No longer “essential”. What does this mean for the mental and behavioral health of Americans?


No longer "essential"

What does this mean for the mental and behavioral health of Americans?

The American Health Care Act (AHCA) may reduce the availability of mental health, substance use, and behavioral health treatment and services. AHCA provisions will allow states and businesses to opt out of providing these services at an affordable cost, leaving many Americans to go without coverage for their mental and behavioral health needs. Mental health-related issues have been found to account for more than 217 million work days lost, as well as cost society $193.2 billion annually in lost earnings alone. Spending money on mental health, substance use, and behavioral health treatment and services is an economically sound strategy, essential for creating a thriving workforce, economy, and society for all Americans.


We’ve all read the headlines: the American Health Care Act (AHCA), which is now in the hands of the Senate, is the administration’s vision for healthcare in the United States. While the AHCA has implications across all types of health conditions, we will focus here on one area in particular: mental health. Before we dive into what the AHCA proposes about mental health care, let’s quickly review what our coverage under the Affordable Care Act (ACA) currently grants us.


The current state of mental health coverage under the ACA

It’s estimated that 11 million Americans whose incomes are 138% below the federal poverty level (FPL; 2017 FPL $12,060 for individuals) can now receive coverage for mental health and substance use disorders (SUDs). This substantial increase in coverage is due in part to the Medicaid expansions provided by the ACA, which the Department of Health and Human Services (DHHS) called “one of the largest expansions of mental health and substance use disorder coverage in a generation”. In brief, this expansion re-categorized mental health and SUDs in the Health Insurance Marketplace, moving them to the “Essential Health Benefits” category. Under the ACA, this category requires state coverage on all Qualified Health Plans for those health benefits deemed “essential”. Insurance jargon aside, what does this mean? The quick answer – the Essential Health Benefits category allows millions of Americans access to affordable mental health, SUDs, and behavior health services.


Mental health coverage under the AHCA

The AHCA would remove the very federal requirement discussed above; under the AHCA, mental health, SUDs, and behavioral health services would be removed from the list of Essential Health Benefits. What would be the consequences of this removal? In terms of Medicaid and individual market coverage, health plans could completely drop coverage related to these services. For employer-sponsored plans, larger corporations could also decrease benefits in these areas, providing only the minimum required. Under another AHCA provision, Medicaid would be restructured to have per capita caps by state, meaning payments to states would be capped based on the number of people enrolled in their Medicaid programs. The Congressional Budget Office estimates that $882 billion will be stripped from the Medicaid program over the next 10 years under the AHCA.


Taken together, how will these cuts in coverage impact Americans? Serious mental illness and SUDs are very costly (e.g., estimated $131 billion spending on those with behavioral health diagnosis, close to half of Medicaid spending in 2011). Those with schizophrenia and bipolar disorder alone have a per capita spending of greater than $35,000 per year. In Washington state, intensive outpatient evidence-based practices cost an average of $5,679 per client, ranging from $1,238 per client for Dialectical Behavioral Therapy to $15,788 per client for Multisystemic Therapy. Ask yourself, with the proposed changes to mental health, SUDs, and behavioral health services coverage, can the clinical needs of all Americans still be met under the AHCA?


What are the consequences of no coverage for mental health?

Now that we have a clear picture of the differences in how mental health and SUDs will be (or not be) covered under the AHCA, we can discuss the societal impact of these changes. Specifically, what is the economic impact of NOT covering these kinds of services? There are various levels used to assess the economic impact of illness. The first we have already discussed: the direct costs, which involve the actual medical expenditures produced by the illness. There are also indirect costs associated with illness, which encompass individual or societal costs incurred due to reduced or lost productivity. Under the AHCA, employers are able to reduce enrollment and/or benefits, which will produce indirect effects on the economy and society at large. Next we will explore what those indirect costs are specific to mental health and SUDs.


How will the AHCA change the American workforce?

What comes to mind when you begin to think about the indirect costs of health care? We will focus here on two of the most salient costs: productivity loss (i.e., hours worked) and lost earnings. According to the National Institute on Drug Abuse (NIDA), those with alcohol or drug abuse accounted for an estimated $80.9 billion in lost productivity alone. Add workplace accidents and increased health-care and insurance costs to the mix and this number spikes to $276 billion lost. The Center for Prevention and Health Services estimates 217 million work days lost annually due to mental health and SUDs. Furthermore, mental illness and SUDs are the third leading cause of long-term disability in the United States. A study conducted by the National Institutes of Mental Health found that serious mental illness costs society $193.2 billion annually solely in lost earnings. When looking at both productivity and earning losses, the numbers speak for themselves – not investing in mental health has clear indirect costs on the capacity of the American workforce.


How can spending now save later?

We know that not investing in mental health and SUDs is costly to our society, but do we know that investing now can save money down the road? The answer to this question is easy: yes. The Institute of Medicine and the National Research Council found that for each dollar invested in early treatment and prevention programs, a range of $2 to $10 in savings is observed across health, criminal, juvenile justice, and education costs, as well as productivity. To provide a real-world example, when the Massachusetts Department of Mental Health implemented a jail diversion program they observed an initial cost $400,000 offset by $1.3 million savings in emergency health services and jail costs due to program implementation.


In sum, we have explored both the financial and human toll of not investing in mental health, substance use, and behavioral health treatment and services. We have quantified the cost of not caring. Can we as Americans afford to move toward a country where these services are not considered essential?


How can you help?

Are you concerned with how the AHCA will impact the healthcare of all Americans? It is crucial that our senators hear our concerns. Please use this tool developed by Families USA to email your Senators and contact them by phone:

Volunteer: The WA Science-Based Policy Center is a non-partisan, statewide organization started by the March for Science – Seattle, whose mission includes using a scientific framework to identify areas in need of policy interventions and taking a pragmatic, non-ideological, science-based approach to policy solutions. Other activities will involve increasing the scientific literacy of legislators, creating educational material to help increase literacy of the legislative process among scientists, and helping facilitate interactions between scientists and legislators so that we can achieve evidence-based policies.Click Here to sign-up to join the WA Science-Based Policy Center


About the Author: This weeks blog was written by WA Science-Based Policy Center member Caitlin Dorsey. 

Caitlin N. Dorsey is a Midwestern transplant, nearing her first year of living in the PNW. She is a graduate of Indiana University, where she earned a Bachelor of Arts with Distinction in Psychology (with Departmental honors) and Sociology, and a minor in Counseling. Caitlin is an implementation scientist who is passionate about promoting the adoption and integration of evidence-based practices, interventions, and policies. She is a volunteer for the WA Science-Based Policy Center and a member of the Social Issues Policy Group. 




1.      APA Voices Concerns with American Health Care Act:

2.      Federal Poverty Level (FPL):

3.      Affordable Care Act Expands Mental Health And Substance Use Disorder Benefits And Federal Parity Protections For 62 Million Americans:

4.      Implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA):

5.      House Passes AHCA, Puts Mental Health and Addiction Care in Jeopardy:

6.      Obamacare Repeal Seen As Weakening Mental Health Protections:

7.      Research and Evidence-Based Practices for Children and Youth in Washington State:

8.      Economic Impact:

9.      The Impact of Mental Health and Addiction on Economic Well-Being:

10.  The Cost of Not Caring: Nowhere to Go:

11.  The Economic Costs of Alcohol and Drug Abuse in the United States:

12.  Is Substance Abuse Costing Your Company?:

13.  May Is Mental Health Awareness Month -- Here's Why Companies Should Care: