Kathleen ThomasIt's National Public Health Week! We’re spotlighting the daily themes of the week with a series of guest blogs from APHA members. Today’s NPHW theme is behavioral health and our guest blog comes from Kathleen Thomas, PhD, MPH, a behavioral health economist whose work focuses on improving access and quality of care for mental health services. She is a senior research fellow at the Cecil G. Sheps Center for Health Services Research, adjunct associate professor of health policy and management at the University of North Carolina at Chapel Hill and past chair of APHA’s Mental Health Section.

Maybe we should try a market solution to ensure that people get the mental health services they need? If people could shop for their insurance, companies would be encouraged to compete for customers. We could mandate purchase and provide subsidies for those who couldn’t afford it. With everyone covered by health insurance, practices would spring up and provider shortages would be a thing of the past. That’s what Stuart Butler of the conservative Heritage Foundation proposed in 1989 in a lecture entitled, Assuring Affordable Health Care for All Americans.

The Affordable Care Act (ACA, P.L. 111-148) looks remarkably similar. A number of its features hold particular promise for people with mental health conditions. The ACA makes health insurance available to individuals who heretofore were unable to purchase it due to limited income or pre-existing condition exclusions. It allows children to remain covered through their parents’ plans through age 26. It also allows states to expand Medicaid to adults below age 65 with income up to 138 percent of the federal poverty level who are not otherwise eligible for Medicaid. Plans offered via the health insurance marketplaces, expanded Medicaid and most others must now include essential health benefits including ‘parity’ in coverage of mental health services equal in value to that of general health services. In addition, the marketplaces provide a way to offer consumers choices among plans. State standards of coverage for most individual and small group plans and for expanded Medicaid are set by means of benchmark plans. States shape the quality of their health insurance offerings through their benchmark plan decisions, both in the marketplace and Medicaid. The ACA provides a foundation to ‘stimulate the creative juices of the states … combined with a requirement for basic health coverage.’ Oops, that was the Heritage plan. You can see they’re quite similar.

A number of positive impacts of the ACA are emerging for people with mental health conditions. People with mental health conditions are less likely to be uninsured and to report unmet need for care. For young adults with mental health conditions, the extended eligibility for dependent coverage reduced lack of insurance, unmet need and out of pocket expenditures. Moreover, Medicaid expansion is associated with an increase in medication-assisted treatment of opioid use disorder. Among adults with chronic conditions, the ACA improved access, affordability and self-reported health status. And, among people with disabilities, individuals living in expansion states were more likely to be employed compared with those in non-expansion states. Medicaid expansion has resulted in improvements in insurance coverage, and in access, use, affordability and health outcomes for insured populations generally, as well as improved financial health of provider organizations. Moreover, after an initial uptick health care spending in the U.S. started to slow.

Despite the harmony between early conservative ideas and current policy, recent congressional efforts to dismantle the Affordable Care Act have been described as death by 1,000 cuts. These efforts included several attempts to repeal and replace the act, which would have resulted in millions more people left uninsured. When those efforts failed, the administration eliminated federal payments to insurance companies to pay cost-sharing subsidies. Since companies still have to pay the subsidies, they raised premiums, which the federal government subsidizes, adding billions to the federal deficit. The administration also made it harder to enroll by reducing funding to help people with the enrollment process and shortening the enrollment period. Next, Congress passed legislation as part of the tax bill that eliminates the individual tax penalty for failing to have health insurance coverage, which negates the individual mandate starting in 2019. As a result, more healthy people who don’t care about insurance as much will dis-enroll, sicker people will remain insured, and premiums will rise more, weighing most heavily on the people who don’t receive subsidies.

Important common ground exists between the ‘three-legged stool’ of the Affordable Care Act and the four objectives of the original Heritage plan, that: (1) all citizens are guaranteed universal access to affordable health care; (2) inflationary pressures in the health industry are controlled; (3) government assistance is concentrated on those who need it most; and (4) the system encourages innovation. We need to focus on these shared values to ensure that people get the mental health services they need.

To learn more about National Public Health Week and get involved, visit www.nphw.org. Don’t miss today's kickoff forum with U.S. Surgeon General Jerome Adams and a panel of experts in-person or via livestream at 1 p.m. ET.