A Foot (or Seven) in the Door: The Affordable Care Act

Ron Manderscheid, Ph.D.
Executive Director, NACBHDD

Ron ManderscheidIt is said that a problem well-stated is half-solved. In my last post, I identified the significant economic, geographic, service system, and interpersonal challenges that can slow or thwart entirely the ability to get needed prevention, diagnosis, and treatment services for behavioral health conditions. I pointed out how, as a result, few people with mental health problems ever get either behavioral or physical health care services, resulting in shortened lives by as many as 25 years.

In this post, I examine ways in which the challenges to accessing behavioral health care can be overcome. In particular, I look at ways in which implementation of the Patient Protection and Affordable Care Act (ACA) is a real and vital tool to help people with mental conditions get, retain, and benefit from individualized, consumer-centered care and services.

The ACA and Behavioral Health: The Basics
Challenges to access, as noted in my last post, include problems getting in the door in the first place, and, once inside, getting appropriate, quality care. The ACA is already helping on both counts. And, when it goes into full effect in 2014, it will be of even greater help to people with mood disorders, schizophrenia, other mental health conditions, and any co-occurring illnesses, such as substance use. Provisions of the law itself account for some of the improvements. Programs being implemented through the US Department of Health and Human Services are helping in other areas.

Getting in the Door
Today, I’ll begin with how the ACA helps people with mental and substance use problems take the first steps toward full access by helping them “get in the door.”  Here are seven ways ACA helps people get in the door:

  1. Through both the optional state Medicaid Expansion and the mandatory state Health Insurance Marketplaces, the ACA will make health care insurance coverage available to millions of people with behavioral disorders and their families. In January 2014, the optional state Medicaid Expansion will broaden coverage to all people at or below 138% of the federal poverty level. (The US Supreme Court found that the Medicaid Expansion is optional rather than mandatory; hence, not all states will be providing this insurance coverage.) And it has the potential to add 18 million beneficiaries to the Medicaid rolls, around 40% of whom have behavioral health conditions. Insurance through the mandatory state Health Insurance Marketplaces will add another 20 million previously uninsured individuals, one in four of whom (25%) has a behavioral problem. Why will so many people with mental health conditions gain Medicaid eligibility under the ACA? That’s because so many people with chronic, remitting behavioral problems are unemployed, underemployed, or only occasionally employed, resulting in both limited income and, often, no health insurance. For both programs, enrollment begins on October 1, 2013, and insurance becomes effective on January 1, 2014.
  2. The ACA already has and will continue to extend insurance under a parent’s plan to young adults up to age 26. To date, more than 6.6 million young adults under age 26 have been able to stay on their parents’ insurance plans. The teen and early adult years are particularly critical when it comes to behavioral health issues, and not just because youth is often a time of testing, emotional turmoil, and, frequently, risk taking. Rather, it’s a crucial time because half of all lifetime cases of mental and substance abuse disorders begin by age 14 and 75% arise by age 24. Because early identification and intervention can yield early recovery, the ACA’s provisions that ensure the availability of health coverage for teens and young adults to age 26 is key.
  3. More than 71 million Americans can now get free preventive services. That’s important when it comes to mental and substance use problems, since behaviors and symptoms that signal the likelihood of future problems often arise 2–4 years before a problem is recognized or a diagnosis made. On average, it takes as many as 8 years after the onset of evident symptoms for young people to get into treatment. By then, the costs of care are greater, and care effectiveness is reduced. Prevention and early intervention can preclude or reduce the personal and economic impact of the problem. In addition, early intervention for mental health problems can prevent or delay the onset of substance use conditions.
  4. The ACA already has eliminated pre-existing condition clauses that can reduce access to affordable coverage for all persons under age 19. As a result, today, 17 million children can no longer be denied insurance because of a preexisting condition, like asthma or bipolar disorder. Beginning on January 1, 2014, this protection will be extended to persons of all ages. As a result, adults with remitting behavioral problems will not be denied health insurance coverage.
  5. The ACA eliminates both annual and lifetime insurance coverage limits for care for behavioral disorders. This will reduce, if not eliminate, the likelihood that care will need to be terminated when ceilings are reached, a considerable problem for chronic problems like behavioral conditions.
  6. The ACA enhances parity for behavioral health benefits. Together with the Mental Health Parity and Addiction Equity Act, the ACA takes major strides toward ensuring that any health insurance plan offering behavioral health benefits provides coverage and benefits that are comparable to those available for physical health. This has the potential to expand behavioral health benefits and federal parity protections to 62 million Americans.
  7. The ACA’s insurance navigators help assure the right coverage is selected, based on what a consumer needs. Real people will help individual consumers negotiate the range of insurance options available for which they qualify.

Your Turn
Which of these seven changes to the system will benefit you the most? How? What is left to be done? Comment below to let us know!

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