What ACA re­peal could mean for men­tal health cov­er­age

Modern Healthcare - - NEWS - By Steven Ross John­son

Men­tal health ad­vo­cates fear the loom­ing death of the Af­ford­able Care Act means los­ing hard-fought ground on ex­pand­ing ac­cess to treat­ment for men­tal ill­ness.

Many view the ACA—which in­cludes men­tal health services and treat­ment for sub­stance abuse as re­quired ben­e­fits for health plans—as the most sig­nif­i­cant of three leg­isla­tive pil­lars of that progress.

“This is an­other rea­son why the im­me­di­ate re­peal of the Af­ford­able Care Act cre­ates a cas­cade of un­in­tended con­se­quences that are not go­ing to be ac­cept­able to the vast ma­jor­ity of peo­ple,” said Paul Gionfriddo, pres­i­dent and CEO of Men­tal Health Amer­ica.

Nearly nine years ago Congress adopted leg­is­la­tion in­tended to im­pose par­ity in health cov­er­age for men­tal health services. The Obama ad­min­is­tra­tion im­ple­mented the law in 2013 with fi­nal reg­u­la­tions that re­quired health plans to have the same de­ductibles, cost-shar­ing and cov­er­age lim­its for men­tal health services as of­fered for med­i­cal and sur­gi­cal services.

Congress added more pro­tec­tions late last year in the 21st Cen­tury Cures Act, signed by Pres­i­dent Barack Obama in De­cem­ber. The law in­cludes tougher en­force­ment of par­ity re­quire­ments and calls for HHS to help health plans com­ply.

Both the 2008 Men­tal Health Par­ity Eq­uity Act and the 21st Cen­tury Cures Act won bi­par­ti­san sup­port. But the ef­fec­tive­ness of both laws would be se­verely hindered by ACA re­peal.

“The irony is you can have a de­cent par­ity law, which we do, the over­sight of the 21st Cen­tury Cures Act, but if you take out the Af­ford­able Care Act’s es­sen­tial ben­e­fits pro­vi­sion, then you could ef­fec­tively gut it with­out even in­tend­ing to,” Gionfriddo said. “Some­body who casts a re­peal vote with­out com­ing up with an al­ter­na­tive that’s go­ing to be in­clu­sive of peo­ple with men­tal health is­sues would be do­ing a lot to un­der­mine this new leg­is­la­tion.”

Among the sup­port­ers of re­peal­ing the ACA is Rep. Tim Mur­phy (R-Pa.), who penned many of the men­tal health pro­vi­sions folded into the 21st Cen­tury Cures Act. Mur­phy con­tends the ACA has failed to im­prove ac­cess to men­tal health­care even as the rate of Amer­i­cans with­out health in­sur­ance has fallen to the low­est on record.

“The Af­ford­able Care Act did not im­prove the fed­eral men­tal health sys­tem, it sim­ply ex­panded in­ef­fec­tive, in­ef­fi­cient poli­cies that have not de­liv­ered treat­ment be­fore tragedy,” said Mur­phy spokes­woman Carly Atchi­son. “Rep. Mur­phy wel­comes the op­por­tu­nity to work across the aisle, and re­mains com­mit­ted to en­sur­ing that those with se­ri­ous men­tal ill­ness can get the treat­ment they need with in­sur­ance that isn’t pas­sive, but in­stead works in part­ner­ship with the pa­tient.”

“The irony is you can have a de­cent par­ity law, which we do, the over­sight of the 21st Cen­tury Cures Act, but if you take out the Af­ford­able Care Act’s es­sen­tial ben­e­fits pro­vi­sion, then you could ef­fec­tively gut it with­out even in­tend­ing to.” PAUL GIONFRIDDO Pres­i­dent and CEO of Men­tal Health Amer­ica

Pres­i­dent Don­ald Trump’s ad­min­is­tra­tion has yet to un­veil any spe­cific plans for what would re­place the ACA. Last week, a group of Repub­li­can se­na­tors in­tro­duced a bill dubbed the Pa­tient Free­dom Act. It would re­tain some of ACA’s pro­vi­sions, in­clud­ing re­quir­ing in­sur­ers to cover men­tal health and sub­stance use dis­or­der services and main­tain­ing par­ity rules for plans sold on the in­di­vid­ual mar­ket.

The pro­posed bill would also al­low

“I don’t think it’s con­sis­tent to pro­fess a great de­sire to im­prove men­tal health and to help peo­ple with men­tal ill­nesses and at the same time to talk about block grant­ing the en­ti­tle­ments that they have and es­sen­tially elim­i­nat­ing the en­ti­tle­ment they have now through Med­i­caid.” JEN­NIFER MATHIS Deputy le­gal di­rec­tor at the Bazelon Cen­ter for Men­tal Health Law

states to keep in place the ACA’s Med­i­caid ex­pan­sion or cre­ate a “state and mar­ket-based al­ter­na­tive.”

The Trump ad­min­is­tra­tion and con­gres­sional lead­ers, mean­while, fa­vor turn­ing Med­i­caid into a block-grant pro­gram, which would give states a fixed amount of money to pro­vide health­care for low-in­come res­i­dents.

Pre­vi­ous Med­i­caid block-grant pro­pos­als have as­sumed sig­nif­i­cant sav­ings from the model. Pol­icy ex­perts say that means states would have to re­duce el­i­gi­bil­ity, nar­row the scope of ben­e­fits or im­pose cost-shar­ing re­quire­ments.

How Med­i­caid plays out is cru­cial, said Dr. Maria Oquendo, pres­i­dent of the Amer­i­can Psy­chi­atric As­so­ci­a­tion, be­cause peo­ple who suf­fer from men­tal ill­ness are dis­pro­por­tion­ately likely to be un­em­ployed or have low-wage jobs with no health ben­e­fits.

Med­i­caid is the sin­gle largest payer for be­hav­ioral health services in the U.S. In 2009 the pro­gram ac­counted for 26% of all spend­ing on men­tal health services, ac­cord­ing to a June 2015 re­port by the Med­i­caid and CHIP Pay­ment and Ac­cess Com­mis­sion.

Cov­er­age of be­hav­ioral health services pro­vided un­der Med­i­caid was found to be gen­er­ally more com­pre­hen­sive than services cov­ered by plans sold in the ACA mar­ket­places, ac­cord­ing to a June 2015 study by the Kaiser Fam­ily Foun­da­tion.

“The whole ar­ray of in­ten­sive com­mu­nity-based men­tal health services that peo­ple with sig­nif­i­cant psy­chi­atric dis­abil­i­ties need, that’s all through pub­lic men­tal health and that’s all Med­i­caid-fi­nanced,” said Jen­nifer Mathis, deputy le­gal di­rec­tor at the Bazelon Cen­ter for Men­tal Health Law. “I don’t think it’s con­sis­tent to pro­fess a great de­sire to im­prove men­tal health and to help peo­ple with men­tal ill­nesses and at the same time to talk about block grant­ing the en­ti­tle­ments that they have and es­sen­tially elim­i­nat­ing the en­ti­tle­ment they have now through Med­i­caid.”

Re­peal­ing the ACA’s pre­mium sub­si­dies and the Med­i­caid ex­pan­sion with­out cre­at­ing other av­enues for cov­er­age would mean 30 mil­lion more Amer­i­cans would be unin­sured in 2019, ac­cord­ing to the Ur­ban In­sti­tute. That num­ber as­sumes 13 mil­lion fewer peo­ple would be cov­ered by Med­i­caid and CHIP.

“The risks that we’re fac­ing now with ACA re­peal are peo­ple los­ing cov­er­age al­to­gether,” Mathis said. “And par­ity doesn’t get you any­thing if you don’t have cov­er­age to be­gin with.” ●

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