Mental Health Care: At Risk in GOP Reform Proposal

Mental health continues to live on the fringes of the health care delivery system. According to the former Surgeon General, “even more than other areas of health and medicine, the mental health field is plagued by disparities in the availability of and access to its services,” with significant barriers related to patients’ socioeconomic background. “We have allowed stigma and a now unwarranted sense of hopelessness about the opportunities for recovery from mental illness to erect these barriers. It is time to take them down.” Quality mental health care is in our best interest: one in five Americans has a mental health condition in a given year and, by some estimates, one in two Americans can expect one over the course of their lifetime.

While the Affordable Care Act (ACA) made some attempts to improve its inadequacies, mental health care has taken a back seat in the never-ending debate on health care reform. Recently, House Republicans released their “repeal and replace” plan, the American Health Care Act (AHCA), which was quickly dismissed by many on both ends of the political spectrum as “regressive“ and “critically flawed.“ Senator Cotton of Arkansas urged his fellow Republicans: “pause, start over. Get it right, don’t get it fast.”

LDI Senior Fellows Colleen Barry and David Mandell addressed some of the AHCA’s more troubling components with regard to mental health care in a well-timed New England Journal of Medicine Perspective. Their chief concerns? For individuals with psychiatric and developmental disabilities, aspects of the AHCA place their “future in jeopardy.”

1. The ACA designates ten categories as essential benefits that must be covered, including mental health services and pharmacy, and expanded mental health parity laws, which require insurers to treat mental health conditions similarly to physical conditions. While the AHCA maintains the essential benefits in commercial coverage, it removes the requirement that extends these benefits to Medicaid, the largest provider of mental health care services. Currently, the AHCA does not address mental health parity, though Pennsylvania’s Rep. Tim Murphy proposed an amendment to codify current parity law.
2. The AHCA would transform Medicaid from its current federal-state partnership structure to a state administered fixed per capita rate, effectively ending Medicaid’s historical open-ended formula and shifting it to a defined contribution program. Critically, the bill as originally drafted does not change the services to be provided and groups to be covered, meaning states will have to choose between using state dollars and findings alternative ways to cut benefits within the bounds of existing law. If states aren’t assured a federal match for dollars spent, they will likely be more conservative and less creative with their spending, which is a particular detriment to services for individuals with severe mental health conditions and high service needs.
3. Millions of Americans with and without disabilities have gained insurance under the Medicaid expansion. Under the AHCA, the enrollment will freeze in 2020. As a result, low-income individuals who lose employer-based health insurance after 2020 will be unable to have continued coverage.
4. Another proposed policy change strongly supported by President Trump is to allow the purchase of insurance across state lines in an effort to improve market competition. Most states have now introduced insurance mandates that require insurers to cover the treatment of some conditions, including autism, and some fear that interstate insurance will prompt states to rethink the desirability of requiring coverage mandates that could drive up the price of in-state insurance. Further, there may be incentives for employers to cross state lines and cherry pick state-level policies in order to cut costs.
    

These issues will only exacerbate the problems that the mentally disabled face. Annual spending on mental health care in the US in recent years was around $200 billion dollars, a drop in the $3 trillion bucket. There is a severe shortage in providers, and no reason to expect it to get better. Issues with insurance coverage and low reimbursement rates further compromise access. Oh, and don’t forget about the stigma. In addition to managing their symptoms, those with a mental disability continue to be “robbed of the opportunities that define a quality life: good jobs, safe housing, […] and affiliation with a diverse group of people.” As a result of these and other issues, nearly 60 percent of adults with a mental health condition had not received treatment in the previous year.

Mental health care isn’t a sunk cost. Rather, it’s a long-term investment, and a good one at that. Every $1 spent on treatment for mental health care yields an estimated $4, which is similar to the return on addiction treatments. Among other things, treating mental health is associated with stable employment, lower rates of criminal recidivism, a reduction in the transmission of HIV, and less utilization of health care at large. So, as the debate on health care rages on, remember that mental health care isn’t a short game. We’re not going to reap the benefits today or tomorrow. Instead, they’ll accrue and compound over the course of our lifetime.