Three articles in this issue of the journal review economic and policy implications for mental health delivery of the Patient Protection and Affordable Care Act, referred to as the ACA. The authors highlight opportunities for great improvement, as well as challenges, in the financing and delivery of mental health care in the United States. The ACA incrementally expands existing insurance, and it also creates and encourages the development and diffusion of important new institutions and organizational forms that will govern insurance markets and service provision. Garfield and colleagues describe these expansions. McGuire and Sinaiko explain the role of health insurance exchanges in restructuring the individual and small-group markets. Druss and Mauer explain the potential of new organizational forms to promote integration of mental health and other medical care, along with improved approaches to specialty care delivery.
In each case, important potential gains in social welfare are noted, with an emphasis on key choices that must be made by those implementing the blueprint set out in the ACA. Gains in coverage among people with mental and substance use disorders are intertwined with the problems of poverty, illiteracy, and social isolation. Special efforts will be required to engage and enroll this deprived and frequently costly population. McGuire and Sinaiko explain that competitive insurance markets have functioned especially poorly in providing coverage to people at elevated risk of mental health and substance use problems. They review measures that might be adopted by new health insurance exchanges to mitigate historical failures in private insurance. The analysis presented by Garfield and colleagues highlights that gaps in services will remain despite coverage expansion, particularly for social supports that are not likely to be covered by private health insurance. Funding for wraparound services will continue to be important. Finally, Druss and Mauer suggest improvements in the infrastructure to promote improved mental health care within newly created medical homes and accountable care organizations. They call for development of a broader range of quality measures in mental health and the use of information technology by specialty providers.
The ACA reinforces the place of mental health and substance use disorder care in the health care mainstream, building on the 2010 implementation of parity requirements for coverage of behavioral health care in private health insurance. Even though the field may have entered the mainstream of health care reform, it is still important to recognize and address the unique challenges to the health care system posed by individuals with mental and substance use disorders. The government and other stakeholders must redouble their commitments to craft policies that account for the sometimes exceptional circumstances presented by mental health care delivery.
