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.
14 comments
Upside at the end of the day: mot people will be able to seek out providers and have some semblance of reimbursement for it.
Downside: who they will find that is credible and responsible, and will such providers work for slave labor wages, well…
Ironic, isn’t it, called the Patient Protection and Affordable Care Act. Well, how do Congress and Barack Obama define Protection, and affordability?
I guess we’ll find it out after we read it?
Double irony in that last sentence, eh?
I was worried that my Marketplace coverage would not pay my doctors well enough. I’ve had the insurance for 9 months now so I’ve been able to ask my doctor’s offices if my insurance re-imburses them well. In every instance, they have looked over my accounts and told me that their payments are on par with other companies. I’m just saying, it may not be true that the Marketplace insurance doesn’t pay doctor’s well. Maybe the ACA is a better thing than you thought.
At any rate, I’m very happy I have coverage now, as I was uninsured before.
I’m just a mom researching ACA coverage for my 26 year old who’s had a psychotic break in the past and currently sees a therapist regularly. He’ll quit if he has to pay the bills in full himself. My kid won’t qualify for Medicaid. So far, it seems to me that the insurance companies have managed to make flexible mental health office visit care less affordable by making copays possible only AFTER paying very high individual deductibles — unlike much of the care for physical illness. I’m so disappointed that mental health is still so undervalued in this society and culture, and so manipulated by insurance companies. I’ll be looking at the Gold and Platinum policies and double checking the insurance company shenanigans to be sure they will actually cover what their summaries suggest. No wonder in our culture that more and more desperate kids have little recourse to getting well. What a shame.
Unfortunately the ACA did absolutely nothing to help me. I am still stuck with the same high deductible insurance plan that I cannot afford the premiums and that doesn’t pay for anything, including prescriptions, until I spend $4000 (which is low I know many who have $10,000 deductibles, but either way no one can afford it. $4000 may as well be $1,000,000.) I was so hoping to be able to find treatment this year. But now I will go without yet again, while paying for a service I can’t use due to cost.
I will continue to watch my mental health decline at the steady rate it has been for the last few years. Hopefully I will be able to keep my job, as working is becoming harder. However I can’t go on disability, I am the sole provider for my family. We would not survive on $800 a month. So, the struggle must go on until I collapse.
Until our country gets over itself and realizes a single payer system is the right answer, instead of pandering to capitalists who require $15,000 a year in premiums, thousands of dollars in deductibles, and pay out as little as they can then we have no hope. Working in health care I see what insurance companies pay your doctors. I’ve seen a patient pay a $30 co-pay on a $137 visit, and the insurance company paid $13. The doctor had to write off the rest. I’ve seen an insurance company pay $7 for a $160 visit. I wish I could pay my utilities company $7 for the $150 bill I received and they write off the rest.
And yes, taxes would go up. But you won’t be paying $15,000 a year in taxes on a family of 4 (which is the yearly cost. That’s a semi-decent new car every year!) Also, although taxes would go up, you would not longer be paying that heavy premium, so you’d actually be saving money every year.
Would it be perfect? No. But it would be better than this
Disclaimer up front, I used to be a proponent for the single payer system model when I first finished residency, but, I have learned A LOT about what such a system offers, and it has as much risks as benefits, and that is not a good choice at the end of the day. As illustration to this Risk/Benefit ratio, would you accept a medication or procedure that had as much a likelihood of causing complications as much as effectively treating an illness? Basically, would you flip a coin to decide on your care options?
The single payer system does not tell you one simple and very important fact that all those countries across “the pond” do not tell you for fear of overtly embarassing the politicians who promote it: monies and resources are finite, so, at the end of the day, in a truly fair and equal society, it is first come first served, and someone has to be at the end of the line, thus risking being left out or offered less efficacious opportunities. And, the way this debate about PPACA has progressed, (really to me regressed) the tolerance and expectations of a sizeable portion of this society has the Glenn Close character attitude in Fatal Attraction: “I will not be ignored”!
So, careful what you wish for, the system sucks as is, no argument from me, someone who has worked in Community Mental Health much of my career, so I know the effects of poverty, lack of options, and plain marginalization of being in society well.
You can’t let politicians ALONE set the bar here. You are dealing with characterologically disordered people who made this legislation, just look how they are arguing it is no big deal that right now 5-10% of the population losing insurance coverage to have to purchase more expensive coverage as the alternative is either no big deal, or that is the demand to pay for the care of the alleged 30 million without any coverage.
I say at my blog that as of today, 40% of our voting population supports either torture or taxation without restraint, ie they are entrenched Republicans or Democrats respectively to those 2 beliefs. And those 2 attitudes, in my opinion, are frank antisocial attitudes to take.
It is ok to torture people without even judging them guilty first, or, to continue to take more money away from honest hard working citizens without accountability or dialogue first.
If you honestly see no problems with both or either of those 2 perspectives, well, you validate my comment at political blogs:
we get the electorate we deserve!
Just my opinion.
Hello. I have been dealing with mental health issues since I was a kid. The lack of care is horrible. I live in Northern Californa. My county (Shasta County) doesn’t even have their own psych ward. They ship patients 150 miles away to surrounding areas such as Sacramento. Instead of running their own hospital, they rent beds from hospitals in surrounding counties. So on the rare times I am admitted, I never know what hospital I am going to go to. And what’s harder is I am so far away no friends or family can afford the gas to come visit. So I only can get phone calls, and only if one of the 30 patients are not using the one single phone on the ward. Most recently I was in the hospital and was put on two new meds which had a VERY bad effect. I was discharged before the new meds had taken effect. At home the reaction was the worst urges to take my life I have ever felt. I ended up overdosing 6 times in 3 weeks. Not once was I admitted back to the hospital. Instead I was sent home after being stablized. Not that mental health dose anything anyway. If you go to mental health and are suicidal, they call a ambulance to take you to the ER where you are held 1-2 days before a mental health worker comes to evaluate you. Then 9 times out of 10 your sent home. Like I said, reguardless of being suicidal and overdosing 6 times I was constantly sent home. The other 5 attempts could have been prevented. It was two weeks before my family doctor had discovered the two new medications had prior warnings of the chance to cause severe suicidal thoughts. No one told me. I just assumed my depression was gatting worse with age. My point is, help I should have gotten was denied. As I know so many other people experience. Just wrong. The ER shouldn’t be acting as a temp psych ward. Nor are the staff trained for that. In the ER patients are placed in a exam or “isolation room” with a guard at the door. My last ER visit resulted in injury due to untrained security guards. I have PTSD and the particular exam room was similar to a room I was severely abused in. I was fine for a few hours and then flipped out. I just needed to step outside the room when the guard was seeing me come out the room he grabbed the door handle so I couldn’t open the door. I freaked out not being able to get the door open. When the door did open, 6 staff rushed in and pulled me onto the exam bed and put me in restraints. But as promised during another visit, to cause pain to those put in restraints they put my right arm to my side like they are supposed to by law, but to cause pain and discomfort they took my left arm and pulled it tight to the head of the bed pulling all the muscles in my left arm. It just goes to prove how cut backs effect those who just need help. Security NOT being a trained psychiatric tech has no bussiness caring for mental health patients. And has no right to cause a patient pain because the person happens to be requiring more help than just sticking them in a isolation room gives. The system is severely broken. Anyway, thanks for letting me share why I think mental health care needs fixing.
In the long run of humanity, capitalism will not work. It is anti-human and anti-earth. And for sure it will not work in the healing arts. We don’t seem to be morally, emotionally, psychologically, and spiritually developed and mature enough to take care of each other without the profit motive, and competition. Its sad but true. So much of what we hear from the media, politicians, economists, military leaders, bankers, and multinational corporations is about economic growth and military defense. This is ignorance and causes unnecessary suffering.
Dr. Grohol, here is the question to which I can’t find an answer, not even in the NYT article today. Will an insurance company now be obligated to cover (with co-pays, etc.) unlimited psychotherapy visits for a patient who is merely dealing with neurosis, stress, anxiety, etc., and otherwise is living a regular life, if that insurer covers unlimited visits to a doctor? How about psychoanalysis? Will that now be covered? (Assuming one can find a therapist who takes the insurance in both cases). Can you clarify?
I am going inpatient on Monday to a facility that is an in-network facility with my ins. co. The facility’s website states that their treatment program requires a 30-day minimum stay. Once you begin the admission process however, you are warned that the ins. co. only pre-authorizes 3-4 days at a time and that they can decide at any time that they will stop paying. If you show the slightest improvement, they will claim that you can be moved to outpatient treatment. Does it matter that this facility is a 6-hr drive away from my home and so completely impractical? No, and there is no psychiatric treatment facility in my community. I simply cannot get this level of care at home.
I am told that they will balk that if I am so incapable of caring for myself, why am I not being immediately admitted? No matter the practical considerations of having to wrap up personal matters such as making sure bills will be paid, purchasing supplies that you need to pack, packing itself, making transportation arrangements and such. Frankly, I don’t know how I am going to be able to get all that stuff done, because I can’t get out of bed in the morning. In the last month, I have managed to make it to work only 2-3 days per week. When I am not at work, I’m home in bed, in front of the TV or on my computer. I’m not eating, showering or performing any household chores and I live alone. I think it will be a miracle if I could get better in 30 days, but I doubt if the ins. co. will allow me the chance.
It is so infuriating because if my condition were physical they would not require constant authorization. Despite the mental health parity act they still do not cover mental health treatments equally.
All appreciated, but sometimes the stretch to find something negative is just that. I am not an apologist for ACA, Obama, or anybody else, but I find more light than dark in the situation (NOT from the perspective of being a CEO who has to figure this out for his employees–with THAT hat on, there are nightmares-a-plenty!
jmn
It is clear to me today that Americans want health care; but they don’t particularly want health insurance.
Health insurance companies, however, convinced the government that they are instrumental to the delivery of health care, so the government is compelling people to buy that.
The Administration’s argument is that too many people prefer to be “free riders” — that is, they prefer not to pay for their own insurance while health care reaches an emergency status and is paid for in full by government services (such as emergency rooms)
And there it is:
agendas versus principles, the former what is the basis to this disgusting health care intrusion law, and the latter to what is the basis to health care by providers.
And also, the ignorance of the masses, you get what you pay for is a simple adage for any interaction that involves payment for a product or service.
So if you pay nothing for your health care, and basically act like you deserve a full court press and not only do nothing for the providers but also to yourself, then you end up with nothing of substantial benefit. And hence why this phony debate by the politicians is so empty and vain on their part.
Insuring 30 Million people on the backs of about another 30 Million who can barely pay for themselves and their dependents, is disgusting an agenda. So, keep voting those incompetents, er, incumbents back for another 2-6 more years, and then think you can complain about their failures to represent you.
My reply, is sit down and shut up if you vote status woe! This legislation signals the wake up call to those invested and caring for this country to improve, not impoverish! What is sad is about 40%, 20% each side of the Left and Right, will just reflexively push levers, or check boxes solely for the “D” or “R” after the name next November 4, 2014.
But, that does leave about 55-60% who can exhibit judgment and insight, not dereliction and incite!!!
Timely post , I was enlightened by the facts – Does someone know if my company can locate a template CMS-40B version to type on ?
I think that my state is about 47th in mental health care. There are not many good psychologists who will accept Medicaid. That means that most of the people who need help are not getting it. We also have an opiod epidemic so that is stretching the mental health public health system to the limit.