Mental health advocates continue to herald the Patient Protection and Affordable Care Act (PPACA) as an enormous win for people with mental disorders.

PPACA mandates coverage parity, putting mental health treatment on par with medical care, which means deductibles, copayments, and doctor visits can’t be more restrictive for mental illnesses than medical and surgical coverage.

This means that people who suffer from substance use disorder and illnesses like bipolar disorder, major depressive disorder or schizophrenia, are provided the same coverage as those with cancer, diabetes or heart disease.

Also, if a plan provides for out-of-network medical benefits, it must provide the same for mental health benefits, as well.

PPACA also means that the immediate reform changes that went into effect Sept. 23 under the health-care reform, apply to mental health conditions: non-denial of coverage for children with pre-existing conditions under age 19; preventing lifetime limits on coverage, not allowing new plans to set annual coverage limits; and requiring new plans to offer family coverage for dependents up to age 26.

A Significant Problem

According to the National Institute of Mental Health, (NIMH) approximately 58 million Americans suffer from a mental disorder in a given year, with about 1 in 17 (6%) suffering from a serious mental illness.

About 20% of U.S. youth during their lifetime are affected by some type of mental disorder that impairs their daily activity, according to a new NIMH national study based on 10,000 face-to-face surveys of 13 to 18 year-olds. 

Another 22.2 million Americans aged 12 or older need treatment for substance abuse or dependence, according to the Department of Health and Human Services’ 2008 statistics, the latest year data is available.

Evolution to Parity

“The stigma of mental-health based disorders was at one time enormous, has lessened recently, says Peter Newbould, director of Congressional and political affairs at the American Psychological Association.

“Today there’s a greater understanding that the mind and body are connected. The American people got that before members of Congress did.”

Health-care reform moves beyond the Wellstone-Domenici bill, which was passed in 2008 and became fully effective in July. That legislation was praised as a breakthrough for parity, but only covered Americans in group health plans.

PPACA expands parity to include people with individual health insurance policies, small businesses, and by 2019, will ultimately cover about 32 million uninsured Americans.

Coverage will come through a combination of state-based private insurance exchanges and a Medicaid expansion of the poverty level, according to the National Alliance on Mental Illness (NAMI).

A little more than half of those 32 million will probably go into state exchanges, where they can purchase coverage with pooled risk and therefore lower premiums, says Andrew Sperling, NAMI’s director of legislative advocacy.  

Parity Played Out

PPACA will also foster research for serious mental illnesses and provide expanded support for people with long-term mental health problems.

On the large employer front, workforce health management has gained considerable momentum offering virtually every type of health management program from health-risk assessments to disease management programs to behavior modification programs, according to a 2009 Mercer Survey of Employer Sponsored Health Plans.

For example, Mark A. Cesarano, a managing consultant at the Savitz Organization, reports that conditions like smoking cessation are now increasingly being treated like any disease. 

Anthony M. Kotin, an internist and chief medical officer at Magellan Health Services said,  “100% of Magellan’s employer clients are well aware of the need for the mental health benefits.”

Today, employers have effective screening methods for employees and tools that are very effective in the early identification of an employee who’s depressed, bipolar, suffering from mood disorders, or substance use disorders.

These practices can fall under Employee Assistance Programs (EAP’s) which, according to Kotin, are a big part of employer prevention programs and an important benefit that is frequently underutilized.

A lot of employers don’t promote EAPs. Also, Kotin says, employees are often “suspect” and feel participation might interfere with job security. In fact, employees retain anonymity and receive information telephonically.  

Gray Areas

Beyond some of these specific programs, health advocates are disappointed that the Interim Final Rules (IFR’s) that precipitated the reform bill were not defined clearly. So issues like, copays, deductibles, and duration are still unclear.

This gray area is where plans can manage cost. There has always been a focus on discouraging inappropriate utilization. But Newbould cautions, the one controversy that still has to be played out is the extent to which management becomes a barrier to necessary treatment.

“A plus may be that the [the practice of mental health] has become a documented, objective, well-rounded science,” Kotin says. “We have extremely sensitive tools for documenting improvement of patients with bipolar disorders, schizophrenia or the like.”

Cost of Care

Patients will see one immediate cost impact with the new legislation: prescriptions. Routine doctor visits will result in more written prescriptions for mental health conditions, Cesarano says. That said, experts see increases as minimal, causing less than a 1% increase in rates.

“Over the last 20 years in health care we’ve seen that the right care, at the right time, with the right provider, in the right venue has led to quality, with outcomes up and costs down, says Kotin. The caveat: “It’s a complicated process.”