Health Care Law Offers Wider Benefits for Treating Mental Illness

Until now, people with mental illness and substance disorders have faced stingy annual and lifetime caps on coverage, higher deductibles or simply no coverage at all.

This was supposed to be fixed in part by the Mental Health Parity and Addiction Equity Act of 2008, which mandated that psychiatric illness be covered just the same as other medical illnesses. But the law applied only to larger employers (50 or more workers) that offered a health plan with benefits for mental health and substance abuse. Since it did not mandate universal psychiatric benefits, it had a limited effect on the disparity between the treatment of psychiatric and nonpsychiatric medical diseases.

Now comes the Affordable Care Act combining parity with the individual mandate for health insurance. As Dr. Dilip V. Jeste, president of the American Psychiatric Association, told me, “This law has the potential to change the course of life for psychiatric patients for the better, and in that sense it is both humane and right.”

To get a sense of the magnitude of the potential benefit, consider that about half of Americans will experience a major psychiatric or substance disorder at some point, according to an authoritative 2005 survey. Yet because of the stigma surrounding mental illness, poor access to care and inadequate insurance coverage, only a fraction of those with mental illness receive treatment.

For example, surveys show that only about 50 percent of Americans with a mood disorder had psychiatric treatment in the past year — leaving the rest at high risk of suicide, to say nothing of the high cost to society in absenteeism and lost productivity. The World Health Organization ranks major depression as the world’s leading cause of disability.

One of the health care act’s pillars is to forbid the exclusion of people with pre-existing illness from medical coverage. By definition, a vast majority of adult Americans with a mental illness have a pre-existing disorder. Half of all serious psychiatric illnesses — including major depression, anxiety disorders and substance abuse — start by 14 years of age, and three-fourths are present by 25, according to the National Comorbidity Survey. These people have specifically been denied medical coverage by most commercial insurance companies — until now.

From an epidemiologic and public health perspective, the provision that young people can remain on their parents’ insurance until they turn 26 is a no-brainer: By this age, the bulk of psychiatric illness has already developed, and there is solid evidence that we can positively change the course of psychiatric illness by early treatment.

Mental disorders are chronic lifelong diseases, characterized by remission and relapse for those who respond to treatment, or persistent symptoms for those who do not. In schizophrenia, for example, relapse is common, even with the best treatment. It makes no sense to tell someone with this condition that his lifetime mental health benefit is just 60 days of inpatient hospitalization.

Psychiatric illness is treatable, but it is rarely curable; it may remit for a while, but it doesn’t go away. That is why the current limits on treatment are as irrational as they are cruel — the discriminatory hallmark of commercial medical insurance.

No more. The Affordable Care Act treats psychiatric illness like any other and removes obstacles to fair and rational treatment.

Older people with mental illness will also benefit, because the law will eventually fill in the notorious gap in Medicare drug coverage known as the “doughnut hole.” The law will immediately require drug companies to give a 50 percent discount on brand-name drugs and then gradually provide subsidies until the gap closes in 2020.

On the other hand, poor people with mental illness still have cause for concern. The new law would have expanded Medicaid to insure 17 million more Americans, but the Supreme Court ruled that states could decline to accept this expansion without losing their existing Medicaid funds. In states that opt out of the Medicaid expansion, poor people with mental illness may find themselves in a terrible predicament: They earn too much to qualify for Medicaid, yet not enough to get the federal subsidy to pay for insurance.

But on the whole, the Affordable Care Act is reason to cheer. Americans with mental illness finally have the prize that has eluded patients and clinicians for decades: the recognition that psychiatric illness should be on a par with all other medical disorders, and the near-universal mandate to make that happen.

Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College.

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Health Reform Law Gaining Wider Acceptance: Poll

MONDAY, Jan. 30 (HealthDay News) -- Americans are slowly starting to embrace some key components of the controversial health care reform act signed into law by President Barack Obama nearly two years ago, a new Harris Interactive/HealthDay poll found.

To be sure, Americans remain sharply divided over the legislation, with slightly more than one-third (36 percent) of adults saying they want the law repealed and 21 percent saying they want it to remain as is. Another 25 percent would like to see only certain elements of the law modified, the poll found.

"The public is still divided, mainly on partisan lines, as to whether to implement or repeal all, parts, or none of the health care reform bill," said Harris Poll Chairman Humphrey Taylor.

The poll, conducted earlier this month, found that support for the legislation clearly breaks down along party lines. Almost two-thirds of Republicans (63 percent) said they wanted the Patient Protection and Affordable Care Act repealed, compared to 9 percent of Democrats.

But while poll respondents were split about the law as a whole, many strongly supported key elements of the bill, "with the notable exception of the individual mandate [the requirement that all adults purchase health insurance] which remains deeply unpopular," Taylor said.

That support for certain components of the law seems to be increasing slowly with time. For instance, 71 percent of those polled now back the law's provision that prevents insurance companies from denying coverage to those already sick. At the end of 2010, 64 percent supported this provision.

Other provisions that are showing a slow but steady rise in acceptance since November 2010 include:

allowing children to stay on their parents' insurance plans until they turn 26 -- 57 percent in January 2012 versus 55 percent in November 2010.creating insurance exchanges where people can shop for insurance -- 59 percent versus 51 percent.providing tax credits to small businesses to help pay for their employees' insurance -- 70 percent versus 60 percent.requiring all employers with 50 or more employees to offer insurance to their employees or pay a penalty -- 53 percent versus 48 percent.requiring research to measure the effectiveness of different treatments -- 53 percent versus 44 percent.creating a new Independent Payment Advisory Board to limit the growth of Medicare spending -- 38 percent versus 32 percent.

But the most controversial aspect of the law -- the so-called individual mandate that requires all adults to have health insurance or face a fine -- remains widely unpopular, with only 19 percent of those polled supporting it.

The U.S. Supreme Court is scheduled to hear arguments on the constitutionality of the law starting in late March.

"It's clear that people really appreciate key reforms that are in the Affordable Care Act and it demonstrates how important it is for people to know that those reforms actually are embodied in the legislation," said Ron Pollack, executive director of Families USA, a Washington, D.C.-based nonprofit, nonpartisan group that says it's dedicated to quality, affordable health care for all Americans.

The problem is that many people don't know what's actually in the law, as previous polls, including some conducted by Harris Interactive/HealthDay, have shown.

"People do not understand the health reform bill," said John Goodman, president of the National Center for Policy Analysis, a conservative public policy research organization in Dallas that says it backs private alternatives to government regulation and control. "This reflects a failure all the way around on the part of backers of the bill, critics and the health-care media. No one's explained how this works."

Pollack pointed out that some provisions of the Affordable Care Act aren't scheduled to take effect until 2014.

The poll also found that, by a 55 percent to 45 percent margin, people think health care reform should be addressed by each state separately, rather than at the federal level.

A fair amount of the current Republican primary race to challenge President Obama in the November election has focused on pledges to repeal much or all of the health care act.

Slightly more than half of those polled -- including 61 percent of Republicans -- said they knew that when Mitt Romney was governor of Massachusetts he supported a law that provides health insurance to many people in the state. The law is similar to the federal law signed by Obama in March 2010.

Most poll respondents said they had little or no idea what the Massachusetts law has -- and has not -- accomplished. The legislation, which includes an individual mandate, has provided coverage to a majority of state residents, is popular with most people in the state, but has yet to contain costs.

The poll was conducted online Jan. 17-19 with 2,415 adults 18 years of age and older. Figures for age, sex, race/ethnicity, education, region and household income were weighted, where necessary, to bring them into line with their actual proportions of the U.S. population. So-called "propensity score weighting" was also used to adjust for respondents' likelihood to be online.

More information

For more details on the poll visit Harris Interactive.

To learn more about the provisions of the Affordable Care Act, visit healthcare.gov.

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