Health Care Reform: A Primer for Psychiatrists

In March 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA), Public Law 1111-148, which if fully implemented will transform health care in the United States. This extremely complex piece of legislation is having an impact on all physicians and hospitals, health insurance companies, and managed care organizations as well as families and individuals. For psychiatry, PPACA includes a number of provisions that reverse dates of discriminatory coverage against the mentally ill. Together with the 2008 Mental Health Parity Law, PPACA expands access to comprehensive, nondiscriminatory mental health coverage to most Americans. In summary, it extends insurance coverage to 32 million more Americans, bars insurance companies from denying coverage based on pre-existing conditions or dropping individuals because of illness, and includes mental health and substance use disorder treatment as part of the basic package of benefits in health insurance sold in state-based insurance exchanges created by the law. These changes (plus a requirement that all insurance ultimately must have full parity for mental health and must include substance disorder treatment) put psychiatry, for the first time, on par with other medical specialty services in the U.S. health care delivery system.

Health Care Reform: A Primer for Psychiatrists is a reprinting of three articles previously published in Psychiatric Services and edited by Thomas McGuire, Ph.D., one of the nation's outstanding health economists, who 30 years ago invented mental health economics when he was at Boston University. These articles provide not only a more balanced appraisal of the impact of PPACA on psychiatric care, by emphasizing that the devil is in the details of implementation, but also a primer on the state insurance exchanges in managed care in the effort to control costs. Will mental health care be managed on parity with the rest of medicine, or will psychiatrists experience excessive management to the point of harassment in an effort to keep utilization low? Will mentally ill participants be able to choose plans well in these exchanges and navigate the enrollment and re-enrollment process? Inadvertently or deliberately, will incentives for “adverse selection” take place during the development of these exchanges so that individuals with mental illness will be mostly concentrated in primarily one or two different insurance plans? These questions and more are raised in the initial article by McGuire and Sinaiko on looking at the regulation of the health insurance exchange.

In addition to the state exchange, one of the most important expansions of access to care is through the expansion of Medicaid in PPACA. Those individuals with serious and persistent mental disorders require services that are often not covered by a typical insurance plan and are covered mostly by Medicaid today. These services, such as partial hospitalization, mobile crisis services, assertive community treatment, and case management, are unique to behavioral health, and Medicaid is the strategic funder of these services state by state. With the expansion of coverage, will Medicaid be cutting back these services and providing only the core medical services, such as inpatient hospitalization and pharmacotherapy, after reform is implemented? Cutting behavioral health services may become part of a broader effort to trim Medicaid spending. The second article in this monograph, by Garfield et al., reviews these issues in some depth.

The final article talks specifically about some of the incentives within PPACA to integrate psychiatric services with general medical services in the expansion of the medical home concept to the behavioral medical home and accountable care organization models. Within the act, there are monies to be made available to community mental health centers to colocate primary care services, but the integration of psychiatry and other medical specialties within “patient-centered medical homes” may have a more robust effect on the practice of psychiatry in the near future. There are many challenges in promoting such integration, not the least of which is the need for information technology for these newly emerging innovative care systems, but once again, PPACA provides some monies to build this information technology infrastructure into the future. The third article in this monograph, by Druss and Mauer, reviews these opportunities as well as pitfalls.

With the recent emphasis on deficit reduction, a key question in the implementation of PPACA is whether this legislative act does enough to “bend the cost curve.” Its sheer complexity in its 2,000-plus pages, its effort to redirect the incentives of so many players, and its reliance on the hundreds of private health insurance plans in this country may make it a target for repeal or severe revision in the near future as costs continue to escalate. Regardless, this health care reform primer is fascinating reading for any psychiatrist who has an interest in what the future may bring.