On December 18, 2019, a big piece of healthcare news went relatively unnoticed amidst the impeachment vote in the United States House of Representatives. A federal court based in New Orleans ruled that the “individual mandate” within the Patient Protection and Affordable Care Act (ACA), the provision that imposes a tax penalty on those in the US who do not have health insurance, was not constitutional. The court failed to make decisions on the rest of the law, asking a lower court to decide if the ACA could hold up with the individual mandate removed. Democrats in favor of the healthcare bill have vowed to fight for its longevity, and it’s expected that it will eventually be heard before the US Supreme Court.
Still, the future of the ACA is once again in question, and the countless Americans who have accessed healthcare in the last decade with the help of Medicaid expansion and marketplace subsidies now face uncertainty. So far, the bill is estimated to have saved the country about $2 trillion in health costs. But with the repeal of the individual mandate, 13 million Americans are expected to choose to go without coverage by 2027, leading to an expected 10% increase in annual premiums on average for plans in the individual marketplace. For many, this translates to even higher costs in a country that is already spending disproportionately more on healthcare. Those of us that live with a mental health concern have particular cause for concern.
How the ACA Changed Mental Health Care in the US
- The ACA required that a number of preventive care services, including certain screenings, be available to patients at no cost. One of these screenings was the inclusion of a yearly screener for depression, alcohol misuse, and cognitive impairment.
- Insurance companies could no longer deny plans to individuals based on their pre-existing conditions. This was a big win for the mental health advocacy community, as serious mental health concerns (major depression, anxiety, etc.) were the second most common reason cited for health coverage denials. Even mental health counseling for situational or acute concerns (grief, trauma, etc.) could count as a “pre-existing condition” prior to the ACA.
- The legislation also expanded the existing mental health parity laws in the US (Mental Health Parity and Addiction Equity Act of 2008). The former parity laws required that mental health services had to be covered in a way that was equal to physical health services but only IF mental health services were offered by the plan. Many plans got around these laws by simply not offering coverage for mental health and substance use services. The ACA closed this loophole by listing mental health services as one of the ten “essential health benefits” for individual and employer-provided health plans (different parity laws apply to plans offered by Medicaid and Medicare).
- The Community Health Center Fund, established by the ACA, generated over $11 billion in grants for community health centers, the primary care clinics seeing a huge portion of the country’s under- and uninsured population, to expand services in their communities. Behavioral health services were one of my qualifying service targets eligible for funds.
As a result of these provisions, million uninsured Americans were able to obtain coverage. The number of patients with mental health concerns that were uninsured or could not afford treatment dropped post-ACA implementation. The ACA has allowed providers and health networks to find innovative ways to integrate physical and behavioral health. As a result, patient satisfaction with providers and treatment has, not surprisingly, increased. Nearly one-third of Medicaid dollars are now spent on mental health or substance use disorders. Those living at 138% of the Federal Poverty Line, those who may have previously had to delay seeking care for mental health concerns, are now able to receive earlier intervention and more consistent care.
Having a mental illness isn’t cheap, and healthcare reforms have been instrumental in improving access to care for countless Americans. A 12-month prescription for antidepressants costs approximately $800. An in-patient hospital stay costs more than ten times that. Individuals with depression have more than twice the number of outpatient visits per year than those without and more than three times as many prescriptions. Repealing the Affordable Care Act or dismantling its’ individual provisions could mean that the United States returns to a not-so-distant past where nearly 20% of individual plans offered no coverage for mental health services. With Medicaid expansion removed, 3 million low-income Americans with with serious mental health concerns could find themselves with nowhere to turn for care. Repealing the essential health benefits would allow insurers to go back to side-stepping parity laws. And should states be allowed to reduce Medicaid eligibility again, individuals living with a mental health concern will be disproportionately impacted.
There’s still time for major portions, if not all, of the ACA to be saved. Due to the lengthy court proceedings, the case would not make it in front of the Supreme Court until after the 2020 elections, lending hope that a new wave of elected officials might hinder attempts to dismantle the legislation. But whatever the next year of divisive American politics brings, those living with mental health concerns should not be punished. At a time when illness attributed to mental health or substance use are on the rise in the United States, and at a time when more economic productivity is lost to mental health concerns than any other non-communicable disease, weakening the current mental health delivery system is more than irresponsible: it’s dangerous.