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Rural America is overwhelmed by suicides and overdoses, so-called deaths of despair. Those in power offer well-meaning words but no meaningful action. Worse, they may be making rural America sicker.

In the ongoing national health care debate, coverage for behavioral health needs to be front and center. If rural policymakers are serious about addressing suicides and overdoses in their communities, repealing mandatory behavioral health coverage offered through the Affordable Care Act is a very bad idea.


Deaths of despair, a term coined by Princeton economists Anne Case and Angus Deaton, are those attributable to suicide and misuse of drugs and alcohol. Largely because of them, deaths among white non-Hispanics have been increasing relative to other racial and ethnic groups in the U.S., with an increase of 51% between 2005 and 2016. This translates into more than 1 million deaths, a large proportion of which occurred in rural counties.

Many of the hardest-hit areas are represented by policymakers whose main interest seems to be repealing the ACA without any alternative to guarantee behavioral health treatment to the millions who need it.

Repealing the ACA would deny insurance to 4 million people with behavioral health disorders. The Medicaid expansion provision of the ACA alone has resulted in significant improvements in access to lifesaving treatment for opioid use disorder, such as buprenorphine. In Ohio, Kentucky, and West Virginia, for example, Medicaid covers between 40% and 50% of all prescriptions for buprenorphine, a medication that helps individuals recover from addictions to opioids. Each of these states allowed Medicaid expansion under the ACA.


While these states have the highest death rates due to drug overdoses in the U.S., their federal legislators have consistently voted to repeal the ACA and the Medicaid expansion that comes with it.

The ACA set 10 essential health benefits that all insurance plans need to cover, including behavioral health. For the first time, the message for all insurance was clear: covering treatment for addiction and mental illness is not optional; it is essential. But many policy makers decided to ignore this message when they voted to approve the American Health Care Act. This ACA “replacement” would have allowed states to eliminate essential health benefits, including behavioral health services.

Getting rid of mandatory behavioral health coverage is a giant step in the wrong direction. People with behavioral health disorders already struggle to access treatment. Even with the progress made through the Affordable Care Act, only about 1 in 8 Americans who need substance use treatment get it; less than half of Americans who need mental health treatment get it.

Instead of rolling back mandates for coverage for behavioral health, policy makers need to figure out how to get more people into treatment, not fewer.

What’s more, areas that will suffer the most from repealing the ACA are those in which it’s hardest to get help. There are already significant obstacles to getting access to behavioral health treatment in rural areas, such as lack of transportation, chronic shortage of providers, and stigma. According to one recent study, 65% of non-metropolitan counties do not have a psychiatrist and nearly half do not have a psychologist.

Although repealing coverage mandates for behavioral health will just make the rural sick even sicker, many policy makers don’t seem to care as long as they get to claim they helped repeal the Affordable Care Act.

Legitimate questions can be asked about health care reform. The ACA gets plenty wrong. But on behavioral health, it gets more right. Regardless of political beliefs, how can legislators justify denying life-saving treatment to those who need it the most? Will rural America hold them accountable?

Nickolas Zaller, Ph.D., is professor of health behavior and health education at the University of Arkansas’ Fay W. Boozman College of Public Health.

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