One aspect of the Obama Administration’s Affordable Care Act that’s often overlooked in the media is its attention to mental health and substance abuse treatment.
Overall the landmark legislation hopes to bring near universal health insurance to the United States when the last round of its major provisions goes into effect on Jan. 1, 2014. These provisions include the controversial individual and employer insurance mandates.
But the law goes further though than just getting people insured, it aims to improve the American health care system, especially in the areas of mental health and substance abuse.
Mental health and mental health policy have been favorite topics in the news these last few years with the tragedies in Tucson, Aurora, and Newtown. Pundits from all sides have found a new pastime in discussing and arguing over how the system should be changed.
Opinions aside mental health and substance abuse are serious issues in America. About one in every four adults can be expected to experience a mental illness during the course of a given year, according to stats from the National Alliance on Mental Health (NAMI). That’s nearly 55.7 million people, no small number for a nation of 315 million.
That number of adults rises to one in 17 when talking about more serious mental illnesses like schizophrenia, major depression, or bipolar disorder. For younger Americans the rate continues to climb with one in 10 children living with a serious mental or emotional disorder, according to NAMI numbers.
Substance abuse is estimated to cost the United States over $600 billion annually. A 2012 survey conducted by the National Institute on Drug Abuse found that among teenagers alcohol and cigarette use has declined in recent years but the use of illicit drugs is on the rise.
So it’s no wonder that the Care Act looks to extend coverage and improve treatment of mental health and substance abuse. Let’s take a look at some of the ways it aims to do that.
1. Say goodbye to “pre-existing” conditions
If you have a history of substance abuse or mental illness and sought health insurance in the past you’ve probably run into this roadblock.
An insurance company refuses to sell you coverage because you’re too risky. Or if they do sell you a policy you could expect the premiums to be through the roof expensive.
Now you can say goodbye and good riddance to that policy, its days are effectively over.
Since the March 2010 signing into law of the Affordable Care Act, people considered to have a “pre-existing” condition have had access to health insurance through special state run high risk insurance pools. This is a temporary measure until Jan. 1, 2014 when the last of the major provisions of the Affordable Care Act kick in.
When that happens insurers will be legally barred from denying coverage to anyone. They’ll also be required to charge people for their insurance more fairly, so no more huge monthly premiums because of medical history. Together these policies are referred to as guaranteed issue and community rating.
2. Thanks for the Medicaid
Expanding the federal Medicaid program to more people was a key goal of the battle to pass the Affordable Care Act in 2009 - 2010. Medicaid has always offered robust mental health and substance abuse treatments which were often better and more integrated than private insurance plans
Originally a mandated measure of the Care Act was the expansion of Medicaid in all 50 states. The expansion would extend the threshold for eligibility from 100 percent of the Federal Poverty Line (FPL) to 133 percent for the program. This meant that people with a yearly income of 133 percent of the FPL and below would be eligible to apply for Medicaid. Also single, childless adults would be also be able to apply for Medicaid for the first time.
However, because of the Supreme Court ruling on the Care Act last year, it is optional for states to accept the Medicaid expansion. So far 26 states have announced that they’ll accept the expansion, while 13 plan to decline it.
3. Substance abuse and mental health treatment comes standard
If you’re not eligible for Medicaid but still looking for insurance with the coverage you need for mental health or substance abuse then a plan sold at one of the state health insurance exchanges might be a good option.
The state exchanges will be a one-stop shop for all things health insurance in your geographic area. Sort of like an Amazon.com for health insurance. You’ll be able to browse and compare insurance plans from a variety of insurers at different cost levels.
Every health plan sold at the exchange will need to cover medical services in 10 “essential benefits” categories, as mandated by the law. For us the three most important are the mental health, prescriptions, and substance abuse categories.
Coverage for treatments in all those areas will come standard with any plan purchased through the exchange. This might be a relief for those looking quickly for a plan for next year who don’t have the time to read through the benefits summaries.
For the moment it’s not known exactly which treatments will be offered for each “essential benefits” category. The exact details of what procedures and services will be offered are left up to the states to decide. But the legislation does mandate that mental health and substance abuse coverage must be on par with any medical/surgical treatment.
As part of the essential benefits in the exchange, plans will also cover rehabilitative and habilitative services, ambulance service, and inpatient services.
Enrollment for insurance plans through the exchange will begin on October 1, 2013 for coverage starting Jan. 1, 2014.
4. Short on cash? How about a tax credit?
Sticking with health insurance exchange plans for a moment longer, there are also tax credits available to individuals if they choose to purchase a plan on the exchange.
It gets a little complicated, but essentially if you’re not eligible for Medicaid and your annual income is between 133 and 400 percent of the federal poverty line (FPL), you get a tax credit. If you happen to live in a state that did not choose to expand Medicaid then you’ll be eligible at 100 percent of the FPL.
Here’s how it works. The maximum anyone within the 133 to 400 percent range can pay for health insurance is 9.5 percent of their annual income. That 9.5 percent is also a sliding number, so the less you make the less you’ll pay.
Now with that in mind your tax credit is the difference between the percent of your income that you pay for health insurance minus the cost of the second lowest Silver tier insurance plan available in your area.
Wait what do you mean by Silver tier? Plans sold at the state exchange come in four different levels, so to speak. Each one has a different price with its own range of coverage. Note though that they all do cover the same 10 essential benefits categories, they just have different out of pocket expenses.
●Bronze level - 60 percent coverage
●Silver level - 70 percent coverage
●Gold level - 80 percent coverage
●Platinum level - 90 percent coverage
The coverage percent refers to the amount paid in monthly health insurance premiums versus what the insured would pay out of pocket for treatment. So for a Bronze plan, you would pay less each month for coverage than someone with a Silver or Gold plan, but your out of pocket expenses would be higher.
I know the tax credit stuff can be complicated and a pain to figure out, but don’t worry. We at Vista Health Solutions have put together a calculator to help you determine your tax credit. Check it out here. The Kaiser Family Foundation also created a helpful calculator here.
5. Prevent diseases before they start
Those diagnosed with a serious mental illness or suffering from substance abuse are also at high risk for a range of preventable diseases like obesity, diabetes, heart disease, and cancer.
One of the great things about the Affordable Care Act is that it mandates preventative medical services be provided by insurance companies free of change, so without any co pays or deductibles.
It’s part of a shift in the thinking about American health that the Affordable Care Act hopes to usher in. Moving from just addressing the symptoms of disease to actually preventing it from happening in the first place. And if there is any one area of American health that badly needs improvement it's in the area of preventable diseases.
In the past there has always been this separation of mental health and substance abuse treatments from physical health treatments. Because of the separation a lot of private and workplace health insurance plans skimped on providing sufficient coverage for mental health and substance abuse treatment.
The lack of coverage left many individuals and families to pay enormous sums of money out of their own pocket for treatment. Or forced them in some cases to go without desperately needed treatment because they just didn't have the money.
This is where the Care Act comes it. Because of mandated coverage for mental health treatment and the expansion of Medicaid, the Care Act dismantles that wall blocking people from getting the treatment they need.
While admittedly the Care Act could do more for mental health and substance abuse treatment, it does create some real change in the system. By taking down barriers more Americans will be able to get the help they need to become healthy and stay healthy.
Michael Cahill is Editor of the Vista Health Solutions blog. He has a degree in Journalism from SUNY New Paltz and previously worked as a reporter for the Poughkeepsie Journal and an editor for the Rockland County Times. Follow him on Twitter at @VistaHealth and @ElectronicMike
Updated: June 12 2013