This Month’s Highlights

Implementation in 2010 of the Mental Health Parity and Addiction Equity Act (MHPAEA) required some health plans to change their coverage and management of services to ensure that behavioral health coverage was not subjected to more restrictive limitations than those applied to general medical care. The strict requirements raised concerns about the law’s unintended effects: would plans drop coverage of behavioral health care, tighten utilization management, or cut provider reimbursements? To assess health plans’ early responses to MHPAEA, Constance M. Horgan, Sc.D., and colleagues compared data from a large sample of commercial health plans for the 2010 benefit year (when parity was in effect) and for 2009 (the preparity year). They found that the law had the intended effect of eliminating quantitative limitations that applied only to behavioral health care, such as annual limits on visits and higher copayments. Results also allayed some concerns about the law’s possible unintended consequences. Plans reported only a small decline in the proportion of employers offering coverage of behavioral health services, and no notable decrease in provider reimbursements was found (page 162). In a Taking Issue commentary, Haiden A. Huskamp, Ph.D., notes that MHPAEA and the Affordable Care Act have profoundly changed health care over the past five years and predicts that Horgan and colleagues’ study marks the beginning of a large body of research on these changes (page 149).

Public mental health systems need innovative approaches for addressing the problems of institutional recidivism (inpatient psychiatric rehospitalization and arrests and incarcerations) and poor recovery among people with serious mental illness. The Georgia chapter of the National Alliance on Mental Illness, in conjunction with diverse local partners, developed the Opening Doors to Recovery (ODR) service model to prevent recidivism and promote recovery. Key features of ODR are a mobile outreach team that helps clients connect with community services, cross-agency collaboration, and staff linkages with police. Michael T. Compton, M.D., M.P.H., examined the effects of ODR among participants in 34 counties in southeast Georgia who had at least two inpatient stays in a six-month period. The initial results were promising: ODR clients were less likely to be rehospitalized in the 12 months after enrollment than in the previous year and were better equipped to embrace recovery. The number of arrests, which were rare events, did not change (page 169).

The recent focus on the ACA and on health care coverage and access may have led Americans to confound health care with health. But as Lloyd I. Sederer, M.D., notes in this month’s Open Forum, 90% of the determinants of our health derive from our lifetime social and physical environment: “Behaviors and environment are the primary factors that we will need to change in order to avoid or delay disease and achieve better health.” Dr. Sederer goes on to describe what we know about a key social determinant of mental health, adverse childhood experiences, and the “upstream” policy and social interventions that would improve population health, such as creating better jobs, ensuring food security, providing affordable housing, and developing alternatives to incarceration. Dr. Sederer concludes that not only is there “no health without mental health . . . there is no health or mental health unless we also attend to their social determinants” (page 234).