While the health care–reform debate raged over the last eight years, a quiet progressive victory made lives better for millions of people with surprisingly little controversy—the simple idea that mental health should be taken as seriously as physical health. That’s because a broad coalition of advocates ensured that the Affordable Care Act included the concept of “mental health parity”—meaning insurance providers must provide equality in services for mental- and physical-health care.
But now the Trump administration threatens to just as stealthily unravel the modest gains in mental-health equity by shredding the ACA, sinking those millions deeper into silent despair.
The ACA required both private insurance and state-subsidized Medicaid plans to offer mental health and substance-abuse treatment as an essential benefit—a core safeguard for parity. According to Andrew Sperling, legislative director of National Alliance on Mental Illness (NAMI), though it is unclear what parts of the ACA might be repealed, if the 20 million people who benefited directly from Obamacare lose coverage, mental-health patients would suffer because “there would be fewer plans out there that would be required to comply” with essential-benefit mandates. Parity for zero is still zero. “Obviously, if you don’t have a health plan, you can’t be in compliance with parity.”
After initial repeal through a budgeting process, more damaging cuts may loom ahead. Lawmakers could completely scrap the essential-benefit mandate, pushing mental-health patients into a private individual market that, aside from limited state regulatory protections, may be free to massively discriminate against their conditions.
With or without insurance, mental health currently swallows a growing chunk of federal health-care expenditures, septupling between 1986 and 2005, soaring to some $36 billion annually. The chronically underfunded system covers a quarter of the country’s behavioral health-care costs, from methadone clinics to family counseling. In 2011, nearly 10 million beneficiaries had behavioral health diagnoses. On average, their care cost about triple the spending on other patients.
It’s easy to see how such a stigmatized, misunderstood field of disorders would be one of the first essential areas to be slashed. However, Congress did help improve federal enforcement measures by passing the 21st Century Cures Act. The bill was criticized for its concessions to Big Pharma, but other provisions targeted resources for substance abuse treatment, compliance enforcement for mental health–parity standards, programs for youth mental-health care, and emergency substance-abuse treatment.