Health Care Reform Benefits Americans With Behavioral Health Conditions

Written by on October 31, 2012 in Features - No comments

The Affordable Care Act (ACA), which the Supreme Court recently upheld, is of great potential benefit to people with behavioral health conditions, i.e., people with mental and/or substance abuse disorders.  This is true because, under the provisions of the ACA[i]:

(1)  Many Americans with such conditions who currently do not have health care coverage will get coverage.
(2)  Behavioral health conditions that now are not covered or are only partially covered will be covered (“parity”).
(3)  Coordination of physical and behavioral health care should become more common than it is now.
(4)  Health maintenance activities are encouraged and supported to some extent,
(5)  Community-based care is encouraged and supported.
(6)  Some economic barriers to screening for and treating behavioral health conditions will be eliminated.

Improvements in behavioral health care under the ACA have not been a prominent part of the discussions and debates about health care reform in the United States.  Probably because spending on behavioral health is under 7% of all health spending[ii], mental and substance use disorders just don’t seem to be of the same order of importance as physical health conditions.  In our view this is unfortunate for several reasons.

  • Behavioral health conditions are a source of suffering for the people who have them and often for their family members as well.
  • They are the leading cause of long-term disability as measured by disability adjusted life years (DALYS).[iii]
  • People with co-occurring chronic physical disorders such as heart disease and mental disorders—especially depression—are at substantially elevated risk for disability and premature mortality. [iv],  [v]
  • Care for people with co-occurring physical and behavioral disorders is considerably more expensive than care for people without co-occurring disorders, driving up the overall cost of health care in the United States.[vi]
  • Disabled older adults with co-occurring disorders are more likely to be placed in nursing homes than cared for in community settings, driving up the cost of long-term care.[vii], [viii]
  • People with serious mental illness often do not get the physical health care that they need for obesity, high blood pressure, diabetes, and heart conditions for which they are at high risk and which contribute to low life expectancy for this population.[ix]
  • Improved overall health of Americans, such as reduced obesity, depends on changes in lifestyle and behavior, which rarely happen unless motivation and other psychological issues are addressed.[x]

Improved coverage

People with behavioral health conditions, especially those with serious, long-term conditions are at high risk for poor health, disability, and premature death.  Unfortunately, many of them do not have health coverage and therefore do not get treatment—or get poor treatment—for conditions for which they are at high risk such as obesity, high blood pressure, diabetes, heart and pulmonary conditions, hepatitis, and sexually transmitted diseases, including HIV+/AIDS.

The ACA mandates that all American citizens and legal aliens have health coverage.  Subsidies will be available for people too poor to afford coverage. Employers for the most part are required to cover their employees, with exceptions for small businesses, many of which will get subsidies to pay for coverage.  Medicaid will be expanded to cover people up to 133% of poverty in states that choose this option.  State health insurance exchanges will provide a mass market through which individuals and small groups can purchase standardized health insurance packages at the same rates as large groups.  Young adults up to the age of 26 can continue to be covered under their parents’ health insurance plans.

In addition, health insurance reforms will be of benefit to everyone with health insurance, including people with behavioral health conditions.  The most important of these reforms are that plans will not be permitted to exclude people with pre-existing conditions or to drop coverage of people who become seriously (and expensively) ill.

Parity

The ACA also provides improved coverage of mental health and substance abuse conditions. This is a major advance. A very few years ago, new federal laws required “parity” in the coverage of mental and physical health conditions in employer-based health benefit plans and Medicare, but the provisions were limited. The ACA carries these requirements forward and expands them considerably by making behavioral health services for both mental and substance use disorders part of the basic, minimal coverage package that will be mandated.

The ACA also provides enhanced Medicare coverage of medication, including of psychiatric medications. This will result in (1) reduced out-of-pocket spending on pharmaceuticals by shrinking the phase of personal spending on medications not covered by Medicare, i.e. the “donut hole” and (2) enhanced access to psychiatric medications prescribed by a physician that were not covered in the original version of Medicare prescription drug coverage.

Coordinated Care

There has been widespread agreement for several decades that it is critical to improve coordination of care between the mental health and substance abuse care and between behavioral health and physical health care.  The ACA emphasizes the importance of integrating and coordinating the delivery of physical and mental health services and provides incentives to providers to integrate care, including:

  • Rate increases for medical practices recognized as “medical homes” that provide coordinated care and preventive services, among other features.
  • Increased federal funding for Medicaid payments to “health homes,” which are organizations that coordinate care for people with chronic physical and/or behavioral health conditions.
  • Contracts with “accountable care organizations” — a new type of structure designed to improve care quality and contain costs.

In these, and other health delivery structures “meaningful” use of electronic medical records is also encouraged and supported.

Home and Community Based Services:

The ACA emphasizes services in the home and community instead of in institutions. There are new demonstration grants as well as new opportunities for Medicaid waivers for state efforts to reduce the use of nursing homes and other institutions and instead provide care for people with disabilities in their homes and communities. In this way it carries forward the policy goal of helping people with psychiatric and other mental disabilities to live in the community rather than in institutions. It also will help states to fulfill the mandate of the Olmstead Decision[xi] of the Supreme Court, which interpreted the Americans with Disabilities Act as requiring states to provide supports to enable people with disabilities to live in the “most integrated” setting in the community rather than in institutions.

Health Maintenance

The ACA also emphasizes health maintenance (lately called “wellness”) and preventive interventions. For example, it provides Medicare payments for some preventive health care and health promotion for the first time. This, of course, benefits people without mental illness as well as those with mental illness, but it is particularly important for people at high risk of obesity and the diseases it drives such as hypertension, diabetes, and heart disease—conditions that are particularly common among people with serious mental illness.

Removing economic barriers to screening and treatment

Protocols for high quality primary care, pediatrics, cardiology, and other medical specialties call for routine screening for mental and substance use disorders—especially for depression.  But many, if not most, practitioners do not do screening, let alone provide or arrange for adequate treatment for behavioral health conditions.  Economic barriers are one of the reasons so many practitioners do not follow the protocols of their fields of practice.

One such barrier has been that Medicare and most private health plans have paid less for the treatment of behavioral health services (if covered at all) than for treatment of physical health conditions.  As noted previously, this disparity in financing is being totally eliminated under the ACA.

Medicare has also added payments for:

  • Screening for alcohol abuse and for depression under some circumstances[xii], [xiii]
    (Provisions related to depression also require “follow up”,[xiv] which may help to support the use of care management models that improve outcomes of depression treatment by about 50%.[xv])
  • An annual “wellness visit”, the purpose of which is to develop a plan to maintain or improve basic health.

Another major economic barrier has been the virtual impossibility of coordinating financing of integrated treatment for people who have both Medicare and Medicaid (the “dual eligibles.)  This tends to be a population with co-occurring physical and psychiatric disabilities—which is the population currently most costly to serve in part because of the severity of their conditions and in part because they often do not get care until their conditions are critical and require long-term, very expensive interventions.  Under provisions of the ACA, demonstrations are now beginning to develop systems of coordinated care, and financing, for this population.

Although there undoubtedly will remain economic disincentives to addressing behavioral health conditions in primary care and specialty practices, the ACA does address some of the significant barriers.  Both by providing coverage for services not previously covered and by encouraging the re-arrangement of medical care into large multi-specialty groups linked by electronic medical records, the ACA lays the groundwork for significant improvement of behavioral health services in the context of the delivery of physical health care.

Conclusion:  Will the ACA by itself result in widespread accessibility to high quality physical and behavioral health care for people with behavioral health conditions?  Certainly not.  It will take vast changes in practice and vast workforce development efforts to bring about the kind of overhaul the American health care system needs.  But the ACA lays the groundwork for far better health care (behavioral and physical) for people with behavioral health conditions.



[i] Kaiser Family Foundation.  “Summary of the New Health Reform Law”.  2010.  http://www.kff.org/healthreform/8061.cfm
[ii] Mark, et al. “Changes in U.S. Spending on Mental Health from 1986-2005 and Implications for Policy” in Health Affairs, February 2011.  http://content.healthaffairs.org/content/30/2/284
[iii] Healthy People 2020.  “Mental Health and Mental Disorders” . 2012 http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=28
[iv]For example, Freedland K. et al. “Impact of Depression on Prognosis in Heart Failure” in PubMedCentral, January 2012.  http://ukpmc.ac.uk/articles/PMC3032411
[v] Ciechanowski, P. et al. “Depression and Diabetes … “ in Archives of Internal Medicine, November 2000. .http://archinte.jamanetwork.com/article.aspx?articleid=485556.
[vi]
Druss, BG & Reisinger, W.  “Mental Disorders and Medical Co-Morbidities.”  Report of the RWJ Foundation, February 2011.  http://www.rwjf.org/pr/product.jsp?id=71883
[vii] Fullerton, C.A., McGUIRE, T.G., Feng, Z., Mor, V., & Grabowski, D.C. “Trends in Mental Health Admissions to Nursing Homes, 1999-2005”. Psychiatric Services, July 2009. http://ps.psychiatryonline.org/article.aspx?articleid=100604
[viii] Grabowski, D.C., Aschbrenner, K.A., Feng, Z., & Mor, V. (2009). “Mental Illness In Nursing Homes: Variations Across States. Health Affairs, May/June 2009. http://content.healthaffairs.org/content/28/3/689.abstract
[ix] Colton, C. and Mandersheid, R.  “Congruencies in Increased Mortality Rates, Years of Potential Life Lost, and Causes of Death Among Public Mental Health Clients in Eight States” in Preventing Chronic Disease, April 2006.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1563985/
[x] Van Dorsten, B.  “The Use of Motivational Interviewing in Weight Loss” in Current Diabetes Reports, October 2007. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1563985
[xi] U.S. Department of Justice.  “Olmstead: Community Integration for Everyone.”  http://www.ada.gov/olmstead/index.htm
[xii] Andrews, M. “Medicare Now Covers Annual Screening for Depression” in Kaiser Health News, April 2012.  http://www.kaiserhealthnews.org/features/insuring-your-health/2012/medicare-depression-screening-michelle-andrews-040312.aspx
[xiii] Anon.  “Medicare Coverage for Alcohol  Misuse  Screening and Counseling” in Medicare Interactive, January 2012.  http://www.medicareinteractive.org/page2.php?topic=counselor&page=script&slide_id=1730,
[xiv] Anon.  “Medicare Pays for Annual Depression Screening” in ACP Internist, March 2012 http://www.acpinternist.org/archives/2012/03/tips.htm
[xv] Unitzer, J. et al.  “Collaborative Care Management of Late-Life Depression in the Primary Care Setting: : A Randomized Controlled Trial”  in Journal of the American Medical Association, December 11, 2002.   http://jama.jamanetwork.com/article.aspx?articleid=195599

By Michael B. Friedman, MSW; Lloyd I. Sederer, MD; and Kimberly A. Williams, MSW

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