Health law raising U.S. mental health parity to the next level: Access will widen
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* Kim Krisberg

Nearly every day, the Mental Health Center of Western Maryland gets calls from people who need care but have no insurance and cannot afford to pay out of pocket. The Hagerstown, Md., center cares for about 1,600 patients every month, but there are many in need that the center has no choice but to turn away.

It is a problem that Mark Lannon, MSW, LCSW-C, the center’s executive director, hopes will become less common as the nation’s recently upheld health reform law is fully enacted. In particular, Lannon said the Patient Protection and Affordable Care Act’s mental health access and parity provisions will not only widen access to services, but drive better integration between mental health and primary care.

“The law will definitely improve access,” Lannon said. “And I do believe that increasing accessibility will help people who might deny they have a problem to seek help.”

The movement for mental health parity received a big boost with the 2010 passage of the Affordable Care Act, which builds on previous efforts to bring coverage of mental health on equal footing with other health services. In 2008, federal lawmakers enacted the Mental Health Parity and Addiction Equity Act, mandating that insurers who choose to cover mental health services do so with the same financial requirements and treatment limitations they would apply to other medical care. Unfortunately, the act only applied to employers with 50 or more workers, leaving gaps.

The 2008 law was a significant move to end insurance discrimination against people living with mental illness. However, it was also a “huge opening for nothing to occur,” said Chris Koyanagi, policy director at the Bazelon Center for Mental Health Law. In other words, insurers could still circumvent the parity law by simply dropping coverage for mental health.

Fortunately, the Affordable Care Act goes a big step further by both requiring certain insurance plans to offer mental health and substance abuse disorder services and to cover them on par with other health care. Under the health reform law, mental health and substance abuse services are among the 10 categories of essential health benefits that must be covered by insurers participating in state-based health insurance exchanges as well as by expanded state Medicaid programs. Also, starting in 2014, insurers can no longer deny coverage or raise premiums based on a pre-existing mental illness or substance use disorder.

According to the Substance Abuse and Mental Health Services Administration, nearly 46 million Americans were living with a mental illness in 2011, and about one-fifth to one-third of the nation’s uninsured have mental and substance use disorders.

“This is a huge opportunity for improving access to mental health services — there’s no question,” Koyanagi told *The Nation’s Health*. “But there will be some tricky steps along the way…we’ll just have to see how this plays out.”

In particular, Koyanagi referred to the Supreme Court’s decision that the federal government cannot withhold funds from states that fail to expand their Medicaid programs. The Medicaid expansion — which will be initially supported entirely by federal funds — is now in the hands of state lawmakers. If states forgo expansion and related funding, that decision will likely contribute to the continued deterioration of public mental health services, Koyanagi said.

“Medicaid dollars can help build back up the public mental health system,” she said. “We haven’t been expanding the state mental health system for a very long time. We’ve just gone from dire to very dire. I’d hope states would be delighted to get the federal (expansion) money.”

Like much of the Affordable Care Act’s implementation, how the law’s mental health provisions play out in communities will be largely up to states. State policymakers will not only decide whether to expand Medicaid eligibility, but they will also decide exactly what items and services to include under the 10 essential health benefit categories. Unfortunately, some states might lose out on the opportunity to craft a mental health benefit tailored to its residents’ needs.

One example is Texas, home to the nation’s highest uninsurance rate and ranked among the worst states in per capita mental health spending. In early July, Texas Gov. Rick Perry sent a letter to the U.S. Department of Health and Human Services stating that “Texas has no intention of implementing a state insurance exchange or expanding Medicaid.”

If Perry’s promise holds, federal officials will set up Texas’ exchange instead, which “means we lose a lot of influence over what our mental health services will look like…it won’t be done by Texans for Texans,” said Colleen Horton, MPAff, policy program officer at the Hoggs Foundation for Mental Health at the University of Texas-Austin. She noted that without the Medicaid expansion, residents who fall in the income gap between current Medicaid eligibility and eligibility for subsidies via the state insurance exchange will remain shut out from health care access on the individual market.

“Right now, it’s a wait-and-see situation to see if there’s any change of heart at the state level to take advantage of the opportunity to provide critically needed services,” Horton said. “It’s very obvious that if you have serious mental illness and you don’t get the services you need, you could end up in a state psychiatric hospital, which costs over $400 a day…so, it’s certainly not costs that we escape (by refusing health reform).”

At Austin Travis County Integral Care, which provided mental health and related services to more than 8,000 residents in July alone, demands for services have increased by 10 percent during the last year and a half, said CEO Dave Evans, MA. With one in four residents of central Texas currently uninsured, Evans said the state is at risk of losing a big opportunity to detect and treat mental illness in its early stages.

“Personally, I’m excited, but we need to stay the course,” he said. “This is a sweeping federal law that will still find its expression and significance through state-administered programs, and that chapter isn’t finished being written.”

Evans said he and his colleagues are in the midst of efforts to better integrate mental and behavioral care into the larger health care delivery system — “integration has definitely been given an urgency and push with the Affordable Care Act,” he noted. Better integration will lead to better overall health outcomes for people with mental illness, Evans said. Part of the Affordable Care Act’s quality improvement measures establish and promote patient-centered medical homes, which ideally coordinate care for all of a patient’s needs.

APHA member Ron Manderscheid, PhD, executive director of the National Association of County Behavioral Health and Developmental Disability Directors, said the law’s integration push is “huge” for people with mental illness, who are often in poorer health and have a shorter life expectancy than people without mental illness. He said that among the more than 30 million Americans expected to gain insurance due to the Affordable Care Act, an estimated 10.5 million have a mental health, behavioral health or substance abuse problem. But Manderscheid noted that as more Americans gain access to mental health care, federal policymakers need to invest more in training mental health practitioners and addressing the field’s workforce shortage.

“For us, the (Affordable Care Act) is about social justice,” he said. “Now, our work turns to building the important political coalitions at the local level to press states that are least likely to adopt the Medicaid expansion to adopt it.”

For more information on the Affordable Care Act and mental health, visit [www.bazelon.org](http://www.bazelon.org) or [www.nmha.org](http://www.nmha.org).

*   Copyright The Nation’s Health, American Public Health Association