Health Reform: What You Need To Know
What the Affordable Care Act Offers
By Rebecca A. Clay
Imagine a shift from “sick care” to true health care. That’s how U.S. Department of Health and Human Services Secretary Kathleen Sebelius, M.P.A., describes the transformation that health care reform is bringing to our health care system.
An emphasis on prevention pervades the Affordable Care Act (ACA). “Focusing on prevention rather than waiting until people get to the point where they have to be treated for some sort of acute illness just makes good sense,” said Secretary Sebelius. “We want to take down the barriers that are keeping folks from being as healthy as they can.”
Signed into law in March 2010, the Affordable Care Act will bring health insurance coverage to 32 million Americans who are currently uninsured. For those who already have insurance, the law offers new benefits, plus an end to practices that have kept people from being able to access health care just when they need it the most.
The law is especially good news for individuals with behavioral health disorders, said SAMHSA Administrator Pamela S. Hyde, J.D.
“Right now, estimates show that one-fifth to one-third of the uninsured are people with mental and substance use disorders,” said Administrator Hyde. “Of the estimated 32 million people we anticipate gaining coverage, about 6 to 10 million will have untreated mental illnesses or addictions we can actually help.”
Finding health insurance can be difficult for people with mental health and substance use disorders, explained Administrator Hyde. For one thing,insurers typically exclude individuals with pre-existing conditions. In addition, people with serious behavioral health problems may not be employed and thus lack the insurance coverage that often goes along with employment.
The result has been a widespread lack of health insurance among many of the people who need it the most, said John O’Brien, M.A., Senior Advisor for Health Financing at SAMHSA. “Thirty-nine percent of the individuals who are now served by state mental health authorities have no insurance now,” he pointed out.
“And 61 percent of individuals served by state substance abuse authorities have no insurance.” ACA changes that.
Beginning in 2014 (see timeline), insurers will no longer be allowed to deny consumers coverage because of pre-existing conditions or raise their premiums if they develop problems. Until then, consumers can turn to ACA’s new Pre-Existing Condition Insurance Plan for help.
In addition, coverage options will expand. An expansion of Medicaid will bring coverage to an estimated 16 million new enrollees, said Mr. O’Brien. “Forty percent of them will be under 30 years old,” he said. “That means we need to think about ways to engage that generation in treatment.”
Starting in 2014, individuals can also seek coverage from state-run exchanges—a new competitive marketplace for private health insurance that’s designed to give individuals and small businesses access to affordable coverage.
Essential mental health and substance use disorder services must be covered as part of the benefits package by all insurance policies offered through the exchanges and Medicaid.
One group is already enjoying expanded coverage: adult children of the already-insured. Since September 2010, parents who purchase or renew insurance plans can obtain coverage for their children up to age 26.
It’s not just the uninsured who will benefit from Affordable Care Act, however.
The law’s emphasis on prevention, for example, means that consumers purchasing new plans will no longer have to face copayments or other forms of cost-sharing for preventive services, such as depression screening, drug and alcohol misuse screening, and smoking cessation efforts.
In addition, the law eliminates lifetime caps on benefits and restricts insurers’ use of annual caps for all new plans issued after December 2010. That’s huge, said Steven Randazzo, a special assistant in SAMHSA’s Office of the Administrator.
“Having a chronic condition or caring for someone with a chronic condition is expensive,” he explained. “This change means that you can keep going back to the doctor and keep your coverage.”
ACA also puts a stop to rescission—the practice of dropping patients from coverage, usually when their medical expenses are high—except in cases of
misrepresentation or fraud.
Reform means big changes to those providing services, too. “States are going to be involved more than ever,” said Mr. Randazzo. For one thing, states must establish their insurance exchanges and have them ready for operation in 2014. They must also prepare for the expansion of Medicaid.
That expansion will also trigger changes in SAMHSA’s Mental Health Services Block Grants and Substance Abuse Prevention and Treatment Block Grants. With more people receiving coverage for behavioral health services via Medicaid and the new exchanges, SAMHSA will redirect that funding to whatever gaps in service remain. “We have to figure out how to direct the dollars differently,” said Mr. O’Brien.
Integration of behavioral health and primary care is another major theme within the Affordable Care Act.
For example, the law allows states to add a “health home” option to their Medicaid coverage (see What Are Health Homes?). Health homes “fit all the pieces together” for
individuals with chronic conditions, explained Charles Ingoglia, M.S.W., Vice President for Public Policy at the National Council for Community Behavioral Healthcare. In these long-term relationships, consumers select providers who will be responsible for coordinating all of their care, sharing information electronically with other providers, and handling tasks like followup that often fall through the cracks.
That concept is especially helpful for people with behavioral health issues, said Mr. O’Brien. “Studies have shown that 70 percent of individuals with significant mental health or substance use disorders have one or more chronic conditions,” he pointed out.
Behavioral health providers should already be preparing for the integration of behavioral health and primary care, emphasized Rita Vandivort-Warren,
M.S.W., a public health analyst in the Division of Services Improvement at SAMHSA’s Center for Substance Abuse Treatment.
“It’s important for mental health and substance abuse providers to develop good linkages with primary care practitioners,” she said, adding that there are various models of integration. “Sometimes it’s the behavioral health provider doing screening and brief interventions in the primary care site; sometimes it’s the primary care provider giving services in behavioral health organizations.”
Providers should also ensure that they’re ready to embrace electronic medical records and understand Medicaid billing procedures, added Mr. Randazzo.
Many details of ACA’s implementation are still to be worked out. SAMHSA will play a key role in that process.
To help influence what happens with provisions related to behavioral health, SAMHSA crafted a white paper laying out its vision for a good, modern addictions
and mental health service system. “We wanted to get ahead of the curve,” said Mr. O’Brien.
SAMHSA is already involved in helping to shape specific ACA provisions. States must consult with SAMHSA as they craft their plans for health homes, for example.
Consumers, providers, and other stakeholders should get involved, too, emphasized Mr. Randazzo. They should stay informed about what’s happening, get engaged, and share their input on such matters as what specific behavioral health services will be included in the essential benefits package, how the new insurance exchanges are constructed, and so on.
“We want to make sure behavioral health is at the table,” said Mr. Randazzo. “With other people’s involvement, we can keep behavioral health concerns at the
For more information about the Affordable Care Act, visit http://www.healthcare.gov. This site features a timeline, video chats, and even an interactive database of insurance options in addition to basic information about the law.
For more information about ACA’s impact on behavioral health, visit SAMHSA’s newly redesigned Web site and click on the Agency’s Strategic Initiative on Health Care Reform.