It is good news for people with mental illness and their families that the Supreme Court has ruled that the Affordable Care Act is constitutional. The benefits would have been greater if the court had not made expansion of Medicaid eligibility optional for the states. But even if some states choose not to provide Medicaid for more people who cannot afford health care or health insurance, millions of people without coverage or with inadequate coverage -- including people with mental illness -- will now be able to get the health and mental health care they need.
The ACA benefits people with mental illness in six major ways:
(1) It provides improved coverage of physical health care, which is extremely important to people with mental and/or substance use disorders because (a) they are at higher risk than the general population of having co-occurring chronic physical disorders and (b) they have dramatically lower life expectancy than people without mental illness, in significant part because of poor health and poor access to good health care.
General health coverage improvements that will benefit people with mental and/or substance use disorders include:
• Insurance reforms, such as coverage of pre-existing conditions and maintenance of coverage during long illnesses.
• Access to more affordable health coverage for individuals and small businesses through state health insurance exchanges.
• Expanded eligibility for Medicaid in states that do not opt out of the "requirements" built into the Affordable Care Act.
(2) The ACA also provides improved coverage of mental health and substance abuse conditions. This is a major advance. Just three years ago, new federal laws required "parity" in the coverage of mental and physical health conditions in employer-based health benefit plans and Medicare, but the provisions were limited. The ACA carries these requirements forward and expands them considerably.
(3) The ACA also provides enhanced Medicare coverage of medication, including of psychiatric medications. This will result in:
• Reduced out-of-pocket spending on pharmaceuticals by shrinking the "donut hole," i.e. the phase of personal spending on medications not covered by Medicare.
• Enhanced access to psychiatric medications prescribed by a physician that were not covered in the original version of Medicare prescription drug coverage.
(4) The ACA emphasizes the importance of integrating and coordinating the delivery of physical and mental health services and provides incentives to providers to integrate care, including:
• Rate increases for medical practices recognized as "medical homes" that provide coordinated care and preventive services, among other features.
• Increased federal funding for Medicaid payments to "health homes," which are organizations that coordinate care for people with chronic physical and/or behavioral health conditions.
• Contracts with "accountable care organizations" -- a new type of structure designed to improve care quality and contain costs.
(5) The ACA also emphasizes preventive interventions. For example, it provides Medicare payments for preventive health care and health promotion for the first time. This, of course, benefits people without mental illness as well as those with mental illness, but it is particularly important for people at high risk of obesity and the diseases it drives such as hypertension, diabetes, and heart disease. These are conditions that are particularly common among people with serious mental illness.
(6) Finally, the ACA emphasizes services in the home and community instead of in institutions. There are new demonstration grants as well as new opportunities for Medicaid waivers for state efforts to reduce the use of nursing homes and other institutions and instead provide care for people with disabilities in their homes and communities. In this way it carries forward the policy goal of helping people with psychiatric and other mental disabilities to live in the community rather than in institutions. It also will help states to fulfill the mandate of the Olmstead Decision of the Supreme Court, which interpreted the Americans with Disabilities Act as requiring states to provide supports to enable people with disabilities to live in the "most integrated" setting in the community rather than in institutions.
All in all the Affordable Care Act is a great step forward in America's efforts to meet the needs of people with mental health conditions and to do so in the community rather than in institutions whenever possible. As it is implemented, it should be a great boon to people with mental illnesses and their families, contributing to recovery and improved quality of life.
This will depend, of course, on how well the provisions of the ACA are implemented. Sadly, it is not likely in the current political atmosphere in the United States that ideological disputes will shift to the background so that federal, state, and local governments, providers, insurers, and advocates can focus on critical issues of implementation. We would be happy to be wrong about that.
Michael B. Friedman, LCSW, teaches at Columbia University. Kimberly A. Williams, LCSW, is the Director of the Center for Policy, Advocacy, and Education at the Mental Health Association of NYC.
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