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Continue to Stand for Clients and Behavioral Health Care
By Nina Marshall, MSW

The American Health Care Act (AHCA), the health care repeal legislation recently introduced by House Republicans, had its day in court. Why should social workers care about the outcome, or about future health care legislation, for that matter?

The AHCA would have made it far more challenging for us to fulfill the promise of our Code of Ethics, and the bill's supporters in Congress and the Trump administration may try again to limit access to mental health and addiction services. The Affordable Care Act (ACA) and Medicaid expansion have allowed us to connect our clients to the health care resources they deserve and need. Undermining the ACA and reducing Medicaid expansion would send us backwards, which is something our clients cannot afford—nor can we.

From Gains to Losses
Changes proposed within the AHCA were in direct opposition to the social workers' primary mission "to enhance human well-being and help meet the basic human needs of all people." How can we support a plan that limits access to health care for the most vulnerable?

Social workers are committed to social justice and social change, as well as working to end oppression and poverty through community organizing, advocacy, policy development, and implementation. We're also charged with promoting responsiveness to our clients' specific needs and social problems, including access to health care.

It makes no sense to retreat when we're in the beginning stages of successfully expanding access to treatment for people with mental health and addiction issues. That's thanks to benefit gains under the ACA, particularly for Medicaid and people in the individual and small group markets.

Social workers believe health care is a basic human right. People with insufficient access to health care risk destabilization of other crucial aspects of their lives, especially when things go awry. Per the Kaiser Family Foundation (2016), medical debts contribute to almost one-half of all bankruptcies in the United States. The uninsured are more at risk of falling into medical bankruptcy than people with insurance.

Medicaid Needs Aid
The inherent restructuring of Medicaid would result in a backsliding of benefits for our clients, jeopardizing gains in coverage and access to mental health and addiction care. Americans with mental health and substance abuse issues stand to lose a lot if Medicaid is restructured.

The AHCA would have put the lid on federal funding for more than 74 million vulnerable citizens presently covered by Medicaid. It also would have jeopardized coverage for 11 million adults who became a part of Medicaid because of the expansion (Paradise, 2017). Additional ramifications include the following:

• Researchers from Harvard and New York University estimate that repealing the Medicaid expansion would cut $4.5 billion from mental health and substance use treatment for low-income persons.
• Nearly 30% of people who now have health insurance coverage through the Medicaid expansion have either a mental or substance use disorder or both.
• Many states with the highest opioid overdose death rates have used Medicaid to expand access to medication-assisted treatment; for example, in Kentucky, Maine, Pennsylvania, Ohio, and West Virginia, Medicaid pays for between 35% and 50% of all medication-assisted treatment.
• States hardest hit by the opioid epidemic would be at greatest risk for coverage reductions if the Medicaid expansion were repealed.
• The AHCA would have converted Medicaid into a per-capita cap, meaning states would have had to bear 100% of any costs that exceeded the block grant or caps. This would be an about-face, since, under the ACA, the federal government guarantees matching funds to states for any qualifying Medicaid expenditures.

So, we'd be right back where we started, which would be bad for social workers and clients alike. No one should be without access to health care.

What You Can Do
The policies introduced in the AHCA would have sent us two steps back after we've taken one big step forward to achieve higher-quality care for mental health and substance abuse. Although the AHCA is dead, social workers must continue to urge legislators to protect behavioral health care. The following are some suggestions:

• Start by contacting your legislators. There are several ways to do this. Visit usa.gov/elected-officials for a list of instructions for contacting elected officials. You can also call the US Capitol Switchboard at 202-224-3121 and ask for them by name. Request a meeting using a template available in the National Council for Behavioral Health's "A Handbook for Advocates" (thenationalcouncil.org/wp-content/uploads/2017/03/AdvocateHandbook-v9.pdf). Feel more comfortable writing? A letter template can be found at http://www.thenationalcouncil.org/policy-action/unite4bh/. What should you say? Thank your legislator if they opposed the AHCA, remind them how important it is to their constituents that we expand access to mental health and addiction, and ask them to keep this in mind during future discussion on health care legislation.
• Urge your employer to get involved in advocacy. Share this article with your supervisors and your peers. There is strength in numbers.
• Submit an op-ed to your local newspapers. Tell readers why you believe access to health care for those with mental illness and addictions must be protected. When you write, try to put yourself into the editorial. You have personal and professional reasons why you're worried about what might happen. Readers relate very well to shares of emotion skillfully combined with facts.

Why You Should Do It
Social workers are charged with promoting the general welfare of society. We are encouraged "to advocate for living conditions conducive to the fulfillment of basic human needs." The voices of social workers must rise above the fray to protect our clients now and in days to come. Do not let up on efforts to protect your clients' access to behavioral health care. Remain vigilant—as regressive legislation may be introduced again—and amplify the voices of those who would be affected by cuts to health care.
— Nina Marshall, MSW, is senior director of policy and practice improvement with the National Council for Behavioral Health.
References

Henry J. Kaiser Family Foundation. (2016). Key facts about the uninsured population. Retrieved from http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population.

Paradise, J. (2017). Restructuring Medicaid in the American Health Care Act: Five key considerations. Retrieved from http://kff.org/medicaid/issue-brief/restructuring-medicaid-in-the-american-health-care-act-five-key-considerations.