Obamacare Repeal Has the Addiction Recovery Community Nervous – and Here’s Why

“Devastating impact”

A survey of articles across the board concerning the repeal of Obamacare finds oneself confronted with the words “devastating impact,” with uncanny frequency. Mirroring those sentiments New Hampshire’s Democratic Senator Jeanne Shaheen, speaking for a state with one of the highest overdose death rates in the country, noted her concern for an untried president who tweets from the hip and peppers his speeches with divisive terminology.

“He pledged to take on this crisis, not immediately make matters much worse,” Shaheen said in an email. “Repealing the Affordable Care Act without a replacement is highly reckless and will come at a high cost for people struggling with substance use disorders,” she said.

Certainly, by now, it is fair to ask what is the big complaint Republicans have over a massive bill that has had its ups and downs and might have a flaw or two that needs fixing – as any massive legislation would have – but has otherwise provided about 20 million people with insurance that found health care options out of reach in the past.

For starters, in spite of its strengths, Obamacare is not a universal coverage plan. With leading Republicans pledged to oppose President Barack Obama’s every move as of 2010 – that would be Senate majority leader Mitch McConnell, R-Kent., and House Speaker John Boehner – working any bill through Congress at the time was always heavy going for the 44th  president. Besides, Medicaid was already in place and working reasonably well, which meant the gap in coverage – considering well-off Americans could afford their own plan – was made out of those near the bottom of the pile, but not at the very bottom, where Medicaid had already in place.

That meant using a shoe-horn to fit a new program around what was already working without going too far. This strategy could be said to have worked and failed at the same time, because to knit a new law around all the previous holes in the system created a cumbersome, sprawling law that tip-toed around the existing plans. In hindsight, it might have been easier to wipe previous plans off the charts and start anew. But Obama’s team didn’t do that.

As such, they didn’t come up with a simplified universal health care package, which comes in many different forms around the world and is available in many other countries with far less economic security than the United States. The World Health Organization in 2004 published a list of 16 countries that have universal health care. In Europe, just for starters, virtually all countries have some form of universal healthcare, although some plans only cover people who are sick – which coverage for preventative health care options. Still, countries with universal health care plans include Austria, Belarus, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Iceland, Italy, Luxembourg, Malta, Moldova, the Netherlands Norway and nine other countries.

Even Obamacare failed to live up to those high standards, as critically undeserved groups were left out of the deal.

As was noted by FactCheck.org – a project of the Annenberg Public Policy Center – even Democrats would be stretching to truth if they said the Affordable Care Act covered “everybody.” In fact, “tens of millions” were left out of the package for a variety of reasons.

For one, if you didn’t pay taxes you might have been left out of the loop, since Obamacare enforced coverage through the Internal Revenue Service, which meant anyone avoiding taxes or not paying for legitimate reasons could have failed to sign up and gotten away with it. Secondly, millions of non-citizens were ineligible for Obamacare. That would include 13 million foreign-born adults living in the country, as of 2010, and 11.3 million illegal residents as of 2014, using a figure supplied by the Pew Research Center.

If you filed for bankruptcy, you could have been exempt from participating in Obamacare and if the cost of insurance was 8 percent of your household income or higher, you also could have sidestepped the program. Victims of domestic violence were exempt under the rationale that they might have no choice but to leave a household with a more secure income. Death in the family exempted some, as did unpaid medical bills. You were also exempt if your insurance company canceled your plan and if you had insurance for up to 10 months of the year – for some reason dropping coverage for up to two months – the penalty for noncompliance didn’t apply to you.

A number of hardship factors also allowed residents to avoid having to participate, one of those being that if your state was one of those that did not extend their Medicaid benefits under Obamacare and you fell into a category that would have been eligible for subsidized insurance in another state, you were also able to duck out of the program without repercussions. This final category, according to the Kaiser Family Foundation in 2013, would have added another 5 million persons to the list of those unemployed. At that point, 23 states with Republican governors had decided not to move forward with Medicaid expansion.

In total, in a Congressional Budget Office review, the initial 2010 estimate of having 94 percent of the country insured through Obamacare – a figure that did not anyone in the country illegally – was revised in 2014 to 92 percent.

But let’s review that same check list and casually consider whether or not any of that applies to persons suffering from addictions, including drug addictions and alcohol dependence. Is this a group generally more marginalized than the rest of the population? Let’s give that a casual yes. Is this a group where domestic violence runs higher than average? Probably, that’s true. Is this a group that experiences more deaths in the family than others? By definition, yes. Is this a group with unpaid medical bills or a lower than average income? In all likelihood, that is true.

By many measures, the Patient Protection and Affordable Care Act of 2010, commonly called the Affordable Care Act or ACA and nicknamed Obamacare, has made solid, undeniable gains for the general population and, perhaps in perfect unison with gains made in pharmaceutical interventions for recovering addicts, especially in the field of addiction recovery, where untimely death is already an all-too-frequent visitor.

Just as a murderous spree of opioid addictions was coming into its own, Obamacare was taking the bull by the horns, allowing for an expansion of interventions into high-risk populations and pushing for all the correct changes, including an embrace of preventative care that allowed interventions to reach further and deeper into isolated pockets of despair.

In the end, if you looked up the key provisions in the Affordable Care Act, you will find yourself confronting a list of at least 19 of them. These including prohibiting denial of coverage for pre-existing conditions, eliminating variable rates based on gender or medical history and allowing insurance for children to continue under family plans until the age of 26 – provisions so popular that Republicans are now stuck having to retain or replace them should they ever come up with a plan of their own.

And then there are provisions the Republican Party seems to loath, such as a repeal of insurance companies’ exemptions from anti-trust laws, the mandate for purchasing insurance through a government sponsored exchange or face penalties, a 2.5 percent excise tax on medical devices and a 5.4 percent tax on individuals whose adjusted gross income exceeds $500,000 – or $1 million for married couples filing joint returns.

With a self-proclaimed billionaire in the White House, that last provision certainly rankles Republicans, as the nation’s wealthiest 1 percent is set to gain an average of $195,000 per household should the repeal of Obamacare go through – a circumstance that brings irony to new heights when considering complaints from Republicans that Obamacare is too complicated and too elitists. Of course, evoking the elitist card is meant to draw attention to the Ivy League component of President Obama’s administration, rather than the corp of wealthy elitist that makes up President Trump’s cabinet and staff.

Imperfect as Obamacare might be, however, a distinctly elusive number remains at the core of the health care debate, which is how many U.S. citizens will stand to lose the hard-won health insurance that finally came their way thanks to the 2010 ACA.

Various numbers have been bandied about with the latest estimates now showing as many as 22 to 25 million Americans will lose their health insurance with a repeal of Obamacare. That number, according to the bi-partisan Congressional Budget Office, swells to 32 million within 10 years of the law’s repeal, The Washington Post reported.

The numbers change because the goal posts keep getting moved. The 32 million is assigned to “those who will not have insurance,” rather than those who, strictly speaking, had their insurance taken away because of a repeal. So, that includes people who were in line to sign up for Obamacare, rather than those who are already beneficiaries.

That number also assumes that the repeal comes without a replacement policy, although Republicans are working on a two principle alternative versions. One of those versions is a block grant to the states to set up their own insurance marketplaces free from federal meddling and the other is setting up savings accounts as a means of helping people afford health insurance.

GOP Alternative Proves Deadly

As an alternative to the ACA, House Republicans are pushing for the American Health Care Act (AHCA). This piece of legislation, as indicated in speaker.gov, should promote “competition and consumer choice,” and “modernize American health care.”

The following are the main changes to the ACA. First, those with pre-existing conditions should still be allowed to purchase health insurance (a win for Obamacare). Second, parents would be allowed to enroll their children on their insurance until the children are 26 years old (another win for Obamacare). Third, the “individual mandate” paid by those who opt not to have insurance would be repealed. Fourth, enrollment in the Medicaid expansion would freeze in 2020.

While the ACA focuses on everyone paying premiums based on income, the AHCA allows higher premiums based on age. In fact, under the AHCA, someone older can pay a premium up to five times higher than that of someone younger (as opposed to three times under the ACA). This puts a burden on the vulnerable members of society.

The Congressional Budget Office review of the AHCA estimates that within a year, 14 million more people would be uninsured because of the repeal of the “individual mandate,” and the rise in premiums. By 2020, 21 million more would be uninsured because of the lost subsidies for group insurance and the Medicaid enrollment freeze. By 2026, as the Medicaid changes take effect, 52 million would be uninsured.

This is deadly news for those currently battling substance abuse through Obamacare.

States using the expanded Medicaid program would no longer be required to provide coverage for mental health care and substance abuse treatment, beginning in 2020. Enrolling under the expanded Medicaid program after 2020 would also no longer be an option. The 1.3 million patients (according to Harvard Medical School) currently availing of treatment under Obamacare may very well find themselves left without insurance coverage if the AHCA comes into effect.

Ohio, Kentucky, and West Virginia, which have the highest opioid-related deaths in the country and are using the expanded Medicaid program, are already battling the “epidemic” and will only have a bigger problem on their hands. The switch from income-based to age-based insurance programs ensures as well that even with insurance sold at market prices, the premiums may be enough to discourage those who need the insurance from obtaining it.

The conjecture claiming that 40,000 Americans could die if Obamacare were repealed worried many. Nonetheless, without a clear GOP alternative, it could be shrugged off as “exaggeration.” Now that the AHCA has been reviewed, however, the 52 million uninsured by 2026 and the 1.3 million who will lose substance abuse rehab coverage are staring the anti-Obamacare factions in the eye.

With opioid-related deaths outstripping deaths from vehicular accidents and gun homicides, the Medicaid expansion program is a clear and blatant need. The repeal of Obamacare would be felt deeply in the lives of the families and individuals who depend on it. Switching to the AHCA might even prove deadly for those who, suddenly lacking insurance for substance abuse rehabilitation, slip back into the lives they thought they had escaped.