Some Gaps in ACA Coverage for Patients With Mental Illness

There are some holes in the Affordable Care Act (ACA) when it comes to coverage of mental illness—as well as a few opportunities for improvement that will require attention and advocacy.

That was the message psychiatrist Howard H. Goldman, M.D., Ph.D., delivered to psychiatrists at APA’s 2013 Institute on Psychiatric Services last month in Philadelphia. Goldman, who is editor of the APA journal Psychiatric Services and chair of the Board of Trustees Health Care Reform Strategic Action Work Group, lectured on the topic “Health Care, Health Insurance, and Psychiatric Services.”

Goldman reviewed aspects of the ACA that are bound to benefit patients with psychiatric illness: the removal of exclusions for preexisting conditions and annual and lifetime limits on benefits, the expansion of Medicaid (in states that choose to do so) to include millions more individuals; the opening of health insurance exchanges with plans that may offer subsidies to qualifying individuals; and provisions allowing young people to remain on their parents’ insurance until age 26. This last provision, especially, may be vital for individuals being identified and treated in early psychosis intervention programs, he said.

But Goldman also drew attention to areas in which psychiatrists, and APA as an organization, must be vigilant. Among these is the possibility that health plans in the new exchanges could practice subtle forms of selection bias to discourage patients with psychiatric illness.

“There are some problems with the exchanges we need to be concerned about,” he said. “There remain incentives for plans on the exchange to stint with respect to mental health coverage and to try to not attract as beneficiaries people with mental health conditions.”

Goldman’s APA work group is charged with monitoring the rollout of health reform and its implications for clinicians and patients. He said the question of selection bias would be on the work group’s agenda. “There are activities under way to better understand this,” he said. “It’s an area of concern where more information is needed. But I think if plans know that people are looking at this question, they might be less likely to engage in selection practices.”

Possibly of more immediate concern to clinicians is that exchange health plans are mandated to provide mental health coverage at parity with general medical coverage—but are not required to provide the variety of ancillary services that some patients with severe mental illness may need. These include rehabilitative and supported housing or employment services.

“The other problem with the behavioral health mandate is that it’s a traditional insurance design,” Goldman said. “While there is parity, it doesn’t mean an insurance company will recognize all the array of services we offer patients. It could be a much more traditional benefit of inpatient, outpatient, and maybe partial hospitalization. We may have to advocate with states to provide these kinds of services that are not covered by the exchanges.”

Goldman also drew attention to a little-known provision in the ACA known as 1915i. “That’s a provision that says a state may amend its Medicaid plan to include a wide array of home- and community-based health services,” he said. “That will require advocacy at the state level, and the Board work group is developing advocacy toolkits to help states and district branches know more about 1915i and to help them work with other stakeholders to get their state Medicaid plans to cover these services.”

Goldman concluded: “From my perspective, the ACA is a grab bag of much-needed and much-appreciated elements. But it doesn’t do everything for everyone, and there are things we as a professional association can do to monitor [rollout of health reform] and to advocate for additional changes.” ■