Before the enactment of the Affordable Care Act (ACA), approximately 49 million Americans did not have a health insurance cover (Frank, Beronio, & Glied, 2014). Most people relied on employer-sponsored insurance. The private insurance and employer-sponsored coverages did not provide benefits for mental health and substance abuse patients. Among the Americans that had employer insurance, two percent of the coverages entirely excluded mental health benefits while seven percent had insurance that completely excluded benefits for substance abuse patients (Frank, Beronio, & Glied, 2014). The need for the initiation, development, and enactment of ACA was potentiated by the disproportional representation of mental health patients by the insurance providers, among other factors. According to Frank, Beronio, & Glied (2014), nearly one in five adult Americans has at least one mental health concern. However, the healthcare workforce is inadequately prepared to handle the mental needs of the patients. The ACA might not have been a panacea to the mental health concern of the American population, but it has bolstered the steps in bridging the existing gap in mental health care provision.
There are a variety of provisions in ACA aimed at effecting the biggest changes in the mental health and substance abuse in a generation (Watkins et al., 2014). The major step in the development and adoption of ACA is the expansion of state-specific Medicaid and the proliferation of coverage through the Health Insurance Exchanges (Obama, 2016). Expansion of Medicaid greatly enabled benefits for those who were not previously eligible for coverage. In addition, ACA prohibits private insurance providers from denying people with pre-existing conditions access to health coverage benefits (Obama, 2016). This is beneficial especially to mental health patients who had been locked out of insurance coverage due to a documented mental health diagnosis. Most health insurance denials were based on the high prevalence of pre-existing mental health conditions. The 2008 Mental Health Parity and Addiction Equity Act (MHPAE) set the precedence for ACA, as the latter was developed on the premise of the 2008 law. Unlike MHPAE, ACA recognized mental health and substance use as one of the ten prerequisite health benefits for all insurance coverages.
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Effectiveness of the Policy
The primary goal of ACA in behavioral health is ensuring that mental health and substance abuse patients receive insurance coverage and the care they require just like any other American citizen (Frank, Beronio, & Glied, 2014). The steps in enhancing equity in coverage provision are evidenced by the repealing of insurance denials instigated by pre-existing or documented conditions (Obama, 2016). ACA also identifies behavioral health screening as part of the zero-cost preventive care coverage. Primary issues that are included in the benefits are alcohol misuse and depression for adults. Autism screening for children is also included in the behavioral assessment benefits (Frank, Beronio, & Glied, 2014). These provisions are aimed at strengthening the social functioning of mental health and substance abuse patients. States with expanded Medicaid demonstrated higher access to mental health care than in states that had not enacted the policy.
ACA mandates compliance programs for participating health care providers as one of the conditional requirements for enrolment in the federal reimbursement programs. Organizations and providers have a duty to ensure that they provide services in compliance with the set ethical standards and regulations (Obama, 2016). This is aimed to counter malpractices such as fraud and violation of patient rights before, during, and after provision of care. The policy strives to ensure that an organizational compliance culture is created by providing a framework for effective ethical and social justice compliance established through federal sentencing guidelines. In this regard, ACA adheres to the best practice ethics and standards, thereby uplifting the social values of behavioral health patients. The providers and organizations are legally obligated to provide the required care to the patients without discrimination or violation of patient rights.
The introduction of ACA was arguably the most ambitious regulatory and expansion overhaul of the US health care system since the Center for Medicare and Medicaid was founded. Besides increasing the national insurance coverage for all patients, the provision of quality and affordable health care for all patients including the behavioral health patients was one of the principal objectives for the creation of the policy (Obama, 2016). According to Dogra and Dorman (2016), a preliminary assessment of the quality measures points out that ACA greatly impacted the health care system. The quality measures indicators were based on the proportion of patients who were able to access mental health care and the outcomes of the care offered. These quality measurements have proved to be effective indicators in tracking the progress of the policy, in light of the government’s organizational, and provider goals. However, there have been concerns regarding the effectiveness and feasibility of the policy.
Feasibility and Policy Constrains
The concerns on the effectiveness and feasibility of the policy are economically, socially, and politically instigated. There have been challenges developing performance measures for mental health and substance use disorders (Dogra & Dorman, 2016). Many behavioral health conditions have not been prospectively linked to the outcomes. Behavioral health affects many aspects of a person’s life (Frank, Beronio, & Glied, 2014). This means that treatment is often provided by a wide range of specialists, including those outside the scope of medical practice like social care workers. It is therefore difficult to effectively document and keep track of care provided to mental patients, partly due to the patient confidentiality requirements. The existing gaps in the documentation of patients seeking care make it difficult to assess the complete capacity of ACA in relation to its goals.
There has been a growing debate on the political feasibility of the policy (Dogra & Dorman, 2016). The political feasibility of any insurance legislation is determined on the merits of simultaneous reduction in health care spending and its complexity in implementation. Legislation might have enough votes to pass the congressional requirements, but it might be too expensive to sustain upon its enactment. ACA has been regarded as been too expensive, as the government has to devise other methods of collecting funds for its sustainability (Dogra & Dorman, 2016). Critiques argue that a single payer system would be more sustainable and easier to implement than ACA. By trying to ensure that all Americans have been insured, the policy has raised payments for out-of-pocket patients. Arguably, most behavioral health patients require insurance coverage. However, there are a fraction of the patients who pay from out-of-pocket. This group of patients will be restricted from receiving the mental health care they require.
Recommendations
A recommendation to improve the utilization of the policy across the U.S is to incentivize Medicaid expansion in all the American States. The Supreme Court decision passed in 2012 made ACA’s Medicaid expansion for all states optional. This decision considerably slowed down the expansion of the policy in the states (Mcdonough, 2016). Introducing new incentives to reinforce the existing ones would hasten the expansion of Medicaid in the states. In the first three years of its enactment, the federal government paid all the costs for the states (Mcdonough, 2016). A further reduction of costs from the currently existing rates and premiums would persuade the states and citizens to buy into the policy. This especially would ensure that the remaining uninsured mental health and substance abuse patients receive the required quality and affordable care. Another reform required to strengthen the policy would be to fix the existing “family glitch.” According to Mcdonough, (2016) the glitch is a provision that bars families which require less than 9.56% of their household income to purchase private or workplace coverage from ACA premium subsidies. This limitation has resulted in approximately 2 ‐ 4 million Americans being uninsured.
Conclusion
The Affordable Care Act has been pivotal in bridging the existing insurance gaps that existed for behavioral health patients. ACA was developed on the premise of other mental health acts and parities, and aims to ensure that all the citizens (including mental health and substance abuse patients) receive quality and affordable health care. The policy ensures that as part of its compliance culture, all organizations and providers are mandated to act in accordance with the ethical and legal requirements of care provision. Despite the steps ACA has made in ensuring that mental health patients receive quality care, concerns have been raised on its effectiveness and feasibility. Political and economic implications are major contentious issues that need to be addressed. Other recommendations are the incentivizing the expansion of Medicaid in the states and fixing retrogressive provisions that prevent families and individuals from acquiring coverage.
References
Dogra, A. P., & Dorman, T. (2016). Critical Care Implications of the Affordable Care Act. Critical care medicine , 44 (3), e168-73.
Frank, R. G., Beronio, K., & Glied, S. A. (2014). Behavioral health parity and the Affordable Care Act. Journal of social work in disability & rehabilitation , 13 (1-2), 31-43.
Mcdonough, J. E. (2016). How Might Democrats Try to Improve and Expand the ACA in 2017?. The Milbank Quarterly , 94 (3), 468-475.
Obama, B. (2016). United States health care reform: progress to date and next steps. Jama , 316 (5), 525-532.
Watkins, K. E., Farmer, C. M., De Vries, D., & Hepner, K. A. (2014). The Affordable Care Act: an opportunity for improving care for substance use disorders?. Psychiatric services (Washington, D.C.) , 66 (3), 310-2.
