How the Affordable Care Act Strengthened Mental Health Parity

April 11, 2016 - The Obama administration's Affordable Care Act has brought various benefits to the American people including greater health coverage through the health insurance exchange and Medicaid expansion. Young adults under 26 years of age can now remain on their parents’ health insurance plans, patients with pre-existing conditions will now no longer be denied health insurance coverage, and consumers would not have to manage out-of-pocket costs for preventive medical services all because of the Affordable Care Act.

These provisions also enable more individuals in need of mental health services to obtain treatment due to greater parity between physical and mental healthcare. The Mental Health Parity and Addiction Equity Act of 2008 and the Health Care and Education Reconciliation Act of 2010 also ensured full coverage for patients in need.

Similar plan coverage must be included when comparing more physical medical services to that of psychiatric mental health-related treatment. However, at this point in time, health insurance companies have still not received the necessary guidance from the federal government to incorporate the requirements of the Mental Health Parity and Addiction Equity Act of 2008 into their health plan options.

It seems that the Affordable Care Act and other legislation may not have had as much of an impact in improving mental healthcare access, as one report from the National Alliance on Mental Illness shows that only slightly more than half of psychiatrists countrywide accept health insurance. Additionally, about 25 percent of Americans who purchased health insurance plans through the state or federal exchanges were unable to find a mental health provider in their network.

To find out more information about how the Affordable Care Act and the 2008 Mental Health Parity Act have affected access to mental health providers, HealthPayerIntelligence.com spoke with Constance Garner, Policy Director in the Government Strategies Practice Group at Foley Hoag.

HealthPayerIntelligence.com: Has the Affordable Care Act and the 2008 Mental Health Parity Act been sufficient in ensuring access for mental health services throughout the country?

Constance Garner: “I acted as the lead for Senator Kennedy on Mental Health Parity in 2007 and 2008. I think in terms of that particular bill, it’s good that we did it before the ACA because I think if we had waited to try to do a bill of that magnitude within the ACA, it would have been very hard to get.”

“It tried to address a real issue which isn’t completely addressed yet in our country, which was to try to put on par mental health and substance use disorder with physical health around two areas. One was to bring it on par with copays, out-of-pocket spending, and deductibles so that we weren’t seeing someone with mental health challenges having to pay inequitable copays and deductibles as compared to their physical health.”

“We had some good examples that which we used during the time parity was negotiated. One example involved a patient with a diagnosis of ALS who might be in need of both neurologic services as well as psychological services. ”

“There are two issues at play here: the physical nature of the disease and the mental health adjustment that would have to come to reduce the dissonance between the way the patient is today and the way he or she might be five years from now.”

“Back when we didn’t have parity, the insurance companies may pay for a medical visit 80 or 90 cents on the dollar depending on whether you’re in an HMO or not. If you were in network, you might only have had to pay 20 cents on the dollar. At the same time, if the patient went down the hall after the medical visit to talk to the mental health provider, the insurers may pay only 50 cents on the dollar. There was real inequity in co-pays, out-of-pockets and deductibles. That was one part of it.”

“The other part of it was to be more fair and more on par with day treatment limitations, so that you couldn’t put arbitrary limits on the number of visits for a person with a mental health disorder. If you have a gallbladder problem, you see the doctor as much as is medically necessary, but with mental health, we saw that people had limits on the number of visits they could receive from psychiatrists and other mental health providers.”

“The whole notion of mental health parity was to try to be able to put that particular treatment for co-pay, out-of-pocket, deductibles, and treatment limitations on par with physical health for both mental health and substance use disorders.”

“So it did make a difference. It made a huge difference from where we started. When the ACA came along, the mandate for mental health coverage moved forward. But, there remains discretion in what individual disorders must be covered.

“When we had mental health parity, there was no mandate to cover mental health as a service category. ‘IF you cover mental health, then whatever it is you choose to cover within that, must be brought on par in the financial and day treatment areas.”

“When the Affordable Care Act came along, it was strengthened. In the ACA, they had to cover mental health. Insurance products did have to cover mental health and had to treat mental health on par with physical health.”

“But still, the question remained and it remains today - what diagnoses are covered under my insurance plan? Does the employer or insurer still get to pick? A number of diagnoses that weren’t covered before are covered and they’re on par with physical health, but because there’s not a mandate that says everything in the DSM has to be covered, there’s still a selection process that goes on.”

“There is a lot of pressure to not do that anymore, but there’s no mandate for that. I think there’s still a lot of work to be done to make sure that all mental health challenges and disorders need to be covered and need to be treated on par with physical health.”

“The fact that we have a mandate for insurance has made a difference because people now have access to where they didn’t have access before. We see the difference that makes if you look at the exchanges. We can see now the benefit of having coverage and access to healthcare earlier rather than later.”

“We need to make sure all the mental health conditions are covered. I think that we also need to make sure that there is network adequacy. There is still a lot of issue with network adequacy. Patients need to get to the right provider under the mental health system.”

HealthPayerIntelligence.com: What are some of the biggest challenges that health payers faced when complying with the 2008 Mental Health Parity Act?

Constance Garner: “I think one of the things that payers run into with this is around the interpretation of the law. One of the challenges for a payer particularly in this area, as well as in the disability areas, is the issue of function and paying for functional outcomes. Healthcare payment in medicine has traditionally come from a very medical perspective.”

“There’s a qualitative notion to mental health that should be reimbursed. In talking to insurers, it is important to stress that they are paying for function in physical health all along. It’s just not thought about. If you have an appendectomy tomorrow and you come back to see me, the whole beginning of that visit is going to be about function. Are you eating? Are you sleeping? It’s all about function and that is reimbursed.’”

“Yet when we look at mental health, the notion of paying for functional outcomes becomes a little bit more of a grey area and I think that’s where people struggle with it - how do you measure outcomes for mental health?”

“For example, if you had been coming to see me for some mental health issues that we’d been working on, I would be asking functional outcome questions such as, are you back to work? How is your family situation going? Are your kids going to school?”

“These are functional kinds of outcomes. That, I think, sometimes is hard from a payer perspective because it’s not what they’re used to. That becomes a little bit of an issue.”

HealthPayerIntelligence.com: Have the federal or state health insurance exchanges paved the way in improving mental healthcare services? In what ways?

Constance Garner: “I think the exchanges were the core of the ACA. That provided a place for people who never had insurance before and didn’t have access to insurance before to have a place to go.”

“There are those who will argue that the premiums are high. The degree of illness on the exchanges is high as well. Depending on your risk pool, that will drive whatever the cost of it is. It still gave people access to healthcare that they’ve never had before.”

“I think one of the biggest areas of this whole thing is the young people and the 26 years old provision. There’s two reasons I think that 26 provision has been important. In the exchange, it gives them a place to go, but if you think about it - that 10 years, the 20 to 30 decade, is a decade if you look historically is still a risk decade for young people and you haven’t worked the hours (work quarters) in order to get disability insurance if something were to happen to them. It’s a risk decade for young people.”

“Giving people the option for the 26 years old provision was really an important one for a lot of different reasons. As far as the access to mental health, that’s such an important decade that for those kids, they’ve got access that they might not have had before.”

“The exchange itself gave people who were uninsured gave access to mental health services. It’d be nice if all of the states took up the Medicaid expansion because then we will have all of the holes covered in coverage. That remains to be seen. I think the exchanges became important as an access point.”

HealthPayerIntelligence.com: Are there still disparities between states when it comes to behavioral or mental health services? What needs to be done to put an end to these disparities?

Constance Garner: “In terms of the Medicaid program, coverage is now relatively uniform for behavioral and mental health services. The basic benefit package offered is adequate. The issue, again, is access to providers. You do have a hard time sometimes recruiting the network for Medicaid.”

“Why would that be? A lot of it has to do with payment. Now people have a right to it, but the question is what do you get quality-wise? The other place where improvement is still needed is - we need to put some effort into mental health in schools. Part of it is financing, which is the insurance piece.”

“The other issue is we need to have a better system that schools can rely on - not to burden shift onto schools, principals, and teachers, but to bring to schools the systems of care that are out there in a better way so that those kids get what they need early.”

“Strengthening systems around support early will really help as these kids grow up and maybe we’ll have some positive impact on the mental health crisis in the country. That becomes an issue with insurers around reimbursement. Are they going to reimburse a system that provides services while the kids are in school? I personally think it’s a huge piece that could make a huge difference in this country.”