By Daniel E. Dawes (J.D. ’06) Attorney and author of the book 150 Years of Obamacare
The day after the 2016 presidential election, I fought off the urge to cancel a scheduled speech at the University of Nebraska-Lincoln because I was so preoccupied with the reality that President-elect Donald Trump might fulfill his promise to repeal the Affordable Care Act (aka Obamacare). From a health equity perspective, the implications of this election were clear — advocates would now be consumed with fighting to preserve the gains they had made in health policy and law.
The big question was whether opponents of the Affordable Care Act would be able to follow through and successfully repeal the longest surviving health reform law in America, which provided the greatest expansion of mental health reforms.
The protections in the ACA stretch across all geographic, socioeconomic, racial, gender and age groups, all of which have benefited from passage of the law. Indeed, there are several improvements needed that will help solve the primary complaints about the law, including rising costs and premiums. However, this does not constitute a full repeal, rather a bipartisan repair plan.
The ACA provides protections not only for a family’s primary care and preventive care, it goes deeper into tackling some of the country’s most pressing issues: namely, the opioid epidemic and mental health services.
In Chancellor Ronnie Green’s State of the University address in September he noted the increased mental health needs of the university community, particularly students, as one of the significant challenges facing UNL.
Mental health issues are not new nor is the attempt to include them as an essential benefit in health insurance — actually, it’s about 150 years old. My book, 150 Years of Obamacare, chronicles the tireless efforts of mental health champions like schoolteacher Dorothea Dix who assiduously labored to increase access to and improve mental health services in the United States. In 1854, after much work from Dix and other advocates, Congress passed The Bill for the Benefit of the Indigent Insane, which was promptly vetoed by President Franklin Pierce. Afterward, the federal government managed to only address mental health policy issues in piecemeal fashion until President Jimmy Carter signed a mental health act into law in 1979. Unfortunately, he lost the election and President Reagan set about dismantling many of the achievements of the Carter administration, including the comprehensive mental health reforms.
In the decades that followed, the federal government passed and implemented additional piecemeal legislation aimed at increasing parity between mental health/substance use disorders and physical health. However, it was not until the passage of the ACA that, for the first time in American history, mental health and substance use disorder benefits were mandated as an essential health benefit along with rehabilitative, habilitative, and prevention and wellness coverage.
Each year an estimated 44 million Americans experience mental health conditions. For the first and longest time in history, many with mental health and substance use issues now have access to behavioral health services, support and treatments. This is especially critical in light of the fact that behavioral health has a 40 percent impact on one’s overall health status and is a growing area of interest in public health, particularly for many communities challenged by the opioid epidemic.
Today, opioid addiction is the leading cause of death for individuals under the age of 50 and one in five individuals struggling with this issue are unable to obtain care. Additionally, major depressive disorder is one of the most prevalent mental health problems in the United States that is associated with considerable impairment in functioning, and it affects approximately 16.1 million adults annually. In the next 20 years, depression will be the leading cause of disability worldwide, including the United States.
The Affordable Care Act is the longest surviving health reform law in America, providing the greatest expansion of mental health reforms. It extended parity protections and expanded civil rights protections, required that behavioral health be a priority in comparative effectiveness research, promoted the integration of behavioral health and primary care, included depression and substance use screenings as preventive services at no cost to the consumer, expanded school-based health centers offering mental health and substance use services, and provided other opportunities for behavioral health outreach and education campaigns.
In the face of strong evidence showing that repealing the ACA would jeopardize health care access and protections for millions of Americans, Democrats and Republicans should continue their efforts to repair the ACA to help stabilize the markets, ease the financial burden on Americans, and advance health equity nationally. Being able to access and afford mental healthcare is a right, not a privilege.
Views expressed do not necessarily reflect the official position of the University of Nebraska.