December 18, 2018
Man at the psychotherapist

Mental Health Coverage: In Danger Under Trump?

by Amanda Z. Naprawa  

As the Trump administration begins to take shape, and the GOP-led Congress makes its intention to cut certain benefits clear, we have been hearing a lot about how the Trump presidency might affect the Affordable Care Act (ACA). Unfortunately, there are many other provisions of existing health care laws that may end up on the chopping block too—specifically, those laws that protect mental health care. Interestingly, many federal laws aimed at improving access to mental health have bipartisan support. But because of the overlap between the ACA and many of these other laws, access to mental health is likely to take a direct—and devastating—hit under a Trump presidency.

What is the federal mental health parity law?

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that was enacted in order to address health insurance practices that unfairly limited coverage for mental illness and substance abuse. Prior to this law, insurance coverage for behavioral and mental health treatment often had higher cost sharing (such as larger co-pays for mental health services compared to medical services) and limitations on services (for instance, limiting coverage to 20 inpatient days per year). With the passage of the parity law, however, health insurance companies that offered benefits for mental health or substance abuse treatment could not impose greater limitations on those benefits than on medical or surgicalbenefits. For instance, if an insurer did not limit the number of visits for outpatient medical care, it could not do so for outpatient mental health care.

The parity law has some very specific requirements that must be met by health insurance plans covered by the law. One key provision relates to something called “non-quantitative treatment limitations” (NQTLs), which include things like prior authorization policies, medical necessity guidelines, or restrictions based on geographic location, facility type, or provider specialty. Under the parity law, NQTLs applied to mental health or substance abuse benefits can be no more restrictive than those applied to medical or surgical benefits. For example, a plan cannot exclude coverage for inpatient, out-of-network treatment of substance abuse disorders when obtained outside of the state, if there is no similar exclusion for inpatient, out-of-network medical or surgical treatment. Many other provisions in the parity law ensure access to mental health care on par with access to medical or surgical benefits.

How is mental health parity related to 'Obamacare'?

The 2008 parity law only applied to large group health insurance plans. People who purchased individual health insurance were not afforded any of the protections in the parity law. Thus, as initially enacted, the federal parity law did nothing to help the nearly one-third of Americans with individual health plans who had no coverage for substance abuse, and the 20 percent of those with individual health plans who had no mental health coverage at all. Furthermore, prior to the passage of the Affordable Care Act of 2010(commonly referred to as Obamacare), there were nearly 47.5 million uninsured Americans. About one-quarter of those uninsured people had a mental health or substance abuse disorder.

The ACA has had a significant impact on mental health and substance abuse coverage in the U.S. First, the ACA specifically expanded the federal parity law to include most individual health plans. This allowed individuals who buy their own policies (rather than getting their insurance from a large employer) to reap the protective benefits of the parity law.

Other provisions in the ACA also extended the reach of mental health parity beyond the direct terms of the federal parity law. For instance, the ACA requires that all small group health plans and individual health insurance market plans cover certain “Essential Health Benefits." These benefits include mental health and substance abuse coverage in parity with the particular plan’s coverage for medical and surgical benefits. Thus, through the ACA, individuals who have coverage through small group plans or individual plans now have access to mental health coverage that is essentially the same coverage guaranteed under the parity law. Finally, through the ACA, nearly 20 million people have gained access to health insurance coverage that was previously unattainable or unaffordable. This has meant a significant reduction in the number of uninsured individuals and thus greater access to mental health and substance abuse treatment.

Bottom line: If the Trump administration goes ahead with its promise to repeal the ACA, many Americans will see a huge impact on their mental health coverage. Those who were insured under the ACA will lose all insurance benefits, including access to mental health care. Those who can afford to purchase individual plans without the ACA marketplaces or subsidies, or who are covered under small group health plans, will no longer be guaranteedany sort of mental health or substance abuse coverage, nor the assurance that any coverage offered will be in parity with medical benefits. The tragedy of this is that mental health conditions are widespread and are associated with increased occurrence of chronic diseases such as cardiovascular disease and diabetes. Taking away quality mental health and substance abuse coverage for a wide swath of Americans could have potentially devastating consequences.

Also see How to Get Mental Health Help.