Why Counties Oppose ACA Repeal — Behavioral Health
Counties are often the largest treatment providers for mental and substance use disorders which are already under-resourced in this country. ACA repeal would strain local budgets and cut critical care.

This is Part 2 in a series. You can find Part 1 on protecting the federal, state, local Medicaid partnership here.
The story of behavioral health in this country is two steps forward, two steps back. Congress seems to understand that there is a problem and there’s genuine bipartisan consensus to do something, but details can be more of a struggle. Now, after passing landmark legislation for mental health and substance use, the ACA repeal bills take aim at our most powerful tools.
Medicaid provides critical funding for local behavioral health care
Medicaid is the largest payer for behavioral health services in the US. 20% Medicaid enrollees have a behavioral health disorder.
The American Psychiatric Association opposes the bill because Medicaid is so critical to providing a safety net for people who are suffering. APA President Antonio E. Puente, PhD:
“Medicaid is a critical backstop of coverage for mental health treatment, and for millions of older Americans, children and individuals with disabilities. If the goal is to cover more people, why slash Medicaid when it is already much more cost-effective than private sector plans?”
For states that expanded Medicaid, the number of uninsured people who were hospitalized for behavioral health disorders fell from 20% to 5%. Reducing uncompensated care means more consistent treatment and increased recovery while reducing cost shifting to insurers, driving up everyone else’s premiums.
Medicaid is also critical to addiction treatment paying for about 1/4th of the cost nationally. In some states it accounts for almost half of their Medication Assisted Treatment like methadone, that’s critical in treating opioid addiction. In the midst of an epidemic that is killing more than 50k people a year, steep cuts to the Medicaid would be devastating.
Health researchers Sherry Glied and Richard Frank found that repealing ACA would reverse the progress made in the Cures Act.
We estimate that approximately 1,253,000 people with serious mental disorders and about 2.8 million Americans with a substance use disorder, of whom about 222,000 have an opioid disorder, would lose some or all of their insurance coverage.
Essential Health Benefits
Before adoption of ACA, there were few standards for health insurance policies. Employer based plans, especially with larger groups, tended to be more generous because it spread the risk among more people. The individual market was more of a wild west with plans that left a lot uncovered, leaving people in financial ruin or without treatment when they needed it most. But across the board, access to mental health care and treatment for substance use disorders was often lacking.
ACA created some basic standards for policies that could qualify as insurance plans under the act. Every health plan has to cover these services:
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Hospitalization (like surgery and overnight stays)
- Pregnancy, maternity, and newborn care (both before and after birth)
- Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
You might look at that list and think “that just sounds like health insurance.” You’d be right. Unfortunately, many plans, particularly in the individual market, preferred to not offer expensive services. Particularly for chronic, hard to treat illnesses… like behavioral disorders.
While most of the repeal bills have continued Obamacare’s prohibition on exclusion of pre-existing conditions, if insurers can stop providing behavioral health treatment, the effect is the same.
For the individual market the effect would prove far more destabilizing. Younger, healthier people would naturally select cheaper plans that provide less coverage leaving others in the more comprehensive plans. Who would want to offer the plan that only sick people will choose? For insurance to work, risk has to be spread as broadly as possible.
Reversing course on behavioral health would be tragic for those who are suffering and their families. But it would also have impacts throughout the system. Jails, courtrooms, and emergency rooms have become de facto care providers with poor outcomes at higher costs. Counties are eager to build on recent progress in Congress on behavioral health, delivering treatment our communities deserve.

