Repair rather than replace
The ACA is not without its flaws, but perhaps the best approach is to build on its successes while repairing its weaknesses. Researcher Peter Phalen, MA, looked at changes in rates, usage, affordability, and satisfaction with services for those with moderate and severe mental illness after implementation of the ACA.11 Using a nationally representative sample (N = 35,602), he discovered that those with moderate mental illness, as measured by psychological distress scales, experienced greater gains in finding affordable coverage than those without mental illness.11 However, individuals with severe mental illness showed no improvement on these measures, with the exception of increased satisfaction with current coverage and care. There were no reported increases in health care use or affordability for either group.11
Although the ACA requires prescription coverage, there is no regulation of what insurers choose to include in their formularies, and often brand name drugs, particularly antipsychotics, are not covered. The National Alliance on Mental Illness released a report in 2015 noting that, even with the ACA, individuals continue to experience difficulty accessing behavioral health providers in a timely manner, especially in rural areas. The report also described a lack of parity enforcement for behavioral health coverage.12
What if?
If the ACA is repealed, other legislative acts could continue, in some way, to address the needs of those with mental illness. The 21st Century Cures Act, which has bipartisan support, was passed in 2016 in the hope of reforming national mental health care. The American Psychiatric Association (APA) president, Maria Oquendo, MD, PhD, indicated that the bill enhances parity laws and provides better coordination for national agencies involved in treating psychiatric illness.13 The APA applauded this effort and highlighted these provisions:
- reauthorizing grants to support integrated care models
- reauthorizing grants to train school staff to identify students who need mental health care
- requiring the HHS to develop a plan to enforce parity laws
- providing $1 billion in state grants to address the opioid epidemic.13
The APA has voiced its concern about repealing the ACA without replacement. The APA issued a letter to Congressional leadership stating the organization’s concerns, emphasizing that current law has eased the burden for Americans to access “appropriate and evidence-based mental health care.”14 The APA requested that, in considering reforms to health care law, Congress does not “undo the gains which have been made over the past several years for individuals with mental illness.”14 The APA noted that the proposed ACA replacement bill, released on March 3, 2017, would “negatively impact care for people with mental illness and substance use disorders.”15
Since the ACA was implemented, we have taken for granted many provisions as permanent fixtures of our nation’s health care system. Who now can imagine a denial of coverage for a preexisting condition? How many young adults are ready to purchase their own insurance plans immediately after high school or college if employment is not readily available? Is it reasonable that an insurance plan does not provide prescription coverage or behavioral health services? How will those with mental illness or substance use disorders have reliable access to assessment and treatment?
Repealing, replacing, or enhancing the ACA is a complicated balancing act. We must be vigilant and vocal in asking Congress to continue considering the needs of those with mental illness and substance use disorders.