With the future of the Affordable Care Act in immediate peril, people with mental illness are among those most in danger.
Within hours of his inauguration, President Donald Trump signed an executive order to scale back the Affordable Care Act, making good on his promise to dismantle the act — even without a replacement.
As a clinical psychologist and assistant professor in the department of psychiatry and behavioral sciences at Northwestern University, I have often witnessed how some prioritize their physical health over mental health.
Some, including policymakers, perceive mental health treatment as less important; it is the first expenditure to go when other demands present, or when the individual cost becomes too great. It is often taken for granted how poor mental health can negatively impact physical health and interfere with productivity.
But the social and economic burdens of untreated mental illnesses are tremendous.
Approximately one in five adults, or 43.5 million people, in the United States meet criteria for a mental illness. Less than half of those with mental illness receive the treatment they need.
Mental illness is associated with impairments in interpersonal and work functioning, increased risk of physical illness and three times the all-cause death rate. It is the leading cause of disability adjusted life years worldwide and accounts for 37 percent of healthy years lost from non-communicable disease. In 2010, the global cost of mental health conditions was estimated at $2.5 billion. Two-thirds of the cost was from indirect costs related to disability or death.
It is unknown what exactly the impending changes in health care coverage will be, but it doesn’t look good for mental health treatment.
People with mental illness are disproportionately represented among those who are uninsured and living below the federal poverty line. People who are uninsured are at increased risk for suicide and less likely to receive treatment.
Since the implementation of the ACA more than six years ago, more than 20 million adults gained coverage through early 2016. As a result, the uninsured rate dropped to a historic low, at 8.6 percent.
According to a U.S. Department of Health and Human Services report, “individuals and families of all income levels, age groups, races and ethnicities, and urban and rural areas have seen substantial reductions in uninsured rates.” The largest drops in uninsured rates were seen among individuals who are poor, low-income, Black, and Hispanic.
As a researcher at Northwestern, I examine methods to improve access and engagement in mental health care in community based settings. For the past two years, I have led a study examining the effectiveness of a depression intervention integrated into in a Federally Qualified Health Center that serves low-income, uninsured individuals.
Many of the participants enroll in the study because the program is free and their options for other mental health resources are scarce. The integration of the depression intervention in the facility where they receive their primary care treatment also makes the service more accessible and reduces stigma.
Even though many of the low-income participants in the study have some form of insurance coverage, there are few available resources in the communities to receive treatment. The ACA reduces cost as a barrier to mental health treatment, but there is a need for more service providers to deliver high-quality mental health treatment. Dismantling the ACA would destabilize a system designed to make mental health care equally as accessible as general health.
Mental health coverage was a prominent feature in the ACA from the start, with three key policy changes over the course of its implementation that drastically expanded mental health and substance use disorder coverage.
In 2008, Congress passed the Mental Health Parity and Addiction Equity Act, which required large-group plans that cover mental health and substance use treatment to do so with benefits on par with other medical/surgical care.
The ACA extended the equity act to include individual and small group plans, as well as Medicaid, in addition to the large group plans to which it originally applied. Since 2014, all new individual and small-group plans have covered mental health and addiction treatment, and have been required to do so with benefits that are no less favorable than benefits for medical or surgical care.
As it stands now, all individual and small-group plans effective since January 2016 must cover behavioral health services with no annual or lifetime dollar limits among the essential health benefits (mental health and substance use treatment, hospitalization, ambulatory care services, and emergency room). Insurers can no longer put an annual or lifetime cap on spending for these benefits.
The ACA requires all non-grandfathered health plans — including large-group plans — to cover a range of preventive care at no cost to the patient. Among the benefits included are depression and alcohol misuse screening for adults and adolescents, as well as autism screening and behavioral assessments for children.
Even before the ACA, Medicaid was the single largest payer for mental health services in the United States. The ACA’s Medicaid expansion program allowed for individuals whose household income was 138 percent below the federal poverty level, or $16,238 for a single person household, to qualify for Medicaid. It provided marketplace subsidies for individuals between 100 to 400 percent the poverty level, or $11,770 — $47,080 annual income.
Improvements in insurance coverage were especially dramatic for poor, low-income, and racial/ethnic minorities in Medicaid expansion states. Medicaid expansion has undoubtedly increased access to mental health and substance use services to those in greatest need of treatment. According to the federal Substance Abuse and Mental Health Services Administration nearly 30 percent of those who got coverage through Medicaid expansion have a mental or substance use disorder.
One of the proposed changes to the ACA is to give states more latitude in executing health care legislation. Up until 2014, Medicaid expansion was optional. After 2014, states that opted not to expand did not face any real penalties.
As of September of last year, 19 states had opted not to expand Medicaid. The ACA does not provide financial assistance to people below poverty for other coverage options aside from Medicaid expansion.
As a result, in states that did not expand Medicaid, many adults fell into a “coverage gap” of having incomes above Medicaid eligibility limits but below the lower limit for Marketplace premium tax credits.
Nearly 2.5 million poor and uninsured adults fall into this coverage gap. Giving states more control could lead to fewer states participating in the essential Medicaid expansion and more adults falling in the coverage gap.
Some individuals say if the ACA is repealed, they will return to receiving their health care in emergency rooms as they did previously, but health care in the ER is costlier than primary and preventive care services. The average cost for an emergency room visit is $1627 and $2100 for a 4 day inpatient stay in a psychiatric hospital compared to $100-$200 outpatient counselling visit.
Mental health care in the ER is meant to be reserved for those displaying the most severe symptoms, namely those people who are at high risk for violence toward others or suicide. Individuals with need for mental health services who do not receive necessary mental health treatment often end up homeless or in jail.
To be sure, the ACA has its shortcomings. There is a large coverage gap and marketplace premiums are prohibitively high; the average cost for a silver care plan is $345/month.
Health care professionals are also polarized on their views of the ACA. Some physicians feel that the ACA has increased their burden; they spend more time dealing with regulations and paperwork and less time caring for patients. Others acknowledge that the ACA has been beneficial to those who are poor and otherwise unable to afford medication, testing, and treatment. However, in the Medicus’ 13th annual physicians practice preference and relation survey, less than 3 percent of doctors gave the ACA an “A.” In the 2016 survey by Merritt Hawkins for the Physicians Foundation, only 3.2 percent of physicians gave the ACA an “A.”
While the ACA expanded coverage for mental health treatment, there are simply not enough mental health service providers available to deliver the services.
But the ACA was only the first step in establishing equity in insurance coverage for mental and physical illnesses. Repealing it without any idea of what comes next will prove disastrous.
In December of last year, the American Psychological Association and the American Psychological Practice Association membership drafted a letter to then President-elect Trump outlining six core objectives for federal health care reform, including a call for universal access to a standard package of essential health services inclusive of mental and substance use disorder services and an integration of mental and behavioral health into primary care.
Mental health has long been the step-child of health care. Not only has the health care system de-valued mental health care, but individuals themselves perceive physical health as more important than mental health, leading to delays in receiving treatment and worsening of the condition.
Decades ago, Rev. Dr. Martin Luther King, Jr. said, “Of all of the forms of inequality, injustice health care is the most shocking and inhumane.”
Health care is a basic human right — and mental health is an integral quotient in a person’s total health. Our health care system won’t be equitable for every American unless it addresses mental health.
Inger E. Burnett-Zeigler is a clinical psychologist and assistant professor at Northwestern University, Feinberg School of Medicine, Department of Psychiatry and Behavioral Sciences. She is an NU Public Voices Fellow with The OpEd Project.