I last wrote what the Affordable Care Act (also known as Obamacare or the ACA) will mean to mental health treatment in the U.S. over a year ago. Since the Act’s passage and further analysis of it, it’s time to revisit this topic.
Some of the initial rosy predictions about the ACA are likely not to pan out quite as we had hoped. While the Act will indeed expand coverage and treatment options for millions of Americans who previously had little or no choice, it may also inadvertently take away some treatment options currently in widespread use.
Let’s find out why.
Dr. John Bartlett, the senior project adviser of the Primary Care Initiative of the Carter Center’s Mental Health Program says we still don’t know what a lot of the ACA’s impact will be on mental health care in America: “It’s really not clear at this point, on a state-by-state basis, what any of this [the implementation of the ACA] means.”
So let’s revisit the major components of change due to the Affordable Care Act, and the upside and downside of each.
Mental health care will become more accessible to more people.
The Upside: Most pundits and experts still see this as one of the primary benefits of the ACA, and it’s still true today. If you didn’t have healthcare insurance in the past, the ACA opens up the private insurance market that previously wasn’t readily available to individuals.
Building upon the federal mental health parity act passed in 2008, the ACA is seen not as a breathtaking change of landscape for mental health treatment. But rather, the ACA is another important stepping stone to ensuring that Americans who need psychiatric treatment can have access to it.
The Downside: While the ACA (in conjunction with the mental health parity legislation) includes coverage for the treatment of both mental and substance abuse disorders at equal levels to treatment for physical concerns, limits can and still are placed on such treatments. The limits are more lax than they were perhaps under the older system, but people still do not have access to “unlimited” psychotherapy treatments. Insurance companies still require therapists to obtain authorization for additional treatments after a certain number of sessions has been reached (which varies from insurance company to company).
With more people obtaining either private insurance or joining an expanded Medicaid program, the original prediction was that more people will have inexpensive access to mental health treatment. However, after the Supreme Court in June 2012 gave states the choice of whether to join the Medicaid expansion or not, roughly half of the states have decided not to do so. That means that 6 to 7 million Americans won’t enjoy this enhanced access, because their state legislatures have refused to expand their Medicaid programs, most notably Florida, Texas, Georgia, Alaska, Louisiana, Montana and North Carolina.
People won’t be denied coverage based upon their pre-existing condition.
Upside: This remains true today, and is a huge win for people who haven’t been able to obtain new insurance, because of an existing mental health diagnosis, such as depression, bipolar disorder, ADHD, or anxiety.
Prior to this rule, changing employers or insurance providers often meant having to pretend that a pre-existing psychiatric diagnosis didn’t exist. The new law says that you can’t discriminate against a person because of a pre-existing condition. This means that more people will get the care they need and have it covered by their insurance plan.
It also means an insurance plan can’t cancel your coverage for a pre-existing condition, something that was problematic for many in the past.
Downside: Luckily, there appears to be no downside to this.
People will get better overall care.
Upside: The law was originally designed to help increase incentives to physicians and other health and mental health professionals to look after people across the entire continuum of care — holistically, not just Patient X presenting with Z symptoms. It’s also focused on preventative care, which can help keep a person out of the hospital.
There’s a rich research base that suggests that this sort of integrated, coordinated care is ultimately beneficial to the patient. It can help catch health issues before they become more serious concerns. It can also ensure that if a person gets a life-threatening diagnosis, they’re also seen by a professional for their emotional health needs.
Downside: Sadly, with the U.S. Department of Health and Human Services punting to leave the essential health benefit package definitions up to individual states, each state’s definition is going to be different. When left up to their own devices, many states chose the least comprehensive set of “essential benefits,” since they were also the cheapest.
What this means is that coverage of things like mental health screening in primary care, mental health prevention services, crisis services, and other non-traditional services for the treatment or care of mental health concerns won’t necessarily be covered. If it’s not straight inpatient or outpatient care, it may not be included. This will all largely depend upon the state you live in.
Medication coverage gap in Medicare remains filled.
Upside: If you’re a senior and enrolled in Medicare, the law has already helped save on your prescriptions. With the high cost of many psychiatric prescriptions, the law helped cut the amount a person pays for their name-brand drugs by half when they were in the “donut hole” (between $2,930 and $4,700 in total prescription costs). This helps to ensure that seniors who need their psychiatric medications can continue to afford to take them.
Downside: There appears to be no downside associated with this.
Additional Big Changes
The biggest change from the summer of 2012 is the Supreme Court ruling that upheld the right of states to refuse to expand their Medicaid programs. Since Medicaid is the way the ACA helps provide treatment to those most in need (and the poorest in our society), this means that mental health benefits of the ACA in these states will be the hardest to access.
Without Medicaid expansion, more people will be vying for the same number of treatment providers available today — many of whom do not even take new patients because Medicaid reimbursement rates are generally perceived as uncompetitive by health care professionals. This means that while a patient may technically be able to afford the care, they won’t actually be able to access it.
But it gets worse. The block grants that the federal government gives to the states to help them conduct substance abuse and mental health services are being rolled back, because, according to Dr. Bartlett from the Carter Center, “the intention was to have Medicaid become the primary payer. So in some states, we’re seeing benefit packages [for the treatment of substance abuse and mental disorders] that look a lot more like older benefit packages that just offer inpatient and outpatient care. They don’t cover a lot of the services that fill out the continuum of care and services that we’ve become used to.”
What this means is that — especially in those states not expanding their Medicaid programs — funding for things like partial hospitalization programs, screenings in primary care, crisis intervention services, and more may be cut.
“This is going to play out on a state-by-state level,” says Dr. Bartlett.
“It may turn out that the ACA is really just another in a series of incremental steps toward the improvement of access to comprehensive mental health benefits, and therefore mental health and substance abuse care.”
Time will tell… The picture isn’t entirely clear right now, but we’ll keep you updated as the ACA rolls out in 2014.