By Sarah Ferris
The Affordable Care Act (ACA) led to the biggest expansion in mental health services in several decades, helping to close long-standing gaps in access and coverage for as many as 60 million people.
President Donald Trump promises to gut the federal law, which would include its substantial protections for people with mental conditions. Health care advocates warn that repealing the ACA would have a severe effect on the 43.6 million people living in the United States with a psychiatric illness and the 21.5 million with a substance abuse disorder, according to a 2014 government survey.
The costs of mental health care can be crippling: An estimate by a federal watchdog in 2012 found that people with any mental health disorder spend an average of $1,757 in medical bills each year – with costs totaling as much as $98,058 in extreme cases.
Trump has offered no details about how Republicans would soften the blow to the 60 million people who may lose benefits. Before his inauguration, his website only said that he would “reform our mental health programs and institutions” to help patients and their families. Republicans in Congress have talked about reducing or eliminating mandated benefits, which threatens access to behavioral health. (Even with the ACA, many patients still have barriers to accessing care, partly because of provider shortages, particularly for in-network providers.)
As the GOP develops its ACA replacement this year, mental health advocates plan to push to keep many key protections under the ACA.
Essential health benefits
Insurers selling plans through the Affordable Care Act or Medicaid are required to cover mental health services and substance abuse treatment as an “essential health benefit.” This meant that for the first time, mental health and substance abuse services are on the same list of mandatory benefits as emergency room visits and maternity care. Newly protected mental health services include counseling, psychotherapy and any behavioral inpatient services – all of which can run up steep fees without insurance.
Federal ‘parity’ protections
The ACA expanded the scope of a landmark law that required doctors and insurers to treat mental illness the same as physical illness. The Mental Health Parity and Addiction Equity Act of 2008 applied only to large-group plans initially. The ACA expanded its provisions to include individual and small group plans as well as Medicaid. In those plans, insurers are required to offer the same limits – such as the number of visits covered, deductibles and copayments – for mental health services as they do for medical and surgical services.
Advocates, such as the National Alliance on Mental Illness (NAMI), warn that parity provisions are difficult to enforce, and can still mean that people are receiving subpar mental health treatment. “Comprehensive parity requires equal coverage, not necessarily ‘good’ coverage,” according to the NAMI website.
“If the health insurance plan is very limited, then mental health coverage will be similarly limited.”
Preventative care
All marketplace plans are required to offer 18 types of preventative services without charging a copayment fee – even if the patient hasn’t met the yearly deductible. The list includes screenings for both depression and alcohol abuse.
Annual and lifetime limits
Insurers no longer can cap the amount of money they spend on an individual, through either yearly or lifetime limits. This protection can alleviate heavy financial burdens for patients.
The Government Accountability Office (GAO) reported in 2012 that people with mental health disorders spent as much as $98,058 yearly in the most extreme cases. The average cost for one year of schizophrenia treatment amounts to $16,098, according to research published in BMC Psychiatry. Those costs were substantially higher for patients who had experienced a personal crisis triggered by their illness, such as hospitalizations, arrests or suicide attempts.
People with a severe mental condition are also more likely to develop a substance abuse disorder, further increasing costs. An estimated 7.9 million people have both a mental disorder and a substance use disorder, according to a 2014 survey by the Substance Abuse and Mental Health Services Administration (SAMHSA).
Pre-existing conditions
Under the ACA, insurers no longer can deny people coverage, raise premiums or restrict services because of a person’s pre-existing condition.
Advocates say this protection is particularly crucial for people with serious mental illnesses that can require chronic care, such as schizophrenia, depression and bipolar disorder.
Before the ACA, mental health disorders were the second-most common of pre-existing conditions that led to health insurance denials, according to the GAO report.
Trump and other GOP leaders have said they favor keeping this protection under the ACA. However, Democratic supporters of the ACA point out that pre-existing condition protections, sometimes called a guaranteed issue, can’t stand on their own because they require other provisions to balance the risk.
Medicaid expansion
Thirty-one states and the District of Columbia have used federal dollars from the ACA to broaden their eligibility for Medicaid. As a result, an additional 9 million low-income people have enrolled. In making its case for the other 19 states, the Obama administration had argued that Medicaid expansion leads to better mental health care.
A study by the National Institutes of Health found low-income adults with severe mental illness were 30 percent more likely to seek treatment if they had access to Medicaid coverage.
Learn more
- Most of the nation’s 43 million people with mental illnesses still aren’t getting treatment, Politico’s Brianna Ehley reports in “Obamacare and mental health: An unfinished story.”
- A professor of clinical psychiatry writes in the New York Times op-ed, “The Mental Health Crisis in Trump’s America,” about the looming mental health crisis if the Trump administration pushes for an Obamacare repeal.
- Medicaid plans have been unable to meet the demand for mental health services after an influx of new patients from the ACA, Modern Healthcare’s Virgil Dickson reports in “Medicaid plans struggle to provide mental health services.”
- Democrats warn that repealing the Affordable Care Act would undo recent progress made in mental health, including recent GOP legislation. Read mre about this in U.S. News & World Report’s Kimberly Leonard story, “In Obamacare Repeal Efforts, Mental Health Care Poised as a Flashpoint.”
- People with mental illnesses say it is still difficult to find mental health providers in their health plans in 2015, even after the federal “parity rule” went into effect. A survey by the National Alliance on Mental Illness, “A Long Road Ahead: Achieving True Parity in Mental Health and Substance Abuse Care,” provides details.
Sarah Ferris covered health care, mainly focused on the Affordable Care Act, for The Hill newspaper for 2-1/2 years. She covers the federal budget – and some health care policy – for Politico.
