Improvements and Shortcomings of the Affordable Care Act

Teenager sits on sofa and talks to counselor in officeWhatever the future holds for health care in the United States, the legacy of the Patient Protection and Affordable Care Act (ACA)—commonly known as Obamacare—will likely be shaped by both its accomplishments and its shortcomings. Many mental health professionals praised the new law for greatly expanding access and care, while others felt not nearly enough was accomplished in the process.

The legislation was signed into law by former President Barack Obama in March 2010, just 14 months into his first term. Since its approval, conservative lawmakers have set their sights on repealing it.

Although a Republican-led effort to repeal and replace the ACA failed without a vote in March 2017, the new presidential administration remains determined to pass new health care legislation. In the meantime, the future remains unclear for both the health care industry and millions of Americans who depend on the ACA. That same uncertainty also faces mental health professionals, with many fearing recent advances in access and care will be rolled back or abandoned altogether.

How the ACA is viewed in years to come may rest in individual opinion, with supporters praising the law’s many good intentions just as opponents focus on its perceived shortcomings. Here are some of the most frequently referenced pros and cons of the Affordable Care Act:

Pro: Expansion of Access

By broadly expanding access to Medicaid, the ACA significantly increased the number of Americans able to receive coverage, including access to treatment for mental health conditions.

The spirit of the ACA reflected and expanded upon earlier federal legislation aimed at improving the overall landscape of mental health care in the U.S., highlighting issues such as access, parity to other forms of health care, and stigma surrounding mental health conditions.

The Mental Health Parity and Addiction Equity Act (MHPAEA) was passed ahead of the ACA with the aim of balancing mental health coverage with comparable levels of medical or surgical care. The ACA extended signature aspects of the MHPAEA to larger markets and health care plans—widely seen as a positive step among mental health care providers.

However, in many parts of the country, access to some of the ACA’s federal funding was blocked or denied at the state level. This left many Americans technically qualified to receive coverage, but still unable to readily access or afford it.

Con: Lack of Referral System

Despite the ACA’s expanded access to mental health treatment, the systems to point people to the right mental health specialist have not been effectively put in place. Many people go to their primary care physician for mental health concerns, but a 2013 report from the Centers for Medicare and Medicaid Services shows only about 20% of these people are referred to a mental health specialist. As a result, many people who seek mental health treatment from a primary care physician do not receive the most effective care for their specific concerns.

True expanded access might only be achieved when the proper referral channels and treatment options are functioning clearly and officially. With mental health, issues of access may ultimately require a broad change in how therapy and mental health treatment are viewed—even among physicians and other health care providers.

Pro: Preventative Care

By requiring coverage for behavioral health screenings, the law placed a new emphasis on preventative mental health care. The requirement that preventative measures be available at no cost to the insured represented a new emphasis on early diagnosis. It recognized the value in detecting issues early enough to prevent larger health care spending later.

Some of the measures included in the ACA’s coverage requirements are depression screenings and behavioral assessments for children.

Con: Gaps in Medical and Mental Health Parity

While mental health treatment is becoming more accepted among health care providers, it is still not universally recognized across all insurance plans. Insured individuals are more likely to have coverage denied for mental health services compared to physical health care, and psychiatric medications are often more difficult to get approved compared to more traditional prescriptions.

Many believe these gaps in coverage were not adequately addressed under the ACA, leaving an ongoing lack of parity with other forms of care, both in funding and distribution of services.

Prior to the ACA, parity meant an insurer offered mental health benefits only somewhat on par with traditional medical benefits, said Nadereh Pourat, PhD, a professor of health policy and management from the University of California, Los Angeles Fielding School of Public Health.

“The repeal of the ACA [would set] the clock back to when you could buy a cheaper policy without these benefits,” Pourat said. “But if you needed them unexpectedly, you would have to pay for them yourself.”

Pro: Coverage for Young Adults

One popular element of the ACA that may prove difficult to eliminate is the extension of coverage for young adults under a parent’s plan until they reach age 26. In terms of access to mental health treatment, the extension of coverage represented an opportunity to bring preventative care to a generation of young adults during an age when many may struggle to afford their own insurance.

With mental health concerns among young adults on the rise, these preventative measures carried the potential to help millions address their symptoms early, potentially with lifesaving outcomes.

Con: Barriers to Access

By mandating individual coverage, and by requiring all plans to cover mental health and addiction treatment, the ACA expanded mental health services nationwide. Despite this, other barriers continue to challenge access.

With mental health, issues of access may ultimately require a broad change in how therapy and mental health treatment are viewed—even among physicians and other health care providers.Research shows psychiatrists were significantly less likely than general practitioners to accept private insurance in the years following implementation of the ACA. In a 2014 report published in the journal JAMA Psychiatry, more than half the psychiatrists surveyed did not accept Medicaid or Medicare. The primary reason given was low reimbursement for their services.

The report also suggests a shortage of psychiatrists may be a factor in whether most accept insurance. High demand for psychiatric services may convince psychiatrists they do not need to accept insurance. This can further impede access to mental health treatment.

Access to quality health care is crucial, Pourat said, and providing it should not be equated with purchasing everyday consumer goods, such as a television.

“People’s lives don’t hang in the balance if they don’t have access to a TV,” Pourat said.

The ACA’s legacy will likely be shaped significantly by what follows it. However, as Congress has not yet been able to introduce a viable replacement plan, it seems the Affordable Care Act will remain in effect for the foreseeable future.

References:

  1. A long road ahead: Achieving true parity in mental health and substance use care. (2015). National Alliance on Mental Illness. Retrieved from https://www.nami.org/About-NAMI/Publications-Reports/Public-Policy-Reports/A-Long-Road-Ahead/2015-ALongRoadAhead.pdf
  2. Bishop, T. F., Press, M. J., Keyhani, S., & Pincus, H. A. (2014). Acceptance of insurance by psychiatrists and the implications for access to mental health care. JAMA Psychiatry, 71(2), 176. doi:10.1001/jamapsychiatry.2013.2862
  3. Goodman, J. (2016, December 8). Shocker: Republicans may not repeal Obamacare. Retrieved from http://www.forbes.com/sites/johngoodman/2016/11/17/shocker-republicans-may-not-repeal-obamacare/#410881f8377b
  4. Lee, E. (2012, July 12). Update: How Obamacare is benefiting Americans. Retrieved from https://www.americanprogress.org/issues/healthcare/news/2012/07/12/11843/update-how-obamacare-is-benefiting-americans/
  5. Luhby, T. (2016, November 11). Obamacare under President Trump: What happens next? Retrieved from http://money.cnn.com/2016/11/10/news/economy/trump-obamacare/
  6. Starr, P. (2013). Remedy and reaction: The peculiar American struggle over health care reform. New Haven: Yale University Press.
  7. U.S. Department of Health and Human Services. (n.d.). Health insurance and mental health services. Retrieved from https://www.mentalhealth.gov/get-help/health-insurance/

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  • Bud

    Bud

    April 7th, 2017 at 9:53 AM

    My premiums have gone up so much this year that I don’t know how much longer I will be able to afford it. I get the subsidy but that still isn’t enough to keep this is reach for me and my family. I agree with so many parts of this that it is hard fro me to be critical but that it is affordable is likely becoming more and more of a joke in my state.

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