Background
Mental health is a fundamental component of overall health. Mental illness affects people of all ages and incomes and can be as debilitating as any other major medical illness. According to the National Institute of Mental Health, about one in four adults (almost 60 million people) have a diagnosable mental disorder in any given year. In the past, many people with mental illness who had health insurance did not receive treatment because insurers typically placed more restrictions on coverage (e.g., higher deductibles and copayments and stricter treatment limits) for mental health and substance abuse services than for other health services.
The ACA has helped end many of these restrictions. For example, health plans provided through the state health insurance exchanges are required to cover services for mental health and substance abuse, and must provide such benefits at parity with medical and surgical benefits (i.e., they cannot impose financial requirements or treatment limitations that are more restrictive than those required for other covered health conditions). The ACA also extended mental health parity to populations newly covered by Medicaid in states that chose to expand the program. Previously, only Medicaid-managed care plans were subject to parity requirements.
The ACA prohibits insurers from denying or taking away health coverage on the basis of mental illnesses. It also ends lifetime and annual limits on the dollar value of benefits, which will reduce out-of-pocket expenses for individuals with long-term service and medication needs.
People who are not eligible for Medicaid and cannot afford to buy health coverage on their own may be eligible for ACA-related premium- and cost-sharing subsidies that will reduce their costs. This is an important change, given that cost is the factor most often cited by people who recognize that they need mental health treatment but do not get it.
Other ACA provisions promote integrated service delivery for the mentally ill. People with serious mental illnesses die an average of 25 years earlier than the general population, largely due to co-occurring medical conditions and poor access to medical care.
Many of the ACA’s parity-related provisions augment the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The MHPAEA requires group health plans for businesses with 51 or more employees to cover mental illnesses and substance abuse at the same level as they do physical ailments. However, these provisions only apply to plans that choose to offer mental health and substance abuse coverage. The law does not require plans to cover all mental and substance use disorders, but they must provide equivalent coverage for the diagnoses they have selected. Further, the MHPAEA does not supersede any state law that provides stronger consumer protections, benefits, rights, or remedies.
The Federal Employees Health Benefits Program, the world’s largest employer-sponsored health insurance program, requires parity between mental health benefits and benefits for other conditions, and 49 states and the District of Columbia have some form of parity law.
Effective mental health interventions range from specific medications to treat schizophrenia, to specific models for treating depression in primary care settings, to supportive housing for homeless people with mental illness. These and other mental health interventions have proven to be cost-effective.
Nevertheless, discrepancies exist between the type of mental health care known to be effective and the type of care that is delivered. According to a 2006 report by the Institute of Medicine (IOM), the challenges to providing care for mental health and substance abuse include the stigma associated with a mental health diagnosis and the frequent need to coerce patients into treatment. Other challenges include a less developed system for measuring and improving care quality, the need to link a greater number of providers, less widespread information technology, and the structural and functional separation of mental health care delivery from other components of the health care system. One final challenge is that diagnostic criteria and treatments have typically been developed and validated on young and middle-aged adults, and thus may not necessarily be applicable to older adults.
Further, long-standing efforts to deinstitutionalize mentally ill patients have not led to corresponding and necessary changes in community-based mental health care delivery. In combination with substantial reductions in mental health funding, this shift has made it difficult for many patients to obtain the mental health services that they need. These difficulties are made worse by the current shortage of geriatric mental health and substance use workers.
A 2012 report by the IOM, The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? found that the number of providers entering, working in, and remaining in the fields of primary care, geriatrics, mental health, substance use, and geriatric mental health and substance use is very small.
Mental Health: Policy
Improving services
The IOM’s recommendations on improving the quality of the overall health care system should be applied to mental health and substance abuse settings but tailored to reflect the distinct characteristics of such care. In particular, evidence on effective treatments and services specific to diverse older populations should be synthesized and disseminated, and the competency, capacity, and diversity of the workforce must be strengthened.
Efforts to reduce prescription drug abuse must ensure appropriate access for patients with legitimate medical needs.
States should ensure adequate funding for mental health and substance abuse services, develop comprehensive and coordinated delivery systems for such services, and require service providers to undergo special training in cultural and ethnic sensitivity.
States also should ensure that mental health and substance abuse services (both privately and publicly funded) meet high standards for quality, monitor the public’s access to and satisfaction with services, protect clients’ due-process rights, and involve consumers, their family members, advocates, mental health coalitions, and professionals in planning, implementing, and evaluating services.
States should also implement initiatives such as education, training, and respite care that support family and other caregivers.
Coverage
Federal and state governments should support proposals to require adequate and affordable mental health and substance abuse coverage. For example, the use of advanced practice registered nurses (APRNs) in the provision of some services to Medicaid patients may increase access to mental health services and also prove cost-effective. Mental health services should have parity with (i.e., be covered at levels equivalent to) other health services.
Federal and state governments should rigorously monitor and enforce parity requirements in plans offered through the state health insurance exchanges and in Medicaid managed care, benchmark, and benchmark-equivalent plans.
Costs
The Department of Labor should rigorously monitor and enforce the MHPAEA, particularly with respect to ensuring that businesses accurately estimate implementation costs. Congress should ensure that restrictions on mental health and substance abuse services in health plans not addressed by the MHPAEA do not exceed those for physical health services, including day or visit limits and cost-sharing levels.
States should ensure parity beyond the provisions of the act for all plans providing mental health and substance abuse services.
Data collection and reporting
Federally funded programs should collect and report data on the use and cost of mental health and substance abuse services for older people, including people enrolled in managed care plans.
Workforce
Primary care providers should be trained to recognize mental and substance abuse disorders in older populations. Mental health and primary care providers should be trained in state-of-the-art treatments.
Health care providers should receive training in effective suicide prevention strategies for older adults that include guidelines for recognizing, assessing, and managing at-risk behaviors.
The development of the primary care and behavioral health care workforce should be integrated so people with mental and/or substance use disorders receive the same care regardless of setting.
The IOM’s recommendations on strengthening the geriatric mental health and substance use workforce should be implemented.
Coverage denials
Insurers should be required to show cause before denying payment for specific medications prescribed by a physician to manage a mental health condition in cases where the physician deems the insurer’s recommended substitute to be less effective or medically inappropriate.
Community-based providers
The federal government should increase funding for community-based mental health and substance abuse services through the mental health block grant. A larger portion of funds should be targeted toward nontraditional providers of services for the older population, such as hospice programs, adult day-care centers, and other community-based long-term care providers.
Community mental health centers should be encouraged to reach out to older adults, who typically will not self-refer, by providing services at other sites and establishing affiliations with area agencies on aging. Mental health and substance abuse services should be accompanied by culturally relevant outreach efforts.
Managed care
Protections are needed for those in managed care plans who have mental health or substance abuse disorders in order to ensure their access to necessary services, including emergency services and mental health specialist care.
Policymakers should evaluate managed behavioral health care to assess whether enrollees have access to appropriate, high-quality, and timely care.
Research
Additional funding should be made available for research on the complex epidemiology of mental health and substance abuse problems of older Americans, as well as on preventing and reducing mental disorders and alcohol or substance abuse among older adults. Research should evaluate the impact of specific therapies—especially prescription drugs—on outcomes for older patients, including individuals in nursing homes and other residential settings, those rurally isolated, and older adults with serious mental illnesses.
The Centers for Medicare & Medicaid Services and the Substance Abuse and Mental Health Services Administration, through research and demonstration projects, should encourage innovative delivery models for mental health and substance abuse services (e.g., integrated care), in order to bring services into homes, senior centers, residential care facilities (including board and care homes), and federally assisted housing sites.
Policymakers should support ongoing research to evaluate the impact of specific mental health and substance abuse services on patient outcomes and on the use of other health services and behavioral health systems, including various types of carve-outs. Evaluations should examine access (e.g., timely service and an array of appropriate services), enrollee satisfaction, outcomes of care (e.g., the ability to live independently), and systems integration (e.g., tracking in other systems, such as criminal justice and education) to determine if mental health programs are working.
Medicaid
Medicaid law and regulations should provide for payment at adequate rates for mental health and substance abuse services. Individuals should be able to choose the same delivery system for mental health and substance abuse services as they do for physical health services. For example, individuals who select a fee-for-service plan should have access to mental health and substance abuse services, as well as physical health services, on a fee-for-service basis.
Quality
States should set and enforce strong licensing standards for community mental health centers.
Prisons
States should improve mental health and substance abuse services in criminal justice settings through increased funding and better collaboration with the larger mental health system. For example, states should establish jail-diversion programs (possibly through the use of specially trained police or on-site crisis teams) to minimize the number of seriously mentally ill individuals who are inappropriately incarcerated. Inmates with a serious mental illness should receive psychiatric and substance abuse services while in jail and follow-up care upon release.