The Clock Is Ticking on the 7 Million Uninsured with Behavioral Health Conditions

Ron Manderscheid

Ron Manderscheid, PhD
Executive Director
National Association of County Behavioral Health & Developmental Disability Directors

Now is the time to help the 7 million uninsured Americans with behavioral health conditions understand their health coverage.

In a recent post, Hannah Sentenac discussed the challenges young adults face accessing mental healthcare. Because many Millennials are choosing job flexibility and self-employment over traditional employment, they are faced with the costly prospect of purchasing their own health insurance; and many have simply chosen to go without. Even for Millennials who have insurance (either employer-sponsored or self-purchased), high co-pays and hefty out-of-network charges have prevented many from obtaining mental health treatment, she states.

What Hannah and anyone with mental health concerns should know is that the Affordable Care Act—despite its well-documented flaws—puts coverage, and more pointedly mental health care, within reach for many. Last year, an estimated 10.3 million people gained coverage under the ACA. However, the Department of Health and Human Services (HHS) estimates about 32 million Americans still lack coverage; of that number I estimate that at least 7 million of those people live with behavioral health conditions.

Polls show that cost concerns are the main reason people remain uninsured. Yet many people who think they cannot afford insurance may actually be covered at no cost under Medicaid expansion; and those who do not qualify for Medicaid may be eligible for assistance with monthly premiums and out-of-pocket costs.

We must take it upon ourselves to help those 7 million people with behavioral health conditions get enrolled. The second ACA open-enrollment has begun, but it ends February 15, 2015, so the clock is ticking. Whether you are a mental health provider, someone who supports a family member with mental illness, or living with mental illness yourself, you have a responsibility to get informed about coverage options. And everyone should know they have the right to affordable mental healthcare.

As you set out, here are some key points about the ACA and mental healthcare to keep in mind.

1. Federal subsidies can help with monthly premiums.

Under the ACA, people earning between 138 percent of the federal poverty level (FPL) and 400 percent FPL ($16,105 and $46,680) qualify for federal subsidies (in the form of tax credits). These subsidies help with the cost of monthly premiums. These subsidies are only available if the plan is obtained through the marketplace.

Although the Supreme Court recently agreed to hear a case challenging the federal government’s ability to provide subsidies, the subsidies are currently there for the taking.

2. Cost-sharing subsidies can help defray out-of-pocket costs.

Under the ACA, anyone earning up to 250 percent FPL ($29,175) can also receive help with out-of-pocket costs. With the cost-sharing subsidy, those earning 100 percent to 150 percent FPL will pay just 6 percent of healthcare costs out of pocket. That’s compared with the standard 30 percent out of pocket. Those earning 150 percent to 200 percent FPL pay 13 percent out of pocket; and those earning 200 percent to 250 percent FPL pay 27 percent out of pocket.

This cost-sharing assistance is only available if the insured purchases a “silver” or higher plan on the marketplace.

3. Medicaid expansion can help some people get coverage for free.

Under the ACA’s Medicaid expansion, millions of Americans who did not previously qualify for free health insurance now do. For people who live in Washington, DC, and the 28 states that chose to expand Medicaid, anyone earning up to 138 percent FPL can now receive coverage under Medicaid. About 3 million people gained Medicaid coverage during the first enrollment period. However, millions more newly eligible remain unenrolled, and individuals with serious mental illness make up an estimated 7.1 percent of those people.

Unfortunately, some people who live in the states that chose not to expand Medicaid will fall into the Medicaid gap. As the ACA intended for most low-income people to receive coverage through Medicaid, there are no subsidies available in non-Medicaid expansion states for people who earn less than 100 percent FPL. Tragically, many of the people who are shut out of Medicaid live with mental illness. According to a report from the American Mental Health Counselors Association, the states that are not expanding Medicaid leave more than 3.7 million Americans with mental illness without healthcare coverage.

However, federal tax subsidies are available for people in these states who earn between 100 percent and 138 percent FPL to assist in purchasing health insurance on the marketplace.

Learn more about the Medicaid expansion and what it means for you at

4. Insurers must provide coverage for mental healthcare.

Together with the Mental Health Parity and Addiction Equity Act, the ACA guarantees equal coverage for mental healthcare. That means any plan offered as part of the marketplace, and any employer-sponsored plan with 50 or more employees (100 or more starting in 2016), must provide mental health benefits comparable to medical benefits.

In addition, mental healthcare is considered one of 10 Essential Health Benefits under the ACA. That means all plans offered through the marketplace must provide mental health benefits.

Even people who already have coverage should take note of the parity provision. Because parity is the law of the land, anyone who is being made to jump through hoops for their mental health coverage (with higher co-pays, longer waits, or more obstructions to care) should think about reporting the abuse to the Coalition for Whole Health by contacting me directly, and enrolling in a new plan.

For any new individual or small group plans that started on or after July 1, 2014, mental health benefits are a covered Essential Health Benefit and must be provided by law.

5. There is a lot of enrollment help available.

Although the enrollment period is (so far) free of the glitches that marred last year’s roll-out, many people still have questions about how to enroll and how to find appropriate coverage. What’s more, we know from experience with mandatory insurance in Massachusetts that people with serious mental illness tend to be more difficult to enroll in health insurance. For some, the complex application process poses too much of a hurdle.

Fortunately, there are many resources to help people navigate the marketplace and enrollment. At, people simply enter a zip code to find locate local, in-person help. People can also see if they qualify for subsidies with an easy-to-use calculator. Enroll America also offers a number of enrollment resources and links. Finally, I’ve covered these issues in greater detail on my blog over the past three months.

The ACA may not be perfect, but it is still the best chance for affordable mental healthcare for uninsured Americans. Help spread the word, because the clock is ticking.

Editor’s note: Watch the DBSA webinar on healthcare reform to learn more about how to select the insurance coverage that best fits your needs

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