Another day, another study on the benefits of the Affordable Care Act and what we risk losing as the Trump administration continues its sabotage.
This time it’s a study on ACA-related gains in mental health coverage. The new research, just published in Health Affairs, found a “significant” increase in the availability of behavioral health coverage after the ACA went into effect. They also found an increase in the level of behavioral health coverage post-ACA — more specifically that coverage of behavioral health services came into parity with medical and surgical benefits.
“The results of our study suggest that plan issuers responded as intended to the ACA provisions that established behavioral health coverage as an essential health benefit and extended parity requirements,” the study concluded.
Under the ACA’s consumer protections, insurers have to cover a set of essential health benefits (EHB), which includes mental health and substance use services. The law also requires parity, or that behavioral health services be covered at the same level as other medical services and not be subject to unfavorable benefit limitations. The ACA essentially enshrined mental health parity into the insurance system, building on the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act. The 2008 law required group plans that do cover behavioral health to do so on par with other medical services; however, insurers could get around the parity rule by simply excluding behavioral health from their coverage plans.
The National Alliance on Mental Illness reports that about one in five U.S. adults, or nearly 44 million people, experience mental illness in a given year. About one in five young people ages 13 to 18 experience a severe mental disorder, and rates of serious mental illness among young adults are rising.
The new Health Affairs study specifically looks at the impact of the ACA’s parity and EHB rules on the scope and level of coverage for behavioral health care in relation to medical and surgical benefits. To do that, researchers looked at data from 2013 (before parity took effect) and 2014 (post-parity) using 138 individual and small group health plans from 12 states. In each state, researchers picked insurers with the greatest market shares.
In 2013, across benefit categories, a lower proportion of plans offered in-network coverage of behavioral health compared to medical/surgical services. After parity took effect in 2014, that gap closed as insurers dropped their behavioral health exclusions and came into compliance with ACA protections.
More specifically, in pre-parity 2013, only 81 percent of plans covered mental health conditions in their inpatient networks and 77 percent included substance use disorders. By 2014, all the plans had inpatient in-network coverage for behavioral health conditions. The study found similar coverage improvements for outpatient care, office visits, emergency department visits and prescription drugs. On the flip side, however, researchers found that out-of-network coverage for behavioral health fell in 2014, as did out-of-network coverage for medical and surgical care.
Coverage for three particularly important behavioral health services — intensive outpatient treatment, intermediate care, and post-acute or rehabilitative treatment — went up in 2014. Post-parity, for example, the proportion of plans covering post-acute care for behavioral health conditions went from 65 percent to 100 percent. In 2014, the study found far fewer plans required copays for initial in-network visits for behavioral health services. Almost all the plans studied required copays for out-of-network care and that didn’t change between 2013 and 2014.
Researchers write of the ACA gains: “The main implication of these increases in the scope and level of insurance coverage for behavioral health conditions from 2013 to 2014 in the individual and small-group markets is that enrollees potentially will have improved access to services because they are more affordable.”
The study also estimates that if Republicans succeed in repealing the ACA’s protections, up to 20 percent of the plans they studied would drop their behavioral health coverage.