Patients with Mental Illness No Better Off under Obamacare

Obamacare doesn't help mental health patientsUnder President Barack Obama's health care law, which aimed to end health insurance discrimination for mental health services, an estimated 62 million patients now have better coverage. But a new report from the National Alliance on Mental Illness shows the policies still have a long way to go before they can make a difference in the lives of people living with mental illness. 

Source: Source: US News - Kimberly Leonard | Published on April 2, 2015

From lack of access to psychiatrists to expensive costs for medications, the study reveals a variety of issues that NAMI says show insurance companies are falling short in coverage of mental health and substance abuse disorders, collectively referred to as "behavioral health" services. 

The Mental Health Parity Act, enacted in 2008, requires mental health benefits in some employer-sponsored plans be provided on the same terms of other medical care. When the Affordable Care Act became law in 2010, coverage was expanded to private health plans sold in state and federal marketplaces, where Americans can buy tax-subsidized plans based on their income. Mental health care is one of 10 required benefits, just like maternity care and vaccines, for all plans sold. 

But the definition of "parity" is murky at best. 

"We're all still trying to understand what it means," says Sita Diehl NAMI's director of state policy and advocacy. "Gray areas remain, and we are finding them out as we go along."  

Caroline Pearson, vice president for health reform at Avalere Health, admits the lack of a clear definition made the analyzing the NAMI study difficult. "We tried to adhere to the current mental health parity regulations, but they are not sufficiently specific to be able to make a really clear judgement," she says. 

Part of the problem is that many psychiatrists do no accept insurance, charging patients out-of-pocket for care instead. Pearson also points out that benefits listed on a plan may not be clear.  "There's a whole array of nuance," she says. For instance, a plan might list that it covers in-patient psychiatric care but doesn't specify the kind of facility in which that care may take place. 

For the report, NAMI surveyed 2,720 customers and analysed 84 health insurance plans - both employer-provided plans and ones purchased through the marketplaces - in 15 states.  

The project was funded by pharmaceutical companies Eli Lilly and Co., Genentech, Otsuka Pharmaceutical and an anonymous NAMI donor.  

In response to the report, Clare Krusing, the spokeswoman for America's Health Insurance plans, the trade association for the industry, said in a statement that health plans had a unique understanding of the challenges patients and their families face when it comes to managing behavioral health conditions. "The goal is to ensure patients have access to the right care at the right time and in the right setting," she said. ?

The Substance Abuse and Mental Health Services Administration found in a 2013 report that 9.6 million adults reported having a serious mental illness, such as major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder, panic disorder, post traumatic stress disorder or borderline personality disorder. People with mental illness require an individualized treatment plan that could require medications, therapy and participation in peer support groups.

"Any barrier that stands in the way is cause for saying ‘never mind,' and your life falls apart," Diehl says. ?

Untreated mental illness can lead to unemployment or homelessness, and people may turn to substance abuse to self-medicate, which can make symptoms worse. Some turn to suicide, and many end up in prison instead of receiving care. 

Nearly a third of NAMI survey respondents reported insurance companies denied authorization for mental health and substance abuse care because the insurance companies deemed the care not medically necessary. "In the absence of uniform criteria, insurers have adopted their own standards and have often not been forthcoming about informing beneficiaries about these standards," authors of the report wrote. 

The report follows a series of bad news for mental health advocates. NAMI found in a December report that funding for behavioral health services still lags at the federal and state level.

Also, despite intended expanded access under the law, a report from U.S. News in October showed that Americans with mental health issues or substance use disorders aren't lining up for care. It found some Americans didn't know know about the new provisions, while others were barred by loopholes in the law or fell into a coverage gap because their state didn't expand Medicaid for low-income people and they could not afford to buy private health insurance. People who don't have coverage are more likely to put off medical care or to skip it altogether. 

"With mental illness, that's the beginning of a slippery slope, and your life can come completely apart," Diehl says. "It makes sense to pay at the front end and make it affordable." 

But even with health care coverage there remain gaps in the care a patient can access, the report shows. Recent projections from the Congressional Budget Office, the nonpartisan score-keeping agency, revealed that premiums on average are significantly lower for people purchasing health insurance through the marketplaces than originally anticipated. This was touted by the White House as good news, but authors of the CBOreport say the lower premiums may be due to beneficiaries selecting lower-cost plans - ones that have limited provider networks. This means their insurance may not cover the doctors, hospitals, procedures or even individual members of a surgical team, potentially heaping costs on consumers. 

"The networks looks good on paper, but when you actually try to find a provider you end up with a lot of roadblocks," Diehl says. "Narrow networks are an egregious problem." 

There also aren't enough mental health providers in the networks, the report finds. Participants in the survey said it was most difficult for them to find a therapist or a counselor, and only slightly less difficult to find a psychiatrist. According to the federal government's Substance Abuse and Mental Health Services Administration, 55 percent of counties do not have a practicing psychiatrist, psychologist or social worker. Rural counties, in particular, are affected by the shortage. 

Even if the medical provider is included in a health care network, he or she may not be available. In January 2015, the Mental Health Association of Maryland published a study that revealed only 14 percent of psychiatrists listed in the qualified health plans in the Maryland marketplace were actually accepting new patients and available for an appointment within 45 days - the suggested wait time. 

Findings also showed that customers had a difficult time paying for medications, and that certain medications, like some antipsychotics, were not covered at all or only available with high out-of-pocket costs.  For marketplace plans, denials were nearly twice the rate for other medical care.

"[The Department of Health and Human Services] needs to regulate health plans and costs so consumers don't end up sharing this much of the cost," Diehl says. "Without the regulation, Congress should work to decrease out of pocket costs." 

NAMI made a variety of other recommendations in its report, from publishing more information about health plans' specific coverage to establishing easily accessible procedures for filing complaints. 

"It's an improvement in terms of access, but it's not the improvement we had hoped for in terms of coverage yet," Diehl says. "We have more work to do to achieve parity."