NYAPRS Note: This piece underscores the important role the ACA has played in increasing access to behavioral health services through its advancement of mental health parity and its deeming them essential services within the healthcare exchange. These efforts have been hampered by inadequate enforcement of parity with insurance companies, the subject of a federal task force and of a study that has been proposed within the mental health legislation working its way through Congress.
It also emphasized great shortages in the capacity within the BH workforce, further diminished by many practitioners’ unwillingness to take Medicaid and the law’s advancement of integrated physical and behavioral healthcare.
Obamacare and Mental Health: An Unfinished Story
By Brianna Ehley Politico July 13, 2016
America's mental health system is having a breakdown. Suicide rates are at a record high; drug addiction is epidemic. There aren't enough therapists, particularly not enough who accept insurance. And too often the most vulnerable and severely ill end up on the streets, or fill our prisons and jails.
The Affordable Care Act was never meant to mend every crack in the system. It did zero in on the insurance side of reform - but there's still a lot of heartbreak.
The 2010 health law includes mental health and substance abuse treatment as one of 10 "essential benefits," meaning that all health plans sold in the new exchanges and Medicaid must include it. It broadened the reach of a 2008 mental health parity law, so all insurers must cover behavioral health on the same terms as any other type of medical treatment. Significantly, it forbids health plans from rejecting people with preexisting conditions, including mental illness and addiction. That's a big deal.
The law also set in motion programs that will try out new ways of caring for mental illness - including integrating primary care and behavioral health, so they work hand in hand.
But for the roughly 43 million people in the United States who suffer from mental health problems each year, the bottom line is that most still aren't getting treatment.
Stigma persists; Congress can't legislate that barrier out of existence. Beyond that, there's a serious shortage of behavioral health specialists, and a dwindling number of clinics and hospitals, particularly in rural areas, designed to treat and house people with serious mental illnesses. Care is expensive, even for people who are covered.
Shanna Marshall is an insured, middle-class mother from Virginia. Her son Anthony, 20, has severe depression and he's addicted to painkillers. He's in jail for larceny. He was granted permission to temporarily leave jail to seek treatment last winter.
The family struggled to find in-network inpatient treatment, and had to go all the way to California to find it. After Anthony's 28-day stay, the bills started coming -- $46,000 for the facility, $8000 for the doctors, counselors, therapists and medication. The insurers deemed his care was not "medically necessary" - even though it was court-ordered. His parents don't know what they'll do when he gets out of jail in August and is required to get more treatment.
"We're working out payment arrangements, but it's devastating," she said. "How do you put a price on the life of your child."
Beyond Obamacare, Congress and the White House are looking at other solutions through legislation or regulation - addressing opioid abuse; loosening outdated restrictions on Medicaid hospital payments; updating mental health programs and patient privacy laws to make it easier for family members to get treatment information.
But even in the areas Obamacare did address, there are gaps, acknowledged by the president himself. "We have made progress expanding mental health coverage and elevating the conversation about mental health," he said in a statement marking Mental Health Awareness month in May. But he added, "Too many people still do not get the help they need."
The administration says 20 million people now have health insurance because of Obamacare. That includes some who would have been denied coverage because of their preexisting mental illness, and those who could not have afforded insurance without expanded Medicaid or the subsidies to buy coverage on the exchanges. But that's just a first step.
"The ACA has been transformative in so far as that we were able to get mental health and addiction considered as an essential health benefit," said former Rep. Patrick Kennedy, a recovering addict who co-authored the Mental Health Parity and Addiction Equity Act of 2008, a precursor of some of the new Obamacare rules,"We are no longer considered an afterthought."
But benefits don't automatically translate into treatment. Care can be costly; people have trouble paying their out of pocket share, even if they are lucky enough to find an in-network provider. Many therapists - psychiatrists, psychologists and others in behavioral health - won't take insurance at all. That was true with private insurance before Obamacare, and it's a particular problem with exchange plans and Medicaid plans which don't pay providers well. And there are waiting lists for substance abuse treatment.
A 2013 study published in JAMA Psychiatry found that just 55 percent of psychiatrists accepted private insurance, compared to 89 percent of other specialties - and that was before the ACA expansion and its narrow networks. The study found similar gaps for Medicare and Medicaid. Low reimbursement, onerous preapproval processes, and too much paperwork are all reasons that psychiatrists, many of whom are in solo or small practices, decided not to take insurance, Maria Oquendo, president of the American Psychiatric Association, said in an interview.
A recent report from the CDC confirmed that more Americans with serious psychological disorders now have health coverage, but a large number are foregoing treatment because they just can't afford it.
Enforcement of other Obamacare mental health requirements - such as the parity rules requiring that behavioral health be treated like other diseases, or the inclusion of depression screening in free preventive care - has ranged from weak to nonexistent.
"Many of the insurance companies have stepped up on paper and have made statements about embracing the law," Oquendo said. "The truth of the matter is there still are significant difficulties."
Advocates say the parity laws are so complex that they are difficult for state regulators to enforce.
"The regulation spans hundreds of pages that applies to some plans but not all. So conducting a comprehensive analysis is very time consuming and nearly impossible for the state health insurance commissioners to regulate all of the plans," said Rebecca Farley from the National Council on Behavioral Health. "Even as a consumer, even if you know the law, identifying violations can be very hard."
President Barack Obama recently set up a task force that is charged with figuring out how to effectively enforce mental health and substance abuse parity and it has begun its work. Advocates want the administration to begin disclosing which insurers are not complying with the parity laws, though that would have to overcome a lot of insurance industry resistance.
But it's not all a gloomy picture. Some providers are cheering on the ACA's mental health effort and say that it has saved them millions while also helping people with serious mental illness get care.
Steven Sharfstein, the outgoing CEO of Baltimore-based Sheppard Pratt Health System, a psychiatric hospital that has branches throughout Maryland, said when it comes to inpatient care, Obamacare has been great for mental health. Fewer uninsured people are showing up in the emergency room needing crisis treatment for mental health disorders, more are coming in with coverage. In his system, total uncompensated care costs dropped by two-thirds, from $1.2 million per month before the Affordable Care act, to $400,000 per month.
"If one of the goals was to expand access to inpatient care, the law is doing a fantastic job," he said.
Outpatient care, Sharfstein said, is a far more challenging story, given the challenge of finding in network providers.
Kennedy described the task of finding an in-network mental health provider as a "Kabuki dance." He said those that can afford to go out of network do so Those that can't afford it often forego care.
"There's no question that the ACA has opened up more treatment opportunities for people across the country," he said. "That being said, what's playing out isn't close to what the law was supposed to require."