Researchers at Brandeis University recently published two articles in Psychiatric Services that examine access to behavioral health care in insurance plans after the passage of the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) and the 2010 Affordable Care Act (ACA). Their findings paint an encouraging picture, in which overall access to mental health and addiction treatment has increased and is mostly covered on par with medical coverage.
However, the authors encourage continued vigilance of this progress in light of continued efforts to weaken or repeal the ACA. They note that insurance coverage of behavioral health treatment is more important than ever, given the treatment needs of the opioid addiction epidemic and a national increase in the suicide rate.
Both papers are a product of the Institute for Behavioral Health (IBH), part of the Schneider Institutes for Health Policy at the Heller School for Social Policy and Management. IBH Director Constance Horgan, one of the authors, says, “These two studies examine what’s been happening to private health plans in recent years, which given the policy changes is very important to track.” Horgan notes that this work is part of the ongoing Brandeis Health Plan Survey on Alcohol, Drug and Mental Health Services, which has been through four rounds.
The 2008 MHPAEA mandated parity between medical and behavioral health coverage, doing away with common insurer practices that charged higher copays for mental health or limited the number of behavioral health visits. However, this legislation only applied to health plans that cover behavioral health at all—creating a loophole in which insurers could elect to stop offering this coverage altogether.
Along with IBH colleagues, Professor Dominic Hodgkin, lead author on the paper titled “Federal Parity and Access to Behavioral Health Care in Private Health Plans,” decided to see whether insurers were taking advantage of that loophole.
“There was a lot of concern that this would happen,” says Hodgkin, “but our study shows that there wasn’t a widespread drop of behavioral health coverage. In fact, two thirds of health plans had expanded covered behavioral health services since 2010.”
There was also another loophole in the legislation, he adds, which left it up to insurers to decide which diagnoses they considered behavioral health at all.
“For example, a plan could say they didn’t believe substance use was considered a behavioral health diagnosis, and exclude that treatment from their coverage,” says Hodgkin. “We checked to see whether that had happened, and the good news is we didn’t see it for substance use. However, we did see rapid growth in the exclusion of autism as a covered behavioral health diagnosis, which is very concerning.”
In addition to the 2008 parity legislation, the 2010 Affordable Care Act (ACA) dramatically increased access to behavioral health services by expanding access to Medicaid coverage and by including behavioral health treatment as an essential health benefit that many plans are required to cover.
Scientist Maureen Stewart is lead author on the second paper, titled “Behavioral Health Coverage Under the Affordable Care Act: What Can We Learn From Marketplace Products?” This study compared behavioral health benefits offered in the group insurance market to those sold in the ACA marketplaces.
Says Stewart, “We wanted to see if the ACA had resulted in robust behavioral health coverage, or if health plans were trying to discourage individuals with behavioral health conditions from enrolling by offering less generous behavioral health coverage. Basically we found that although ACA marketplace plans were similar to comparable plans available in the group insurance market in terms of covered services and authorization requirements, the ACA marketplace plans had narrower networks, which could result in less access.”
“Having smaller provider networks could be a tool to control costs or discourage coverage,” continues Stewart. “We need to keep an eye on network size and waiting times to see if people are still able to access the services they need, if their plans have narrower networks.”
Narrower provider networks could become a problem given the treatment needs resulting from the opioid crisis and general mental health trends.
Horgan adds, “The opioid crisis has created an ever-increasing and dramatic need for addiction treatment. The need for mental health services and the suicide rate have also been increasing in the U.S., so it’s really important that insurance coverage for these services be available and accessible to meet these needs.”
Taken together, these studies demonstrate progress in improving access to behavioral health services, though all three researchers note that there are still improvements to make, and that continued behavioral health parity is closely linked to strong health policy.