Access to Mental Health Care

 VII. Key Issues: Regulation & Reform >> C. Health Reform >> Affordable Care Act (ACA) >> ACA Impact Analysis >> ACA Impact on Access >> Impact on Access to Care >> Impact on Access to Mental Health Care (last updated 10.1.17)
Lead Editor – Dana Beezley-Smith, Ph.D.

Also see ACA and Mental Health Care

Expanded Coverage

  • Affordable Care Act Expands Mental Health/Substance Use Benefits and Federal Parity Protections (Department of Health and Human Services, 2.20.13)
    • About 3.9 million people currently covered in the individual market will gain either mental health or substance use disorder coverage or both.
    • We estimate that 1.2 million individuals currently in small group plans will receive mental health and substance use disorder benefits under the Affordable Care Act.
    • 7.1 million Americans currently covered in the individual market who currently have some mental health and substance use disorder benefits will have access to coverage of Essential Health Benefits that conforms to federal parity protections as provided for under the Affordable Care Act and the Mental Health Parity and Addiction Equity Act.
    • Because the application of parity to Essential Health Benefits will also apply to those currently enrolled in non-grandfathered plans in the small group market, 23.3 million current enrollees in small group plans will also receive the benefit of having mental health and substance use disorder benefits that are subject to the federal parity law.
    • The Affordable Care Act will expand insurance coverage to a projected 27 million previously uninsured Americans through access to private health insurance in the individual and small group markets, the Marketplaces and Medicaid. Essential Health Benefits, including mental health and substance use disorder services subject to parity requirements, will be available to this newly covered population.
    • Through the Affordable Care Act, 32.1 million Americans will gain access to coverage that includes mental health and/or substance use disorder benefits that comply with federal parity requirements and an additional 30.4 million Americans who currently have some mental health and substance abuse benefits will benefit from the federal parity protections.
    • By building on the structure of the Mental Health Parity and Addiction Equity Act, the Affordable Care Act will extend federal parity protections to 62 million Americans. 

Mental Health Parity

FAQS About Affordable Care Act Implementation (PART XXIX) and Mental Health Parity Implementation. “MHPAEA does not mandate that plans and issuers cover MH/SUD benefits. Rather, it applies only if a plan or issuer provides those benefits. However, other provisions of Federal and State law may require coverage of MH/SUD benefits, including the EHB requirements applicable to non-grandfathered individual and small group market coverage under the Affordable Care Act…Contemporaneous with the issuance of the MHPAEA final regulations, the Departments published FAQs about Affordable Care Act Implementation Part XVII and Mental Health Parity Implementation addressing a group health plan’s disclosure obligations under MHPAEA and ERISA generally, as well as the specific information a participant is entitled to receive when a claim for MH/SUD benefits has been denied. In addition to reiterating that “instruments under which the plan is established or operated” under ERISA section 104 includes documents with information on medical necessity criteria for both medical/surgical and MH/SUD benefits, as well as the processes, strategies, evidentiary standards, and other factors used to apply an NQTL, this guidance noted that other provisions of Federal law require such disclosures.” (CMS, 10.23.15)

Parity Rule for Medicaid and CHIP

  • “The Centers for Medicare & Medicaid Services (CMS) today announced a proposed rule to align mental health and substance use disorder benefits for low-income Americans with benefits required of private health plans and insurance. The proposal applies certain provisions of the Mental Health Parity and Addiction Equity Act of 2008 to Medicaid and Children’s Health Insurance Program (CHIP)… The proposed rule ensures that all beneficiaries who receive services through managed care organizations or under alternative benefit plans have access to mental health and substance use disorder benefits regardless of whether services are provided through the managed care organization or another service delivery system. The full scope of the proposed rule applies to CHIP, regardless of whether care is provided through fee-for-service or managed care.” (CMS, 4.6.15)
  • Mental Health Parity in Medicaid Plans Would Help—Not Solve—Limited Access. “Proposed regulations ensuring mental health parity in Medicaid managed-care plans promise better coverage for important services like substance-abuse counseling—at least for beneficiaries who have providers. But the CMS rules won’t guarantee more providers will participate… Mental health stakeholders agree Medicaid and CHIP beneficiaries will be helped by the rule. But they were mixed in their assessment of whether more providers will join managed-care networks and treat program beneficiaries.” (Modern Healthcare, 4.7.15)
  • CMS Finalizes Mental Health and Substance Use Disorder Parity Rule for Medicaid and CHIP. “The Centers for Medicare & Medicaid Services (CMS) today finalized a rule to strengthen access to mental health and substance use services for people with Medicaid or Children’s Health Insurance Program (CHIP) coverage, aligning with protections already required of private health plans. The Mental Health Parity and Addiction Equity Act of 2008 generally requires that health insurance plans treat mental health and substance use disorder benefits on equal footing as medical and surgical benefits.” (CMS, 3.29.16)

Analysis

  • When It Comes To Insurance, Mental Health Parity In Name Only? “By law, many U.S. insurance providers that offer mental health care are required to cover it just as they would cancer or diabetes care. But advocates say achieving this mental health parity can be a challenge. A report released earlier this week by the National Alliance on Mental Illness found that ‘health insurance plans are falling short in coverage of mental health and substance abuse conditions.’ Reporter Jenny Gold of Kaiser Health News tells NPR’s Arun Rath that patients are still having trouble getting their care covered. In this interview, she outlines some of the issues confronting both patients and the insurance industry.” (National Public Radio, 4.4.15)
  • How Government Regulation Is Undermining Mental Health Care.  “Anyone who has given two seconds worth of thought to it knows that school shootings are not occurring because we have a gun problem. They are occurring because we have a mental health problem. So what are we doing about that? Not much. Despite several mental health parity laws, government regulation is one reason why so little is being done. ObamaCare is probably making things worse. If the market for medical care worked like a normal market, providers would specialize, advertise and actively recruit patients who have problems that need to be solved. But standing between the patients and the providers are third-party payers (employers, insurance companies and government). And in direct response to government regulations, these payers have no interest in solving the problems of the mentally ill.” Goodman, John. (Forbes, 12.15.15)
  • A Push for More Data on How Insurers Cover Mental Illness. “Psychiatrists tell stories of suicidal patients being required to get prior authorization from their insurance company before being admitted to a psychiatric hospital. Advocates talk of patients struggling to find a mental health clinician who accepts his or her insurance plan. Some see it as a sign that insurance companies don’t treat mental health or addiction treatment as they would physical illness – despite a federal law requiring it. But some also acknowledge that it’s not clear whether those stories represent isolated cases or show a pattern of practice that violates federal law… But while providers and advocates have embraced a legislative proposal that calls for a working group led by the Connecticut Insurance Department to gather data comparing approval and denial rates for certain behavioral health and medical services, health plans oppose it, saying lawmakers should allow other recent laws and data collection efforts to develop before imposing another requirement.” (Connecticut Mirror, 4.1.16)
  • The Affordable Care Act and Strengthened Mental Health Parity. “Similar plan coverage must be included when comparing more physical medical services to that of psychiatric mental health-related treatment. However, at this point in time, health insurance companies have still not received the necessary guidance from the federal government to incorporate the requirements of the Mental Health Parity and Addiction Equity Act of 2008 into their health plan options. It seems that the Affordable Care Act and other legislation may not have had as much of an impact in improving mental healthcare access, as one report from the National Alliance on Mental Illness shows that only slightly more than half of psychiatrists countrywide accept health insurance. Additionally, about 25 percent of Americans who purchased health insurance plans through the state or federal exchanges were unable to find a mental health provider in their network.” (Health Payer Intelligence, 4.11.16)
  • Even Under Parity Rules, Plans May Charge Higher Specialty Copay for Counseling. “The Mental Health Parity and Addiction Equity Act of 2008 requires most health plans to provide mental health and substance abuse treatment benefits that are at least as generous as the plan’s benefits for medical and surgical care. There’s no rule of thumb. A health plan may charge a higher copayment in some circumstances under parity rules, said Alan Nessman, senior special counsel for legal and regulatory affairs at the American Psychological Association Practice Organization. It’s called the two-thirds test. In general, a plan can’t charge a higher copayment for mental health services than it applies to two-thirds of medical/surgical services. So, for example, if a health plan applies a $50 copayment to outpatient medical/surgical services by in-network providers at least two-thirds of the time, an insurer can charge a $50 copayment for all outpatient mental health services that are provided in network as well.” (Kaiser Health News, 4.12.16)
  • Kaiser Health Tracking Poll, April 2016: Substance Abuse and Mental Health Parity Laws. Policy makers have enacted legal protections aimed at addressing access to care for individuals with substance abuse problems and serious mental health conditions. The Mental Health Parity and Addiction Equity Act, ushered in as one of the many provisions of the Affordable Care Act, legally requires insurance plans to have the same rules for mental health benefits and substance abuse treatment as other medical services. However, many Americans remain unaware of these requirements. About four in ten (43 percent) know that health plans must have the same rules for mental health coverage, while an identical share thinks insurance companies can have separate rules and 13 percent don’t know. Fewer (30 percent) are aware that the requirement applies to substance abuse treatment, while over half (53 percent) incorrectly say insurance plans can have separate rules for substance abuse benefits and 15 percent don’t know. Individuals with personal connections to substance abuse and mental health conditions are no more likely than those without personal connections to know about the legal protections around such treatments.” (Kaiser Family Foundation, 4.28.16
  • Why Is Mental Health Care Hard to Find? “Finding mental health care is not as easy as finding physical health care. There are several reasons for this. NAMI explains there is a, ‘Critical nationwide shortage of mental health professionals, including psychiatrists and licensed therapists.’ In-network providers may not be able to take new patients. There may be no available in-network providers in a given area. Many individuals must choose between traveling for treatment, paying out-of-pocket prices or foregoing care. Another reason for gaps in mental health care coverage is that providers may not accept insurance. NAMI found, ‘Only 55% of the nation’s psychiatrists accepted insurance compared with 88% of physicians in other medical specialties.’ Accepting insurance takes time out of already over-booked schedules. Psychiatrists also report low reimbursement rates. Mental health care providers may not have the interest or incentive to deal with insurance companies. A final reason for gaps between mental and physical health care coverage also involves difficulties finding accurate directories of providers who do accept insurance and are taking new patients.
    NAMI suggests several options for fixing treatment inequality.

    • Accurate directories can help patients find professionals.
    • New regulations could require that insurance companies cover out-of-network care as in-network care when the former isn’t available.
    • Working with insurance companies could be made simpler and more rewarding for mental health care professionals.
    • Integrating mental and physical health care can help dissolve the lines between the two. (Michael’s House Blog, 2016)
  • Out–of–Network, Out–of–Pocket, Out–of–Options. “Despite the federal parity law, the promise of parity remains elusive. Consumers continue to face significant challenges finding a provider, getting an appointment and paying the bill for mental health care compared to other types of specialty medical care. For the sake of millions of children and adults affected by mental health conditions, NAMI calls on health plans—and state and federal lawmakers— to address these disparities and improve access to quality, affordable mental health care. “ (NAMI, November, 2016)
  • ACA Repeal Will Prove Good for Psychiatric Practice.  “I lobbied for mental health parity legislation for years, and the American Psychiatric Association supported the passage of the ACA in 2010 to ensure access to mental health benefits for Americans. But let’s stop kidding ourselves about the ACA’s real world consequences to the psychiatric care of our patients. Despite hard work over the years to expand parity for mental health services, psychiatric and substance use care at this moment is commonly restricted to managed care behavioral carve-out networks or time-limited programs. Those restrictions grew under the ACA.” (Clinical Psychiatry News, 1.17.17)

Greater Population Needs

  • Current and Future Funding Sources for Specialty Mental Health and Substance Abuse Treatment Providers. “With ACA’s full implementation, spending on behavioral health will likely increase under private insurance and Medicaid. Parity in private plans will also push a larger share of payments for office-based professionals from out-of-pocket payments to private insurance. As ACA provides insurance for formerly uninsured individuals, funding by state behavioral health authorities of center-based treatment will likely refocus on recovery and support services. Federal Medicaid rules will increase in importance as more people needing behavioral health treatment become covered.” (American Psychiatric Association, Psychiatric Services 2013, Vol. 64, No. 6)
  • High Mental Health Costs for Young Adults. “High mental health costs for young adults threaten to undermine a key assumption of the Affordable Care Act: that insuring more young people will lower costs because they are healthier and require less expensive care. An analysis of insurance records of 6.8 million people 18 to 35 years old… showed that 18% had been diagnosed with a mental health condition, such as depression or an eating disorder…Treating a young person for depression costs about $7,000… about the same as the cost for treating an older person for high blood pressure. But doctors diagnose twice as many people with depression as for high blood pressure.” (USAToday, 11.6.13)
  • Millions of Newly Eligible in Need of Mental Health/Substance Abuse Care. “In the District of Columbia and the 25 states where the expansion is under way, nearly 1.2 million uninsured adults newly eligible for [Medicaid] coverage will have substance abuse problems, according to federal estimates, and more than 1.2 million are projected to have some sort of mental illness. An estimated 550,000 of those will have serious mental disorders that impair their everyday functioning.” Article includes a table with a breakdown of these figures by state. (McClatchyDC, 2.13.14)
  • Childless Medicaid Recipients Have Greater Mental Health and Substance Abuse Needs. “When Oregon’s Medicaid program began accepting childless adults in 1994, the new enrollees logged three times as many mental health and substance abuse treatment visits as the program’s low-income parents.” (McClatchyDC, 2.13.14)
  • Are Rising Mental Health Claims a Sign of Things to Come? “In a review of claims data for almost 100 Mercer employer clients, representing approximately 2.5 million members, we found that the Mental Health and Substance Abuse per member per year cost trend (for allowed charges) rose nearly 11%, in stark contrast to overall medical PMPY trend of 3.5%. And while MH/SA claims represent a small percentage of the overall medical claim costs (4%), a spike in the cost may be a symptom of a larger issue – and an opportunity for employers to get out in front.
    • More people – 3.4% increase in the MH/SA unique claimants.
    • More claims per person – 7.5% increase in MH/SA claims per claimant.
    • Fewer claimants are using out of network (OON) MH/SA providers but the  total OON visits are increasing by 7.5% — and the average allowable amount per visit is twice as high for OON providers ($2,097) than for in-network ($1019).

The biggest driver of increased OON utilization may be limited access… More employers are recognizing the importance of behavioral health in the benefit offering; they are increasing the number of EAP visits allowed and adding onsite counselors… The shortage of providers has led a growing number to choose not to join networks — because they don’t have to. With access to in-network providers limited not just in rural markets but also in busy urban areas, more plan members may be making a choice to use out-of-network providers, albeit at a lower benefit level.” (Mercer, 11.17.15)

  • Mental Disorders Top The List Of The Most Costly Conditions In The United States: $201 Billion. “Estimates of annual health spending for a comprehensive set of medical conditions are presented for the entire US population and with totals benchmarked to the National Health Expenditure Accounts. In 2013 mental disorders topped the list of most costly conditions, with spending at $201 billion.” (HealthAffairs, June, 2016)

Mental Health Care Shortages

Overview

  • Report to Congress on the Nation’s Substance Abuse and Mental Health Workforce Issues. “HRSA reported that there were 3,669 Mental Health, Health Professional Shortage Areas (HPSAs) containing almost 91 million people. It would take 1,846 psychiatrists and 5,931 other practitioners to fill the needed slots. This shortage of workers is not evenly distributed as 55 percent of U.S. counties, all rural, have no practicing psychiatrists, psychologists, or social workers (SAMHSA, 2007). Another study (Thomas et al., 2009) found that 77 percent of counties had a severe shortage of mental health workers, both prescribers and non-prescribers and 96 percent of counties had some unmet need for mental health prescribers… As a whole, the workforce is too few, aging into retirement, inadequately reimbursed; inadequately supported and trained, and facing significant changes affecting practice, credentialing, funding, and ability to keep up with changes in practice models driven by changing science, technologies and systems.” (Substance Abuse and Mental Health Services Administration, 1.24.13)
  • Six Ways Obamacare Is Changing Mental Health Coverage. “As the Deeds case shows, there’s already a shortage of psychiatric hospitals and psychiatric services to meet the country’s needs, due to years of government cutbacks in mental health spending. There are only enough psychiatrists available to meet the needs of 53 percent of those who need services, with many more severe shortages in rural areas, according to an analysis by the Kaiser Foundation. Experts fear that as more people enter the system seeking help for mental health and substance abuse issues, the relative scarcity of providers will only get worse.” (The Fiscal Times, 11.26.13)
  • The ACA Can’t Fix Our Mental Health Crisis. “The question now is whether the country’s mental health infrastructure is equipped to deal with an avalanche of new patients. The answer? Probably not.” (The Prospect, 2.25.14)
  • Medicare Extends Mental Health Benefits; Patients Find Doctor Shortage. “Medicare coverage for outpatient mental health care is now in line with medical coverage, thanks to a law that closed the gap as of Jan. 1… With the percentage of psychiatrists that accept Medicare falling well below other doctors, maintaining the mental health side of the equation becomes more difficult… Chiplin hopes the new changes the act put in place will influence these numbers, and the Affordable Care Act has its own implications on mental health.” (California Health Report, 3.26.14)
  • “Even if You Get Insurance Under the New Health Care Law, that’s No Guarantee.” “The Affordable Care Act expands access to mental health care in several ways. It will get coverage for more people, either through private plans or Medicaid — and the benefits will have to include mental health… But all that won’t help much if psychiatrists, psychologists and counselors don’t accept insurance. No one keeps tabs on precisely how many of the 552,000 mental health professionals in the U.S. — according to the Bureau of Labor Statistics — won’t accept private health insurance. But patient advocacy groups and provider organizations say many don’t want to accept low pay rates — and the insurance paperwork… Of 5.7 million adults who didn’t get mental health care when they needed it, nearly half blamed cost or insurance issues, according to a 2005 survey by the Substance Abuse and Mental Health Services Administration.” (Politico.com, 3.4.13)
  • ‘Pastoral Counselors’ Help Fill Mental Health Gap In Rural States. “Kentucky recently became the sixth state (joining Arkansas, Maine, New Hampshire, North Carolina and Tennessee) to allow pastoral counselors to become licensed mental health counselors… Kentucky is among the states with the lowest per capita number of psychologists and mental health counselors. Nationally, the shortage of mental health service providers is more acute than other medical areas. According to HRSA, 89.3 million Americans live in federally-designated Mental Health Professional Shortage Areas, compared to 55.3 million Americans living in primary-care shortage areas and 44.6 million in dental health shortage areas…And demand is only expected to increase, thanks to mandates for mental health benefits in the Affordable Care Act and the implementation of the federal Mental Health Parity and Addiction Equity Act.” (Kaiser Health News, 8.20.14)
  • Study Shows Sharp Jump in Young Adult ER, Mental Health Care Under Health Law. “Young adults under the age of 26 who had access to employer-sponsored health insurance used sharply more emergency room services and substance abuse and mental health treatment the year after the health law extended that type of coverage to their age cohort, according to newly released data… Policymakers can likely count the overhaul as a success in fueling an increase in mental health and substance abuse treatment of young adults, said Ken Duckworth, medical director of the National Alliance for the Mentally Ill (NAMI). But it’s adding to difficulties lining up treatment because the supply of beds and doctors isn’t keeping up, he said.” (Commonwealth Fund, 9.29.14)
  • Are People Getting More Care or Better Care Under Obamacare? “The last piece of evidence comes from the mental health field. Although an estimated 62 million patients now have better coverage because of the Affordable Care Act, a new report from the National Alliance on Mental Illness concludes that “patients with mental illness are no better off under Obamacare.” One problem is the high deductibles, discussed above. A second problem is that health plans are keeping premiums down by choosing narrow networks that leave out many mental health providers. Previously, I have called this a ‘race to the bottom.’ A third problem is that the networks themselves are frequently deceptive. Writing in US News, Kimberly Leonard notes that: Even if the medical provider is included in a health care network, he or she may not be available. In January 2015, the Mental Health Association of Maryland published a study that revealed only 14 percent of psychiatrists listed in the qualified health plans in the Maryland marketplace were actually accepting new patients and available for an appointment within 45 days – the suggested wait time.” Goodman, John. (Forbes, 4.2.15)
  • Reports Fault Access To Mental Health Care In Massachusetts. “Despite increases in the number of Massachusetts residents covered by health insurance, barriers to mental health care remain — including low insurance reimbursement rates and clinicians who increasingly rely on clients paying out of pocket. That’s according to a report released Wednesday by the Donahue Institute at the University of Massachusetts. The report found many clinicians are intentionally taking on more private pay clients and one in six don’t accept insurance at all. More than 80 percent say they turn away at least one patient each month.” (Associated Press, 5.6.15)
  • Increased Patient Access Falling Short. “In February 2013, the Department of Health and Human Services announced that because of the Affordable Care Act and full implementation of the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA), 62 million Americans would gain access to improved mental health and substance abuse (MHSA) care. Recent analyses, however, find that the two laws are falling short… NAMI reported additional barriers to MHSA care, some of which also applied to medical treatment, including: high deductibles and copayments; limited information about benefits and provider panels; higher rates of MHSA care authorization denials; and limited access to – and high costs of – psychotropic drugs. The greatest hardship NAMI identified was respondents’ experience in trying to locate covered MHSA therapists ‘followed closely by difficulties accessing psychiatrists.’” (The National Psychologist, July/August, 2015)
  • Are Rising Mental Health Claims a Sign of Things to Come? (pdf) “More employers are recognizing the importance of behavioral health in the benefit offering; they are increasing the number of EAP visits allowed and adding onsite counselors. Some specialty areas in particular experience access issues, such as psychiatry – both adult and child/adolescent… The shortage of providers has led a growing number to choose not to join networks — because they don’t have to. With access to in-network providers limited not just in rural markets but also in busy urban areas, more plan members may be making a choice to use out-of-network providers, albeit at a lower benefit level.” (Mercer Signal, 11.17.15)
  • Obamacare Mandated Better Mental Health-care Coverage. It Hasn’t Happened. “The Affordable Care Act has boosted the number of Americans with health insurance coverage but has not resolved the disparate way in which many insurers treat the costs of mental and physical health care, according to an April report released by the National Alliance on Mental Illness. The report found that federal changes (part of the Affordable Care Act) mandating so-called parity between mental and physical health-care benefits do not, in practice, exist for the vast majority of Americans who are insured… The situation is not good. In fact, it’s dire in a country where nearly 20 million Americans struggle with substance abuse and 42.5 million adults live with some form of mental illness, according to a Mental Health America report released in November 2014.” (Washington Post, 10.7.15)
  • Mental Health Service Cuts Go Along with Connecticut Layoffs. “The 68 layoffs announced last week at the state Department of Mental Health and Addiction Services were accompanied by plans to close a program serving people who are homeless or getting out of psychiatric hospitals or prison, to eliminate an intensive team that works with people living in the community who have mental health or substance issues, and to end a behavioral health program for veterans… Those who work in the mental health system said they’re still trying to determine the implications of the cuts, but raised concerns about the ability of existing providers to absorb the demand. ‘We’re all in crisis mode right now, trying to figure out what all of this means,’ said Kathleen Flaherty, executive director of the Connecticut Legal Rights Project, which represents DMHAS clients on civil rights matters.” (Connecticut Mirror, 4.19.16)
  • Kaiser Health Tracking Poll: April 2016.A majority of Americans say that lack of access to care for people with substance abuse issues is a problem (75 percent), including 58 percent who say it is a major problem… A quarter report that a doctor or health professional has told them or another family member living in their household that they have a serious mental health condition, such as depression or anxiety. Furthermore, about two in ten (21 percent) report that there has been a time when they or another family member thought they might need mental health services but did not get them. Individuals say they didn’t get mental health care because they couldn’t afford the cost (13 percent), insurance wouldn’t cover it (12 percent), there were afraid or embarrassed to seek care (10 percent), or they didn’t know where to go to get care (8 percent)… Nearly nine in ten (87 percent) think that lack of access to care for people with mental health conditions is a problem, including 73 percent who say it is a major problem.” (Kaiser Family Foundation, 4.28.16)
  • Some States Lag Behind on ADHD Therapy. “Federal health officials recommend that preschoolers with attention deficit hyperactivity disorder receive psychological counseling before they are put on medication. But states striving to promote the use of behavioral therapy have been hamstrung by a shortage of mental health providers. They also have struggled to convince providers who are used to prescribing drugs first to shift strategies… In 10 states, fewer than half of preschoolers in Medicaid with ADHD were receiving psychological counseling, according to the CDC data. Among children ages 2 through 5 with private insurance, the numbers were even worse: In 26 states, fewer than half of those kids with ADHD were receiving behavioral therapy. In contrast, more than three-fourths of all preschoolers with ADHD were on medication, generally stimulants such as Adderall and Ritalin. (Pew Charitable Trusts, 5.13.16)
  • Better Mental Health Care Is Worth the Expense. When more than half of people who need mental health care can’t or don’t get it — as is true in the U.S. — other problems arise. For sufferers, these include physical illness, lost earnings, substance abuse and suicide. For society, there is greater crime and homelessness. So legislation in the House of Representatives meant to expand mental health care is welcome… Yet mental health services in the U.S. are so inadequate that these changes would still leave many Americans without the care they need. In the past two decades, mental health services have been shrinking, not growing. From 1992 to 2012, the number of psychiatric beds per capita fell by two-thirds, to just two for every 10,000 people. The U.S. is the only affluent country where the number of psychiatrists per capita fell from 2000 to 2011.” (Bloomberg Editorial, 6.21.16)
  • Suicide Prevention: Access To Behavioral Health Services Lacking. “There are a number of barriers that could be keeping individuals from receiving services that would reduce their likelihood of engaging in self-harm behavior. The differences in the use of services by individuals with commercial and Medicaid insurance indicates that access to care is one of those barriers. The commercially insured were more likely to have a primary care visit, specialty care visit, and prescription drug filled for a behavioral health medication prior to an intent-to-harm-self emergency department encounter. People with Medicaid were more likely to have an emergency department encounter. Hogan and Grumet note that insurance expansion under the Affordable Care Act and parity legislation have reduced financial barriers to treatments that reduce self-harm behaviors. The statistics in Table 1 indicate that some important barriers remain, potentially including patient awareness of services that are available to them and provider acceptance of insurance.” (Health Affairs, 8.10.16)
  • Mental Health And Substance-Use Reforms — Milestones Reached, Challenges Ahead. “More than half of all Americans will have symptoms of a mental disorder at some point in their lives. Yet, persons with these conditions have historically faced limits on health insurance coverage that have restricted their access to treatment, along with shortages of mental health specialists (particularly those who accept insurance) and a treatment system plagued by fragmentation in care delivery. Such fragmentation stems from the historical separation of mental health providers from the rest of the health care system… In this report, we will cover issues that surround treatment for mental disorders, including the prevalence of mental disorders, spending trends, the shortage of practicing mental health specialists, efforts to break down the separation between mental health providers and the rest of the health care system.” (New England Journal of Medicine, 8.18.16)
  • Payment Headaches Hinder Progress on Mental Health Access. “Just 55% of psychiatrists accepted private insurance as payment in 2010 (compared with 89% of doctors in other medical specialties) and the percentage had declined 17% since 2005, according to a 2014 study published in JAMA Psychiatry… The declining willingness to accept third-party reimbursement comes down to dollars and sense. Rates for some of the most common behavioral health services, such as outpatient therapy, diagnostic evaluations and medication management, have not changed significantly in more than a decade… But the barriers that remain could lead to a mental health system that limits many services to people with the means to pay out of pocket. ‘It’s just part of the job in an outpatient practice, knowing that you’ll have to fight with insurance companies,’ said Dr. Bobbi Wegner, a Boston-based clinical psychologist… health plans and government programs implicitly encourage mental health professionals to focus on volume to come out ahead, detracting from the quality of care. ‘Yes there are going to be people who can’t get access, but there are more people being hurt by the access they’re given where they receive lousy treatment.’” (Modern Healthcare, 10.8.16)
  • Study Paints Somber Picture of US Mental Health Status and Access to Care. “Researchers from NYU Langone Medical Center analyzed a federal health information database and concluded that 3.4 percent of the U.S. population (more than 8.3 million) adult Americans suffer from serious psychological distress, or SPD… Weissman says the situation appears to have worsened even though the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Affordable Care Act (ACA) include provisions designed to help reduce insurance coverage disparities for people with mental health issues. She adds that the new report can serve as a baseline for evaluating the impact of the ACA and in identifying disparities in treating the mentally ill… the NYU Langone research team estimates that nearly one in 10 distressed Americans (9.5 percent) in 2014 still did not have health insurance that would give them access to a psychiatrist or counselor, a slight rise from 2006, when 9 percent lacked any insurance. About 10.5 percent in 2014 experienced delays in getting professional help due to insufficient mental health coverage, while 9.5 percent said they experienced such delays in 2006. And 9.9 percent could not afford to pay for their psychiatric medications in 2014, up from 8.7 percent in 2006.” (Medical Xpress, 4.17.17)
  • Recent Changes in Health Insurance Coverage and Access to Care by Mental Health Status, 2012-2015. “Access to care has improved for adults with MMI and SMI in recent years. Of importance, forgone mental health care decreased significantly for individuals with SMI. However, gaps in access persist. We did not find improvements in having a usual source of care, delayed medical care because of cost, or seeing a mental health professional for adults with SMI, which may be attributable to factors not fully addressed by the ACA, such as high cost sharing and continued shortages in mental health.” (JAMA, 9.6.17)

Addiction Treatment

  • How Obamacare is Changing Addiction Treatment Coverage. The ACA “will expand mental health and substance abuse benefits for an additional 31 million Americans, the HHS estimates… The Essential Health Benefits framework, unfortunately, does impose some limits on the extent of addiction coverage, Heller said. Defining benchmark plans for each state, that list of 10 benefits requires only ‘a bare minimum’ of addiction treatment coverage, leaving out medication like methadone.” (Huffington Post, 3.4.14)
  • Does Obamacare Hinder or Help Addiction Treatment? “According to the National Association of Addiction Treatment Providers (NAATP), right now, it is unknown what the effect of the Parity Act provisions of Obamacare will do because they have not been implemented yet. There are many loopholes that NAATP is noticing. One of the loopholes they have found is that the definition of medical necessity is not clearly defined. This is causing a lot of denial of treatment. But the bigger issue for NAATP is that substance abuse disorder treatments are not covered by many insurers because of waivers from the ACA mandate that they have been permitted.” (Main Street, 3.21.14)
  • Barriers Remain, Despite Health Law’s Push To Expand Access To Substance Abuse Treatment. “The law requires that substance abuse treatment be offered to people newly insured through the insurance exchanges or Medicaid, the government health plan for the poor and disabled. But serious impediments remain to widespread access, including a shortage of substance abuse providers and available beds nationwide, say treatment experts and government officials. One significant barrier to access is that drug treatment centers with more than 16 beds can’t bill Medicaid for residential services provided to low-income adults. As a result of the limitation, drug rehabilitation centers across the nation are turning away new Medicaid beneficiaries who need residential treatment.” (Kaiser Health News, 4.10.14)

Facilities

  • How Health Reform Can Help Rural Communities Improve Care for People with Addiction Issues and Mental Illness. “In addition to experiencing rural issues to the fullest, New Mexico has already tried to carry out sweeping reorganizations of behavioral and mental health services – and has found out the hard way that blueprints drawn up by bureaucrats and expert planners often do not work out as expected… On paper, the 2003 New Mexico reforms looked promising. But here are some of the lessons that can be learned from problems that arose during their implementation, especially in rural areas.” (Scholars Strategy Network, August, 2012)
  • Hurdle for Addicts Promised Treatment Under Health Law. “Under an obscure federal rule enacted almost 50 years ago, Medicaid covers residential addiction treatment in community-based programs only if they have 16 or fewer beds… The quirk in the law could have a significant impact on substance abuse treatment in Illinois and the 25 other states that have expanded Medicaid under the new health care law. While millions of low-income addicts have been promised access to treatment through the expansion, the rule will likely prevent many from entering residential programs, a more intensive form of care, even as heroin addiction is surging in many states.” (NewYork Times, 7.10.14)

Psychiatrists

  • Health Law May Not Broaden Access to Mental Health Treatment: Many Professionals Don’t Take Insurance. “From 2009 to 2010, 53% of psychiatrists accepted insurance, compared with 89% of all other physicians who did, said Tara Bishop, associate professor of public health and medicine at Cornell Medical College. She looked at data from the National Center for Health Statistics and released her team’s findings in The Journal of the American Medical Association. ‘We saw declines in the last few years in rates of acceptance, and we were wondering why,’ Bishop said. ‘I think we’ve all heard a lot of patient stories and doctor stories about trying to find a psychiatrist who takes insurance.’ She said she was surprised by the 36-percentage-point discrepancy. ‘It seemed to be getting worse in more recent years,’ she said. ‘We saw similar things for Medicare: 54.8% of psychiatrists took Medicare, as opposed to 86% of other physicians.’… She hopes to conduct similar research about how many psychologists and social workers, such as marriage counselors, take insurance.” (US TODAY, 12.29.13)
  • Understanding New Rules That Widen Mental Health Coverage. “Expanding insurance coverage does not necessarily mean everyone who needs care can easily find it. Many office-based psychiatrists, for instance, do not accept insurance, partly because reimbursement for services has been inadequate. A study published in December in the journal JAMA Psychiatry found that only about half of psychiatrists accept private insurance.” (New York Times, 1.10.14)
  • Acceptance of Insurance by Psychiatrists and the Implications for Access to Mental Health Care. “The percentage of psychiatrists who accepted private noncapitated insurance in 2009-2010 was significantly lower than the percentage of physicians in other specialties (55.3% [95% CI, 46.7%-63.8%] vs 88.7% 1; P < .001) and had declined by 17.0% since 2005-2006. Similarly, the percentage of psychiatrists who accepted Medicare in 2009-2010 was significantly lower than that for other physicians (54.8% [95% CI, 46.6%-62.7%] vs 86.1% 2; P  < .001) and had declined by 19.5% since 2005-2006. Psychiatrists’ Medicaid acceptance rates in 2009-2010 were also lower than those for other physicians (43.1% [95% CI, 34.9%-51.7%] vs 73.0% 3; P  < .001) but had not declined significantly from 2005-2006. Psychiatrists in the Midwest were more likely to accept private noncapitated insurance (85.1%) than those in the Northeast (48.5%), South (43.0%), or West (57.8%) (P = .02).” (Journal of the AMA Psychiatry, February, 2014)
  • “Nearly 91 million Americans live in federally designated mental-health-professional shortage areas, where there’s only one psychiatrist for at least every 30,000 residents. That’s compared with only 59.4 million who live in primary-medical-health-professional shortage areas and 46.7 million who reside in dental-health-professional shortage areas.” (McClatchyDC, 2.13.14)
  • “In this year’s Medscape report, 29% of self-employed and 5% of employed psychiatrists report that they are likely to stop taking new Medicare or Medicaid patients, with more employed psychiatrists (59%) than self-employed psychiatrists (25%) likely to continue seeing new and current ones. About a third of each (36% of self-employed and 33% of employed) are still undecided. Twenty-six percent of psychiatrists report that they will drop insurers who pay poorly.” (Medscape, 4.16.14)
  • Access to Psychiatrists in 2014 Qualified Health Plans. “In June of 2014 the Mental Health Association of Maryland (MHAMD) performed a study to assess the accuracy and adequacy of the psychiatric networks of the 2014 Qualified Health Plans (QHP) sold through the Maryland Health Connection… The study results indicate that only 14% of the 1154 psychiatrists listed were accepting new patients and available for an appointment within 45 days. Researchers spent six months calling multiple numbers for the listed providers to find that 57% of the 1154 psychiatrists were unreachable – many because of nonworking numbers or because the doctor no longer practiced at the listed location. As the number of newly insured continues to grow, wait times will increase, and individuals may forgo care or resort to paying high out of pocket costs to access critical care outside their insurance network if they have the means to do so.” (Mental Health Association of Maryland, 1.26.15)
  • 2015 Review of Physician and Advanced Practitioner Recruitment Incentives. “Psychiatrists, one of the most difficult types of physicians to recruit, were number three on the list of Merritt Hawkins’ most requested assignments, underlying the continued severe shortage of behavioral health specialists” (Merritt Hawkins, 2015)
  • Psychiatry Facing Severe Workforce Crisis. “Not only did psychiatry rank third on the list of recruiting assignments by specialty, with 230, but it came close to tying internal medicine, at 237, for second place. As usual, family medicine occupied the top spot, this time with 734 searches. The shortage of psychiatrists will only get worse, said Travis Singleton, senior vice president of Merritt Hawkins. Forty-eight percent of these specialists are 60 years of age and older and are closing in on retirement. And although psychiatrists are aging out of the profession, the demand for services is spiking, according to Singleton. He cites a report from the Department of Health and Human Services showing that only 41% of adults with any kind of mental illness received mental health services in the past year. ‘It’s very scary,’ Singleton told Medscape Medical News. ‘We’re desperately underserved.’” (Medscape Medical News, 7.30.15)
  • Review of Physician and Advanced Practitioner Recruiting Incentives, 2016.Psychiatry is ranked as Merritt Hawkins’ second most requested search assignment – the first time psychiatry has held this position in the 23 years Merritt Hawkins has compiled its Review. This ranking underscores the alarming shortage of psychiatrists that is developing in many parts of the United States.” (Merritt Hawkins, 2016)
  • Population Of US Practicing Psychiatrists Declined, 2003–13, Which May Help Explain Poor Access To Mental Health Care. Limited access to psychiatrists may be a contributor to the underuse of mental health services. We studied changes in the supply of psychiatrists from 2003 to 2013, compared to changes in the supply of primary care physicians and neurologists. During this period the number of practicing psychiatrists declined from 37,968 to 37,889, which represented a 10.2 percent reduction in the median number of psychiatrists per 100,000 residents in hospital referral regions. In contrast, the numbers of primary care physicians and neurologists grew during the study period. These findings may help explain why patients report poor access to mental health care. Future research should explore the impact of the declining psychiatrist supply on patients and investigate new models of care that seek to integrate mental health and primary care or use team-based care that combines the services of psychiatrists and nonphysician providers for individuals with severe mental illnesses.” (Health Affairs, July, 2016)

Expanding Prescriptive Authority

  • Shortages in psychiatrists who accept insurance or Medicaid patients may present “another argument for prescriptive authority by specially trained psychologists.” (Psychotherapy Finances, 1.5.14)
  • The Physician Specialty Shortage. “When it comes to addressing the specialty shortage with these non-physician clinicians, one area in particular stands out: psychiatry. The field is suffering from a chronic shortage of physicians. Yet in 2013, according to the American Association of Nurse Practitioners, only 3.2 percent of all nurse practitioners were certified in psychiatric mental health.” (Real Clear Policy, 3.12.15)
  • Doctoring Without the Doctor. “‘Do you see a psychiatrist around here? I don’t!’ said Ms. Osburn, who has lived in Wood Lake, population 63, for 11 years. ‘I am willing to practice here. They aren’t. It just gets down to that.’ But in March the rules changed: Nebraska became the 20th state to adopt a law that makes it possible for nurses in a variety of medical fields with most advanced degrees to practice without a doctor’s oversight. Maryland’s governor signed a similar bill into law this month, and eight more states are considering such legislation, according to the American Association of Nurse Practitioners. Now nurses in Nebraska with a master’s degree or better, known as nurse practitioners, no longer have to get a signed agreement from a doctor to be able to do what their state license allows — order and interpret diagnostic tests, prescribe medications and administer treatments.” (The New York Times, 5.25.15)

Changing Roles for Psychiatrists

  • A New Year, A New Model of Mental Care. “As most of you are aware, we are currently not meeting society’s needs and requests for good mental health care… A big, central part of this is psychiatrists. Not surprisingly, it turns out that psychiatrists are the most expensive part of the care pathway, and they are also the least available. It is highly unlikely that either of these things is going to change anytime soon. There is no evidence whatsoever. There is a dramatic shift in medical schools of [fewer] people going into psychiatry, and it is unlikely [that either of those things are] going to happen. Additionally, there is no evidence that reimbursements within insurance panels are going to dramatically go up so that psychiatrists will open their practices to panels… What does that mean? Well, the traditional role of the past 50 years, where psychiatrists saw patients for 30-50 minutes for medication/psychotherapy visits, is probably not sustainable. Psychiatrists are too expensive, and the throughput for patients is just too slow. We are not meeting the demand. We are not getting to people who need the care most. That means we are going to have to practice differently.” Strakowski, Stephen M., MD. (Medscape, Strakowski on Psychiatry, 1.17.17)

Psychologists and Other Mental Health Professionals

  • Mental Health Network Adequacy Uncertain. Insurers seeking certification as “QHPs must demonstrate that their plan maintains a network with a sufficient number and type of health-care providers, including those providers specializing in mental health and substance abuse services. This is to ensure that the plan offers benefits under all 10 identified essential health benefits categories, one of which is mental health and substance use services. However, the Affordable Care Act does not specify what providers, or how many, must be included in a provider network. Insurers seem to be building narrower networks with fewer providers than are typically found in commercial health plan provider networks. It remains to be seen whether these smaller networks, which may have a limited number of psychologists, will satisfy the Affordable Care Act’s network adequacy criterion.” (American Psychological Association Monitor, December 2013, Vol 44, No. 11
  • “As millions of Americans gain health coverage through the Affordable Care Act’s Medicaid expansion, experts say their higher rates of mental health and substance abuse disorders will be difficult to treat due to a lack of counselors and behavioral therapists who accept Medicaid patients.” (McClatchyDC, 2.13.14).
  • Expansion of Mental Heath Care Hits Snag. “Terri Hall’s anxiety was back, making her hands shake as she tried to light a cigarette on the stoop of her faded apartment building. She had no appetite, and her mind galloped as she grasped for an answer to her latest setback. In January, almost immediately after she got Medicaid coverage through the Affordable Care Act, she had called a community mental health agency seeking help for the depression and anxiety that had so often consumed her. Now she was getting therapy for the first time, and it was helping, no question. She just wished she could go more often. The agency, Seven Counties Services, has been deluged with new Medicaid recipients, and Ms. Hall has had to wait up to seven weeks between appointments with her therapist, Erin Riedel, whose caseload has more than doubled. ‘She’s just awesome,’ Ms. Hall said. ‘But she’s busy, very busy.’” (New York Times, 8.28.14)

Changes in Behavioral Health Service Delivery

According to the American Psychological Association, the ACA’s goal for mental health and substance abuse treatment is to extend coverage to millions of uninsured Americans, reduce health care costs for those with and without insurance, and fully integrate psychological services into primary care, preventive services, and benefit packages. Given the shortage in behavioral health service providers and facilities, the movement to large integrated service delivery teams within medical settings, patient-centered medical homes, and accountable care organizations is intended to offer briefer, less specific (an inch deep and a mile wide) care to the newly expanded population of patients. See ACA and Mental Health Care for more information.

Restricted Pharmaceutical Formularies

  • How Obamacare is Changing Addiction Treatment Coverage. “The Essential Health Benefits framework, unfortunately, does impose some limits on the extent of addiction coverage, Heller said. Defining benchmark plans for each state, that list of 10 benefits requires only ‘a bare minimum’ of addiction treatment coverage, leaving out medication like methadone.” (Huffington Post, 3.4.14)
  • Prescription Drugs Harder to Obtain. “ObamaCare participants are twice as likely to face administrative barriers to using certain prescription drugs as people who receive health coverage through an employer, according to a new analysis. The research from consulting firm Avalere Health points to a little-known facet of policies on the ObamaCare exchanges known as ‘utilization management controls.’ The controls allow insurance companies to limit access to certain medications to try and control costs and prevent abuse. People who enroll in ObamaCare plans are likely to encounter the hurdles if they’re prescribed brand-name cancer or mental health drugs, Avalere found. At least 51 percent of brand-name mental health meds come with special controls on the exchanges, compared with only 11 percent on the employer-based market, the analysis found.” (The Hill, 3.24.14)
  • Nearly All ACA Benchmark Plans Violate Rules on Addiction Treatment Coverage. “Despite federal rules that require plans to cover addiction treatment without restrictions, the ACA does not specify which substance use disorder benefits should be covered, leaving that decision up to the discretion of states. The law requires plans cover at least one addiction treatment medication in each of four classes: anti-craving, opioid reversal, opioid dependence treatments and tobacco cessation. The report found that 45% of 2017 benchmark plans were in violation by not providing coverage for an addiction treatment medication that was in each of the four classes… EHB-benchmark plans for Alabama, Michigan, Mississippi, South Carolina and South Dakota violated parity rules that prohibit limits on treatment that applied to addiction treatment only by restricting the number of visits allowed for such services.” (Modern Healthcare, 6.7.16)

Other Access Challenges

  • Three Ways Obamacare Negatively Affects Mental Health Care. [Opinion]: “There are 3 specific ways Obamacare negatively affects mental health care. It is proving to be true in Massachusetts and I am afraid with full implementation of Obamacare it will be true all over the country.” (Ruskin, Karen, 9.30.13)
  • The Affordable Care Act and the Future of Behavioral Health. “A troubling paradox has come to light: with the rise in care (through SSI, Medicaid, and healthcare reforms) and treatment options has come a simultaneous rise in the mentally ill population. Despite more money being spent and more federally funded treatments to address issues of SPMI, mental illness rates are not declining. This increase in the number of SSI recipients with diagnoses of SPMI is leading Congress to question if too much money is being allocated to this vulnerable population. The behavioral health field is likewise stymied by the lack of quality metrics that exist for treating mental health conditions. As Glied put it, ‘we are not good at measuring performance,’ which inhibits our ability to track the impact of mental health interventions over time. Additional challenges exist in sources of financing. Before the ACA’s passage, individual states were responsible for serving as mental health guardians for their mentally ill residents. Now, under the federal umbrella of Medicaid, that local level of monitoring has vanished. Who will take responsibility for caring for this country’s ever expanding mental health population?” (NYU Silver School of Social Work, 3.17.14)
  • Under Obamacare, Barriers to Mental Health Treatment in CA Remain. “When a patient at St. James Health Center needs mental health care, the first thing Susana Farina does is check insurance. The type of insurance patients have — if they have any at all — determines what kind of doctor they can see and even the date of their appointments. The Affordable Care Act covers treatment for some mental health disorders, such as depression and anxiety, but the law is not comprehensive and many Californians with mental illnesses still face challenges accessing care.” (California Health Report, 4.27.14)  
  • The ACA’s Pediatric Essential Health Benefit Has Resulted In A State-By-State Patchwork Of Coverage With Exclusions. “The approach used to establish the Affordable Care Act’s pediatric essential health benefit has resulted in a state-by-state patchwork of coverage with inconsistent exclusions, particularly with regard to services for children with mental or developmental disabilities.” (Health Affairs, December, 2014)
  • Mental Health Coverage Unequal in Many Obamacare Plans. “Insurance coverage for mental and physical illness remains unequal despite promises that Obamacare would help level the playing field, mental health advocates and researchers say. A new study by the Johns Hopkins Bloomberg School of Public Health found that consumer information on a quarter of the Obamacare plans that researchers examined appeared to go against a federal ‘parity’ law designed to stop discrimination in coverage for people with mental health or addiction problems.” (USA TODAY, 3.9.15)
  • Patients With Mental Illness No Better Off Under Obamacare. “Under President Barack Obama’s health care law, which aimed to end health insurance discrimination for mental health services, an estimated 62 million patients now have better coverage. But a new report from the National Alliance on Mental Illness shows the policies still have a long way to go before they can make a difference in the lives of people living with mental illness. From lack of access to psychiatrists to expensive costs for medications, the study reveals a variety of issues that NAMI says show insurance companies are falling short in coverage of mental health and substance abuse disorders…Findings also showed that customers had a difficult time paying for medications, and that certain medications, like some antipsychotics, were not covered at all or only available with high out-of-pocket costs.  For marketplace plans, denials were nearly twice the rate for other medical care.” (US News, 4.1.15)
  • Exchange Plans Include 34 Percent Fewer Providers than the Average for Commercial Plans.Specifically, the analysis finds that exchange plan networks include 32 percent fewer mental health and primary care providers… Importantly, care provided by out-of-network providers does not count toward the out-of-pocket limits put in place by the ACA.” (Avalere, 7.15.15)
  • U.S. Psychiatric Patients Face Long Waits in ERs. “People with mental illness often wait long hours — or even days — in an emergency room before receiving the care they need, according to a new poll conducted by the American College of Emergency Physicians (ACEP). One in five ER doctors polled said they’ve had psychiatric patients who needed hospitalization who had to wait two to five days before being assigned an in-patient bed, the poll found. Two accompanying studies back up the poll results, revealing that patients with a wide array of mental health problems are more likely to wind up stuck in an emergency department for more than 24 hours. ‘Once the decision to admit is made, it can be nearly impossible to find an in-patient bed for these patients.’… Nearly three in five doctors also reported increased wait times and boarding for children with psychiatric illnesses, the poll reported… Parker and Lippert said comprehensive mental health care reform is needed to ease the pressure on emergency rooms. Efforts to improve health insurance coverage of mental health care also could help.” (Health Day, 10.17.16)
  1. 4%-90.7%
  2. 4%-87.7%
  3. 3%-75.5%

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