Change, Challenge, and Opportunity: Psychiatry in the Age of Health Care Reform

And keep your eyes wideThe chance won’t come againAnd don’t speak too soonFor the wheel’s still in spin—Bob Dylan“The Times They Are a-Changin’ ”

The wheel of health care reform is in full spin as we await implementation of the 2014 health insurance changes mandated by the Patient Protection and Affordable Care Act (ACA). Although some reforms have already begun to occur, the majority of changes loom ahead as the law goes into effect in the coming years. These reforms hold important implications for psychiatrists, our allied mental health care providers, and, most importantly, our patients. This article will summarize the key elements of health care reform (HCR) and describe what APA is doing in response.

We can divide the provisions of the ACA into those focused on health care service reform and those focused on health insurance reform. Some of the latter have been in place almost from the passage of the ground-breaking law (for example, ending certain underwriting restrictions for preexisting conditions), while some begin this month or soon (enrollment in health insurance exchanges, Medicaid expansion), and still others have been postponed (for example, the employer mandate will not begin until 2015). The reforms in health care services, though under way, are more slowly affecting practice and the financing of behavioral health services.

Many of us have already benefited from changes in health insurance underwriting associated with the ACA. Children under 19 years old cannot be denied health insurance on the basis of a preexisting condition, and underwriting for all health insurance benefits has become more closely regulated. As of 2014, no one will be denied coverage on the basis of preexisting conditions. Children may remain on parental health insurance policies until they are 26, even if they are no longer full-time students. They will not lose eligibility for health insurance, even if they develop one of the many mental disorders that have their onset around that age.

The most ambitious aspects of the ACA are also the most controversial. The law creates an individual mandate for health insurance, with federal subsidies for individuals who cannot afford the cost and tax penalties for individuals who do not buy insurance. Health insurance exchanges in each state are offering a carefully regulated array of health insurance plans to certain individuals who are not part of employer health insurance schemes. The federal government is subsidizing the premiums on a sliding scale for individuals with incomes between 133 percent and 400 percent of the poverty level. Implementing the health exchanges is a monumental task and will be a challenge for the states and federal government in 2014 and beyond.

While the Supreme Court upheld the principle of the federal health insurance mandate and its tax penalties, it also struck down the requirement that every state expand its Medicaid program to provide nearly universal health insurance coverage for individuals with incomes below 133 percent of the poverty level. Some states are taking advantage of the complete federal subsidy of the Medicaid expansion, but others are not participating in that part of the law. In an effort to improve the coverage afforded by Medicaid, the ACA calls for an increase in Medicaid physician fees, which have historically been so low that many physicians will not accept Medicaid beneficiaries as patients. Except for states that opt out of the Medicaid expansion, the implementation of the ACA in 2014 will bring near-universal health insurance to the United States.

So what does this mean for psychiatrists and patients seeking mental health care? The near-universal health insurance coverage should mean that patients and their families will have lower out-of-pocket costs and should expect a broader choice of doctors and health care programs. It may also create an increase in the demand for psychiatric services and more resources to help pay for them.

Universal coverage is also paired with a mandate that health insurance cover treatment for mental disorders, including substance use disorders, and that the coverage will be at parity in the cost-sharing and managed care provisions of their health insurance policies. The historic Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 applies to the ACA, making this health insurance legislation a triple victory for our field in terms of universal coverage, a behavioral health mandate, and parity.

This victory, however, is not without some concerns. First of all, not everyone in every state will be insured. Some will fail to sign up, some undocumented immigrants will not be covered, and very poor people in some states will not be covered because their state chose not to participate in the Medicaid expansion. Second, not all behavioral health services will be covered. Some support services for individuals with disabling conditions or certain rehabilitation services may not be covered, even in the broader array of Medicaid services. Even there, however, the ACA offers new opportunities in a provision for states to elect to cover some of these home- and community-based services by modifying their Medicaid plans. And finally, even if the main outlines of the policy are known and beneficial, many of the details of parity coverage and regulation have still not yet been worked out, awaiting the issuance of the final rule on the MHPAEA, which is expected imminently.

Health care reform will also change the types of mental health services and ways that they are provided. Among other innovative services, the ACA provides an opportunity for supporting prevention services and early intervention. The law authorizes spending for early interventions in populations at risk for behavioral health conditions. Accountable care organizations (ACOs) and patient-centered medical (or health care) homes offer new opportunities for psychiatrists to practice in “integrated health care” arrangements with new financing schemes. Integrated care creates new opportunities for patients to get holistic care, addressing their co-occurring general medical conditions (see page 13). It also offers new settings for psychiatrists to practice in the mainstream of medical care. To highlight this for APA members, the APA journal Psychiatric Services has launched a new column on integrated care, edited by Ben Druss, M.D., and Psychiatric News devoted the September 18 edition of its e-newsletter, which is available on the Psychiatric News website (http://www.psychnews.org) to the topic.

In anticipation of the ACA and the MHPAEA final rule, APA has geared up to prepare and protect psychiatry and mental health care and ensure the best outcome for our patients. Two years ago, then-President John Oldham appointed a Board of Trustees work group on health care reform focusing on integrated care and chaired by current President-Elect Paul Summergrad, who presented the group’s report to the Board this past March. Following this, Dilip Jeste and I extended and expanded this work group, appointing one of us (Howard Goldman) as chair and retaining outside consultants including Michael Hogan (former commissioner of mental health in Connecticut, Ohio, and New York), Sherry Glied (dean of the New York University Wagner School of Public Health and former assistant secretary for planning and evaluation in the Department of Health and Human Services in the Obama administration), Tom McGuire (a professor of health economics at Harvard Medical School), and David Satcher (former U.S. surgeon general). These work groups are charged with providing the best advice to the Board and developing an action plan to ensure that the HCR process produces the best outcomes for psychiatrists, mental health care providers, and most importantly, our patients.

In addition, APA has engaged former member of Congress Patrick Kennedy as a consultant and spokesperson on mental health policy and legislation. The work group and consultants work hand in glove with the staff of APA’s Division of Advocacy, including Gene Cassel, Sam Muszynski, Nick Meyers, Karen Sanders, and Lizbet Boroughs and are also working with Division of Research staff, including Drs. Darrel Regier, Eve Mościcki, and Farifteh Duffy. In addition, APA has retained the services of a communications company to work with Eve Herold and her staff in the Office of Communications and Public Affairs to develop a communications strategy on HCR topics aimed at our members and stakeholder groups. The activities of these personnel and components will be communicated to APA members on an ongoing basis through Psychiatric News and other APA communications formats.

These are indeed interesting and exciting times, but times in which we must “keep our eyes wide” and be ready to address the challenges and take advantage of new opportunities. ■