Reform Law Ends Most Bias Against Mental Health Care

The Patient Protection and Affordable Care Act doesn't say much about mental health—and that's a good sign, said Richard Frank, Ph.D., deputy assistant secretary and director of the Office of Disability, Aging, and Long-Term Care Policy at the Department of Health and Human Services.

Frank, a health care economist and mental health policy expert who is no stranger to APA audiences, spoke last month at APA's Institute on Psychiatric Services in Boston.

He outlined the three central pillars of the new health care reform law—public insurance expansion, private insurance market reform, and payment and delivery system reform—noting that all three are intended to occur under an umbrella of parity and integration of mental health treatment with general medical care.

“Parity permeates the Affordable Care Act,” Frank said. “The exceptionalism that has characterized mental health policy for the last 50 years is not a part of this law. I see the fact that there isn't very much singling out of mental health as a mark of success. Mental health is a part of the mainstream in this law.”

At the same time, he noted that in a few crucial areas—especially the extension of traditional Medicaid benefits to the seriously and persistently mentally ill and the inclusion of community mental health centers in the definition of a “health home”—the law does contain special provisions that designate serious and persistent mental illness as requiring special attention.

Of overriding importance to the mental health community is the expansion of Medicaid eligibility to 133 percent of the federal poverty level, with income limits of $14,404 for individuals and $29,326 for a family of four. Additionally, the law provides 100 percent federal funding to all states for newly eligible Medicaid recipients for three years, and additional federal matching funds to states that already cover childless adults in their Medicaid programs.

“Medicaid has always been the single largest payer for mental health in this country, and it's going to be more important in the years ahead,” Frank said.

Frank noted that based on 2003-2004 data, the percentage of people without a mental disorder of any kind, including substance abuse, among the uninsured was about 11 percent. But the percentage of uninsured with severe mental illness is about 20 percent, and the percentage of the uninsured with any other mental illness is 18 percent. (And among the uninsured, a remarkable 52 percent have some form of substance abuse disorder.)

“Right away, if you are expanding coverage, you are almost sure to disproportionately benefit people with mental illness,” he said. “And the benefit for those with addictions is even more striking. While the law is important for people with mental illness, it's even more important in the world of addiction, and it creates new opportunities to rethink the way we finance and deliver care to people with addictions.”

Importantly, he noted, the package of benefits for the expanded Medicaid population will not be the same as the traditional benefit, but will look more like the “benchmark benefit” linked to private-insurance models that was established in the State Children's Health Insurance Program (SCHIP) legislation.

(SCHIP, reauthorized in 2009, establishes a “benchmark” benefit that can be the coverage offered under the BlueCross/BlueShield plan for federal employees, a coverage plan that is offered to state employees, or a coverage plan that is offered by a health maintenance organization with the largest commercial enrollment in a state.)

But Frank noted also that there is within the health reform law a provision allowing for exemptions from the benchmark benefit for those with serious mental illness so that they could have access to the more generous traditional Medicaid benefit. “So for example, if you have schizophrenia or bipolar disorder but have not qualified for SSI or SSDI, you can still meet criteria for the traditional [Medicaid] benefit,” Frank said.

The second important element of the Affordable Care Act is reform of the insurance market, establishing insurance market exchanges in 2014 that will operate much as large corporations such as IBM or General Electric do—or as state governments do—allowing individuals and small employers to shop for standardized health packages. The law includes an employer mandate, also beginning in 2014, requiring companies with 50 or more employees to offer coverage to employees.

These provisions all require parity coverage of mental illness, Frank said.

The third component of the reform law is delivery-system and payment reform. And as part of that, a crucial element—and one where Frank said mental health has been singled out for exceptional treatment—is the state-based option for providing “health homes” for enrollees with chronic conditions. In part because of APA lobbying, that provision also includes persistent and serious mental illnesses in the definition of chronic illness.

Frank emphasized that the definition of a “health home” can include community mental health and home health agency services if they meet the criteria for integrating primary care and provide wraparound services. Wraparound services can include case management, home-based care, crisis intervention, individual and family therapy, treatment for substance abuse, transportation, and health education.

“This provision for Medicaid health homes integrates mental illness and addiction treatment into the mainstream thinking about chronic disease, while at the same time recognizing the special circumstances of people with severe and persistent mental illness.”

Frank called the “health home” as envisioned in the law a “broader conception of chronic disease [than commonly envisioned]” and one that “relaxes the idea that a health home is uniquely located in a primary care practice.” Some $50 million is earmarked for co-locating primary care services within behavioral health centers to ensure that people with severe and persistent mental illness receive medical care, and a similar amount is designated for fostering mental health care in community health centers.

Overall, the way that treatment for mental illness, including substance abuse, is regarded within the reform law is “a great mark of advance and something that we should celebrate, not fear,” Frank told psychiatrists at the meeting.

“I think this is really a historic moment in terms of how we care for the sickest people with mental illness and addictive disorders,” he said, “It is a huge opportunity to improve the way we pay for care for people who are extremely vulnerable, but also to rethink how we use our resources.

“Mental illness and substance abuse treatment are entering the mainstream,” Frank said. “We don't mention mental health all the time [in the law] because we don't have to. We have parity, and we have an administration and a field that are committed to doing integration where it is sensible, and recognizing the places where it has its limits.”