Health insurance coverage can be confusing and difficult to navigate with all the loopholes and specialized vocabulary. Finding a good health care plan can be cumbersome and expensive. According to the federal Centers for Medicare & Medicaid, the National Health Expenditure (NHE) is projected to hit $3.21 trillion this year, which averages out to $10,000 per person in the United States. Before President Barack Obama’s health care law went into effect on Jan. 1, 2014, many people with mental health and substance use disorders were often denied coverage because of their pre-existing disorders. The Affordable Care Act does not allow insurance companies to deny patients coverage due to pre-existing conditions. This new reform allows people with mental health and/or substance abuse issues to receive affordable health insurance coverage based on their income.
California and the Affordable Care Act
Nearly 20 million Americans struggle with substance abuse and 42.5 million adults live with some form of mental illness. After the adoption of the Affordable Care Act, millions of adults became, or at least were supposed to become, eligible for mental health care coverage. Each individual state would decide whether or not to expand the Medicaid program — a statewide-funded insurance for low-income and disabled populations.
In California, the Affordable Care Act significantly funds Medi-Cal — the Medicaid expansion program specific to California. In other states, the program is called Medicaid. More than 2 million California residents may benefit from this program. As of Jan. 1, 2014, individuals who earned up to 138 percent of the federal poverty level became eligible for Medi-Cal. In other words, a single person who earned up to $16,243 a year or a family of four who made up to $33,465 a year became eligible for the insurance.
In 2015, 30 states and the District of Columbia adopted the Medicaid expansion program, allowing their residents to benefit from this insurance coverage. Twenty other states, including Texas, Kansas and Florida, did not adopt the Medicaid expansion program, resulting in more than 6.5 million uninsured people and, as a result, no access to mental health care.
The Affordable Care marketplace is an online platform that allows users to choose their health care plans based on their state and personal budget. Some people may qualify for Medicare, tax re-imbursements or discounted health care, depending on their income.
Mental Health Parity and Addiction Equity Act of 2008 update
The Affordable Care Act updated the Mental Health Parity and Addiction Equity Act of 2008 to include equal coverage for both mental health care and physical health care. A patient with asthma would be covered to the same extent as a patient with bipolar disorder; this includes doctor visits, emergency room visits, medications and other treatment regimens.
This all sounded great until the insurance companies decided on what constitutes enough treatment. For example, a patient with Hodgkin lymphoma, a type of blood cancer, will need a specific number of chemotherapy treatments to eradicate the cancer, but there is no specifically defined number of treatments needed for depression. For this reason, many mental health practitioners have opted to drop Medicaid altogether and only accept private insurance, as they can provide a larger number of treatment sessions for their patients.
So what’s the problem?
Yes, it is true that more people have access to mental health and addiction health care under the Affordable Care Act, but more providers refuse to accept the Medicaid insurance plans, and specific mental health conditions may not be covered under a specific plan on the health care marketplace. For example, some states under the Affordable Health Care plan do not cover specific mental health conditions, while other states do provide this coverage under their Medicaid program. California may cover autism under behavioral health, but Colorado may not cover this.
The other downside is most people simply don’t understand how insurance coverage works. A poll from the Kaiser Family Foundation revealed that 90 percent of the uninsured didn’t know that open enrollment began Nov. 15, while two-thirds of the uninsured admitted that they knew little or nothing about the online marketplaces where they could compare and buy health insurance. If you are diagnosed with an illness, it is important to become educated not only about your disease but also about how insurance can help you live with your disease. You may never be able to influence politics, but you can help yourself become healthier by educating yourself on these issues. Sovereign Health of California provides behavioral health services for mental health disorders and substance addictions, and accepts most insurance plans.
Written by Kristen Fuller, M.D., Sovereign Health Group writer