Moving mental and behavioral health beyond parity

For much of her adult life, Cassie (not real name) struggled to get out of bed. Taking her kids to school, let alone showering or preparing meals was often more than she could handle. Cassie has bipolar disorder, and while she had health insurance through her employer, it did not offer mental or behavioral health benefits.  The therapy and prescriptions she needed were too expensive. She was desperate, barely holding on.

When key provisions of the Affordable Care Act — specifically, the essential health benefits (EHBs) — took hold in 2014, Cassie, and millions like her, could finally afford the counseling, psychotherapy, and prescription medication they needed. The EHBs closed gaps in coverage by requiring all health plans in the individual and small group markets to cover mental health and substance use disorder services.

As a nurse and a mental health services researcher, I am grateful for the ACA in closing some long-standing gaps in mental health and behavioral health. Like a neglected surgical wound, these gaps — stigma, uncovered care, and denial of coverage — risk dehiscing if the ACA is repealed.

In the past, health reform plugged holes in mental health services by instituting parity. Parity requires health insurers and group health plans to provide the same level of benefits for mental and/or substance abuse treatment and services that they do for medical/surgical care. Before parity, mental health services could have different co-pays and lifetime limitations than treatment for other chronic health conditions. Getting treatment for Cassie’s asthma including prescription medications and visits to see a medical specialist were covered by her insurance, but treatment for her bipolar disorder was not.

And yet parity in coverage did not mean all insurers offered mental and behavioral health benefits. A third of individuals with health insurance they purchased on the individual market still were not covered for substance use disorder services, and nearly 20 percent had no coverage for mental health services

The ACA gave parity the teeth it lacked to close gaps in mental health coverage. It also mandated that Medicaid benchmark plans and qualified plans offered on the Health Insurance Marketplace cover behavioral health treatment and services as part of an essential benefits package.

What’s more, the ACA stopped health insurers from “underwriting”– evaluating the health status, health history, and other risk factors of applicants to determine whether and under what terms to issue coverage. Before the ACA, “declinable” conditions included a current or past diagnosis of alcohol abuse, drug abuse, or mental disorders.  Additionally, many insurers maintained a list of declinable medications, including clozapine, risperidone, lithium, aripiprazole, and haloperidol — common and effective treatments for psychosis.

Critics may argue that expanding services will increase costs to taxpayers. But the cost of health care does not capture the full cost of mental disorders. By one estimate, the cost of untreated mental disorders — the indirect costs incurred through a reduced labor supply, public income support, reduced educational attainment, and costs associated with incarceration and homelessness — is over $300 billion.

Granted, payment for services and treatment is not enough. We must ensure patients have access to treatment. By some estimates, only 40 percent of patients get the medications and counselling they need. The ACA tries to address this by incentivizing delivery-system reform to shift treatment of mental health and addiction services to primary care. But not all primary care physicians are trained to meet the needs of these patients.

If key private insurance market rules of the ACA are rolled back, patients run the risk of inadequate treatment for their mental illness. Whatever happens to the ACA in the new Congress, it’s critical to maintain parity in benefits between mental health/behavioral health and medical-surgical benefits, mental health and behavioral health as minimum essential benefits, and insuring individuals despite pre-existing conditions.

Hayley D. Germack is a nurse and health services researcher and can be reached on Twitter @hgermack.

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