death,” Chirlane McCray — author, activist and wife of New York City Mayor Bill de Blasio — wrote in an op-ed for Cosmopolitan. “Without adequate care, our jails and prisons will see even more people with mental illness and substance misuse problems come through their doors.”
Lacey Roy, a member of the board of directors for the Syracuse chapter of the National Alliance on Mental Illness (NAMI), said she fears losing coverage for the hospitalizations and medications she needs to treat her bipolar disorder.
“My meds that keep me able to contributing to society in a positive manner retail for $3,000,” she said.
Obamacare has improved Roy’s access to coverage by removing restrictions on insurance for people with pre-existing conditions and lifting limits on how much an insurance company will pay out in a person’s lifetime.
“The amazing part that differed from private insurance in the past [was] they didn’t ask about health conditions, what meds I was taking,” Roy said. “It was purely based on income — nothing on existing health, which was my concern. Obama put in place that we couldn’t be discriminated against.”
Roy said if protection for those with pre-existing conditions is removed, that discrimination will return.
“The fact that my brain doesn’t work the same as someone else’s, I feel like I’m getting punished,” she said. “Ninety-five percent of mental illnesses are physiological. There’s chemicals in my brain that don’t work. Why is insulin covered but my meds aren’t?”
Reworking reimbursement
Since bipolar disorder is chronic and incurable, Roy said she is also afraid that lifetime caps on coverage will limit her ability to afford her medication, or prevent her from being able to pay for other health expenses.
“I’m looking at the next 40 years living with it,” she said. “What am I supposed to do … if my arm falls off or I have diabetes or even cancer?”
Dr. Miranda Mohabir, a psychiatrist who runs a private practice in Manlius, said the ACA has helped save money for people with chronic conditions, like Roy, and has helped improve reimbursement for hospitals and emergency rooms that were losing money on treating patients without insurance.
“I think that’s partly why Obama did this, so they would get reimbursed and to keep them running,” Mohabir said.
Roy said she is sympathetic to the plight of health care providers, who could see their profits drop if the federal government changes the way providers are reimbursed.
“The way that they want to pay the physicians and the providers but also reimburse the states for their portion of it is going to reduce the incentive physicians have to treat and be patient with people with a recurring illness,” she said. “It’s going to look better for numbers and profit to treat a ‘one and done’ case. … They have bills to pay. They have to keep their lights on, but if it’s no longer profitable what are they supposed to do?”
Roy, who recently lost her private insurance coverage when she left her job in the financial sector, applied for Medicaid to “get ahead of Trump.” That does not ensure the safety of Roy and the 80 million Americans who rely on Medicaid: House Speaker Paul Ryan and Tom Price, Trump’s pick for Secretary of Health and Human Services, both support changing Medicaid funding “from a defined benefit to a block grant or per capita cap program,” according to The Hill. Instead of guaranteeing benefits to each Medicaid client, the federal government would allocate a fixed amount for each state to divvy up among its Medicaid beneficiaries.
Carolyn Hodges Chaffee, CEO of the Upstate New York Eating Disorder Service (UNYED), said changes to Medicaid eligibility under the ACA expanded access to care for lower-income patients.
“Before the ACA, there were fewer managed Medicaid programs available,” Chaffee said. “There were more managed Medicaid plans so that opened up access to care. … We can actually provide better care for those individuals than those that are insured. It’s a plan that affords them full coverage with very little if any out-of-pocket [expenses].”
Mohabir said more of her patients were able to get insurance coverage under Obamacare, which took effect in 2010. She said many young people benefited from the extension of parents’ insurance benefits to age 26.
“I thought that was helpful for kids right out of college [who] couldn’t get jobs right away and get coverage,” Mohabir said.
“The increase to age 26 — that’s been a godsend to everybody,” said Chaffee, adding that many UNYED patients are in their late teens or early twenties.
Roy noted that the extended age provision is especially helpful to people struggling with mental illness.
“Many mental illnesses manifest themselves in your early 20s when you’re still under your parents’ insurance,” she said.
Downsides of Obamacare
However, the ACA has not been a boon to all mental health consumers. Both Chaffee and Mohabir said the law has negatively affected businesses and people who are covered under health plans through their employers.
“People ended up with much, much higher deductibles on plans that were reasonable before,” Chaffee said. “Many of the plans, in order to control their overall costs, limited it to in-network providers only, which is a very limiting factor because many clinicians that treat eating disorder patients don’t necessarily participate [in those insurance networks].”
Chaffee said reimbursement rates have fallen for some clinicians in private practice. Mohabir said that was the case for a few of her patients’ plans, but not all.
“With some of the plans that were free, the reimbursement rates were lower, but it didn’t make a difference overall,” Mohabir said, adding that 80 percent of her patients are covered by Excellus BlueCross BlueShield.
Mohabir said some of her patients remain uninsured because they would rather pay the penalty for not having coverage, which is 2.5 percent of the household’s income or $695 per adult and $347.50 per child, whichever is higher.
“It’s still much less than premiums,” she said.
Chaffee said the federal government also has no real way to enforce the penalty.
Chaffee said employers have taken a hit, as well, as their insurance costs skyrocket.
“In the last two years, my premiums went up 37 percent,” she said, “and it’s not as good of a plan.”
“Insurance was still unaffordable, especially for small businesses,” Mohabir said.
New Yorkers could be safe
Whatever happens with Obamacare, most mental health consumers in New York state likely will keep their coverage. Deborah Fasser, a spokesperson for the New York State Conference of Blue Cross Blue Shield Plans, said Timothy’s Law, which was passed in 2006, “requires that fully insured health plans sold in the state provide comparable coverage for mental health ailments as it does for medical benefits.”
While Timothy’s Law only applies to large group policies used by businesses with 51 or more employees, those on smaller plans may still find protection, thanks to the 2008 federal Mental Health Parity and Addiction Equity Act.
“It extends comparable protections of mental health coverage to the individual, small group markets and self-insured market, which are only governed by federal law. It also adds substance abuse parity for all coverage,” Fasser said. “With this said, a repeal of the ACA would impact in New York only individual and small group plans. Nevertheless, we are confident that Congress will preserve both mental health and substance abuse parity as part of their ‘repeal and replace’ actions.”
New Yorkers also may benefit from the state’s participation in a two-year, eight-state program that seeks to “integrate community-based physical and behavioral healthcare services and promote access to improved primary care, mental health, and substance-use disorder services,” according to a Jan. 20 release from the New York State Office of Mental Health.
Syracuse Behavioral Healthcare has been chosen as one of the pilot sites for the program, which seeks to develop 13 Certified Community Behavioral Health Clinics (CCBHC) across the state.
“This funding is critical to addressing the heroin and opioid epidemic impacting Central New York. For far too long, our community has faced a shortage of treatment facilities. Sadly, many individuals suffering with addiction are currently unable to receive the comprehensive care that they need,” Rep. John Katko (R-Camilus) said of the CCBHC program. “I look forward to continuing to work alongside Gov. Cuomo and state and local officials to combat this scourge and to support Syracuse Behavioral Health in this new endeavor.”
New York joins Minnesota, Missouri, New Jersey, Nevada, Oklahoma, Oregon and Pennsylvania in the initiative, which is administered by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Medicare and Medicaid Services (CMS).
Despite the flurry of fears over potentially losing coverage, there is still no telling which parts of the ACA will stay and which will go.
“We’re in a wait-and-see situation,” Chaffee said. “I’m just hoping that the correction comes with high deductible plans and managed Medicaid plans stay the same.”
Chaffee said she thinks the protection for those with pre-existing conditions will stay, which certainly is on Roy’s wishlist.
“I don’t want to be an extremist by any means, but I don’t think people realize that the life that I know could be gone rapidly,” Roy said. “It’s not just health insurance — they’re lives.”
