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Why You Should Care About Obamacare

In a landmark ruling, the Supreme Court has upheld President Obama's centerpiece legislation. So what's at stake for people in recovery?

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Healthcare professionals protest outside the Supreme Court last week. photo via

By Jesse Singal

04/03/12

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You don’t know what you got till it’s gone. For the recovery community, that may be the ultimate lesson of the Patient Protection and Affordable Care Act (ACA)—dubbed “Obamacare” by foes and (now, resignedly) friends alike.

Whether the Supreme Court will let the sweeping healthcare law stand or strike down some or all of it will remain an open question until the justices hand down their decision in June. But judging from the past week’s frantic punditry, prognostication—and, for supporters of health care reform, caterwauling over the failure of Solicitor General Donald Verrilli, Jr. to effectively defend the law on the government’s behalf during the first day of the two days of oral arguments—it’s safe to say that things don’t look great.

Should this matter to current or former addicts? Yes, because the new law offers several important provisions that make addiction prevention and treatment more accessible. But paradoxically, many in the recovery community remain in the dark about these benefits, partly as a result of an intentional strategy by the law’s boosters to keep its addict-friendly benefits on the DL.

At issue to the Court is the law’s so-called individual mandate, which, once the healthcare reform fully kicks in, in 2014, will impose modest financial penalties on any American who doesn’t have health insurance. Opponents—almost all of whom are partisan Republicans—argue that it’s unconstitutional.

If you didn’t know about the healthcare law's addiction-friendly benefits, that wasn’t an accident. Their under-the-radar nature “was intentional,” Keith Humphreys says. “If the bill were known to be good for addicts, that would get demagogued.”

That the law is in jeopardy was easily surmised by the tone of the questioning last week. Take this query from Anthony Kennedy—the fifth-most conservative justice on the court (and its swing vote): “Assume for the moment that [the mandate] is unprecedented, this is a step beyond what our cases have allowed, the affirmative duty to act to go into commerce. If that is so, do you not have a heavy burden of justification?”

“Every premise of that question was a misperception,” wrote New Yorker legal expert Jeffrey Toobin. Slate legal writer Dahlia Lithwick took things a step further. Referring to the ban on live video or audio broadcasts from inside the court, she wrote, “[I]f the justices are going to conduct themselves as though they are on a Fox News roundtable, it might be better—not worse—to allow the public to take notice of that fact.”

Obama tried to allay liberal fears at a news conference on Monday. “I’m confident that the Supreme Court will not take what would be an unprecedented, extraordinary step of overturning a law that was passed by a strong majority of a democratically elected Congress,” the president said. (For more on what's right and wrong with Obama's defense, read my piece on today's Daily Beast.)

Obama may be right. If the Court does decide to strike down the law, it could go down in a number of different ways. The Supremes could rule that the mandate is unconstitutional but leave the rest of the law mostly intact. Or it could decide that without the mandate the rest of the law falls apart (which is partially true, in that without the risk-sharing offered by a mandate, other ACA provisions could cause the health-insurance market to spiral out of control, cost-wise) and therefore scrap the whole thing.

Either way, this is really the final stage of determining the law’s outcome; should the Court send the law back to Congress to iron out a kink or two so it passes constitutional muster, all sides agree that there is zero chance that the House and Senate (as presently constituted) could pass another healthcare reform bill.

There’s a lot to keep track of here—both the bill and the arguments for and against it have an almost endless series of complex moving parts. It’s worth noting, though, that the Court’s historic decision will have a significant effect on anyone in need of addiction treatment—whether for themselves, a friend or a family member. But if you didn’t know about the ACA’s addiction-related provisions, that wasn’t an accident, says Keith Humphreys, a Stanford mental health and ACA expert currently based in London who worked in the White House’s Commission on Drug Free Communities from 2009 to 2010.

The under-the-radar nature of these provisions “was intentional,” he explains. “All the advocates as well as the [Obama] administration knew that if the bill were known to be good for addicts, that would get demagogued.”

“We’re a scared bunch,” he says of the community of mental-health advocates and experts. “We know that if we get anything, people want to take it away from us.”

There are four major components of the ACA that have a bearing on addiction treatment, Humphreys says.

The biggest one is related to the idea of mental health care parity—of health insurance plans being mandated to provide “comparable benefits for mental health and addiction as for other health conditions.” Humphreys and other advocates pushed this policy for 12 years, and finally, at the tail end of the Bush administration, Congress enacted it by passing the Mental Health Parity and Addiction Equity Act of 2008, which expanded coverage for over 100 million people by mandating that all plans in the small-group insurance market cover mental health services the same way they cover other sorts of care.

There was a catch, though: The legislation only applied to plans that offered mental-health benefits. Insurers could circumvent the law by simply dropping such care altogether.

The ACA fixes this by applying “parity-plus”—the mandate that insurance plans are required to offer not only comparable mental health services but mental-health services, period—to two of its main features: the expansion of Medicaid benefits upward to anyone whose income is 133% of the federal poverty line or less, and to all plans in the health-insurance exchanges that are being set up to offer coverage options for those unable to get care through their employers.

The second addiction-related ACA provision—and one of the only facets of the bill that has already gone into effect—is the provision allowing parents to keep their kids on their health insurance up to the age of 26.

“Almost everyone who develops an addiction to alcohol or tobacco or to other drugs does so in adolescence or in young adulthood,” says Humphreys. “So lifting the age where you can keep your kids on up to 26 is really important.”

The third is the ban on allowing health insurance companies to prevent new customers from enrolling because of pre-existing health conditions.

“If you talk to recovering people, you quickly learn that it’s very hard for them to get insurance, even after they’ve been clean and sober many years,” says Humphreys. “So it’s big for them.”

Finally, the ACA contains important provisions geared at nipping addiction in the bud. “For everyone who is addicted,” Humphreys explains, “there are three or four people who aren’t addicted, but who at the same time are not using substances in a healthy way.”

So what’s the best way to prevent this unhealthy behavior from growing into full-blown addiction? Public health officials and the government support a protocol of quick, early interventions called Screening, Brief Intervention and Referral to Treatment (SBIRT). As the Department of Health and Human Services explains online, the idea behind SBIRT “is deceptively simple: What if you could stop drinking and substance abuse problems before they became serious enough to destroy people’s lives?”

Studies have shown SBIRT to be a successful method, says Humphreys, “but it hasn’t historically been covered very well by insurers.” The ACA corrects that by categorizing SBIRT as a mandated preventative benefit, meaning Medicaid and insurance plans in the state exchanges will be required by law to cover it (similar to provisions that force them to cover cancer screening including mammographies).

It’s clear that the ACA, as written, would significantly improve how addiction is treated in the United States, greatly buttressing its accessibility and affordability for millions. What’s less clear is what will be left of these provisions after the Roberts Court has its way with the bill.

Jesse Singal is a freelance journalist and a master in public affairs candidate at Princeton’s Woodrow Wilson School of Public and International Policy. He has written for the Boston Globe, the Daily Beast, Washington Monthly, the New Republic Online and other outlets. Follow him on Twitter at @jessesingal or email him at jesse.r.singal@gmail.com.

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