Curbside Consult: Mental Health and the ACA (Part 2)


Harold Pollack: I know Roger Ebert’s memoirwas very complimentary toward AA.

Shifting over towards health reform and relatedissues, one of the things that you said to me was that this is actually in some waysa remarkable time for mental health and substance abuse policy, and that we’ve made a lot ofgains that people might not appreciate.

Why don’t we talk a little bit about that? Maybe we should start with the prequel-storyto health reform and some of the legislation that was passed before the Affordable CareAct.

Were you involved in some of that? Keith: Yeah.

I was involved in the fight forwhat gets shorthanded as “parity.

” Its full name is (I hope I can get this right): ThePaul Wellstone and Pete Domenici Mental Health and Addiction Equity Act, I think, was theactual final title of the law.

That was a 12-year fight from 1996 until 2008 to requirelarge group insurers — in other words, companies that have at least 50 or more employees — tohave any benefits they offered for addiction and mental health be comparable to the benefitsthey offered for other disorders, which they were not required to do.

In other words, it was legal to say, “Ourplan has a copay of 10 bucks for all outpatient visits, except mental health and addiction.

That’s 25 bucks,” or, “You get this many days of inpatient care, unless it’s mental healthor addiction, in which case you get half as much.

” That was a 12-year fight.

The mental healthcommunity, the recovering community, and the addiction field did a tremendous job of goingyear after year, day after day, month after month up to Congress and making the argument,”This is an illness like the other illnesses.

It needs to be covered like those illnesses.

” It was a long slog, to quote Don Rumsfeld,my non-friend Don Rumsfeld.

It was a long slog.

The precious thing about it was thatthis bill took 12 years to become a law and was far more modest than what happened inthe ACA in terms of its effect.

It laid the groundwork in the Congress forwhat happened in the Affordable Care Act.

When those same advocates or people like mecame up and said, “How about we have the Affordable Care Act cover mental health and addictionat parity?” the reaction on the Hill was, “Oh, parity.

Right, right.

We already votedfor that, right? Yeah, sure, fine.

We’ll do that again.

No big deal.

” Harold Pollack: What were some of the shortcomingsin that parity bill that needed to be addressed in health reform? Keith: There were a couple of things.

One is, parity only applied if you had insurancefrom a large employer.

That’s over 100 million people.

That’s important, but there’s nothingfor people with no insurance.

Second, there was a compromise at the veryend.

It was a very near thing getting parity done, because it was the very end of the Bushadministration.

Oddly enough, parity was actually folded into the TARP [financial bail-out]legislation because they were trying to get extra votes for TARP.

I have to check withhim, but I think my friend, Jim Ramstad, who was in the Congress and one of the lead sponsors.


Theyknew he wanted parity so bad, I think they might have put it in TARP to get his vote.

He had voted against TARP initially.

I’m not sure.

I’ll have to check it with Jim someday.

Anyway, there’s great pressure.

The problemwas, the Senate bill and the House bill were different.

The Senate bill said, “If you chooseto offer these benefits, they must be comparable,” and the House bill said, “You must offer thesebenefits, and they must be comparable.

” Even after parity passed in the Senate rule,a company could say, “We’re just not going to offer mental health benefits, period,”and that would still be legal.

It was a tough decision for everybody.

Had to bite the bullet.

It would have been a big gamble to say, “Let’s go to [the House-Senate conference committee]and see what happens,” because this is November.

What could happen is nothing.

It was agreed to take the Senate bill, butthere was a great sense of wanting to complete the unfinished business of actually makingthe benefits themselves mandatory.

That is in the Affordable Care Act.

If you look atthe language, it says not just that if you offer these benefits, it has to be the sameway you would cover anything else, but it used language, as you know, of an essentialhealth benefit.

It says that substance use disorder [and mental health treatment] isan essential part of your benefit.

All the plans in the health exchanges, theMedicaid exchange, and any new insurance plans have to cover these, at parity.

That’s howit was a one-two punch with parity and then ACA.

Something like 62.

5 million people would benefitfrom these ACA provisions.

You had over 100 million on parity.

That’s a lot of peopleeither going from no coverage to some coverage or some coverage to better coverage.

Harold Pollack: Just to go back to that fora minute, 62 million Americans are going to get mental health and substance abuse servicecoverage that they didn’t have before health reform.

Keith: Yeah.


5 million is the sum of twonumbers, which is basically people who had no insurance who got insurance that coveredmental health and substance abuse, but it also covers those people who had that butthey didn’t have it at parity.

It’s both people who went from being a bit underinsured togetting decent insurance and non-insured to getting some insurance.

That number comesfrom Sherry Glied’s office, which is the Assistant Secretary for Policy and Evaluation at HHS.

Harold Pollack: From my point of view as apublic health researcher.


this is really pretty fundamental.

Just to give people asense of things, in 2012, a lot of people ask, “How poor do you have to be to be onMedicaid?” The answer to that in 41 states or so is, zero.

Actually, you could have anincome of $0 and not be eligible for Medicaid if you’re not a mom, you don’t have AIDS,you don’t have a federally recognized disability.

Substance use disorder is not a federallyrecognized disability to get on assistance programs.

[Why does this matter?] Let’s suppose thatyou encounter a beggar on the street in Chicago who asks you for some money.

You think: “Maybethis person has a substance use or mental health issue.


this person should reallyget treatment.

” Then you stop and say, “Well, wait a minute.

Who is going to pay for thattreatment?” The answer right now is: Well, nobody quiteknows.

There’s a patchwork of programs that people haven’t heard of.

There’s a block grantthat goes from the federal government to the states.

A substance abuse prevention or treatmentblock grant will cover some of that.

People can go to a Federally Qualified Health Centerand get some services that they would need.

But, basically, your typical single male adultwith a substance use or mental health problem is exactly the person who is going to be uninsured,or certainly the person who would be underinsured if they were lucky enough to have insurancein terms of these critical services.

So what you were just describing–particularlythe fact that Medicaid will cover these services–is addressing the needs of a huge chunk of peoplewho right now have very limited access to the safety net and impose huge burdens oncities and counties and on all the systems that have to try to take care of them.

Health reform is going to bring these peopleaccess to Medicaid and cover these services.

That is really an enormous change.

From mypoint of view, this is one of the really important things about health reform that most Americansdon’t know about.


Have I gotten anything wrong in that? Keith: No, I think that’s very well said,Harold.

Of course, as you and I both know, that’s a population with higher than averageprevalence of both substance use and mental health disorders.

So it couldn’t be bettertargeted as a new benefit.

We also ought to mention, too, the other change, which startedin 2008 but it’s taking effect this year, is the Medicare change.

When Medicare wasfounded, it had also a discriminatory structure built in.

For outpatient care, Medicare covers80 percent of everything except mental health and substance use, which it only covers half.

That’s a massive copay: 50 percent.

It really made Medicare a much smaller player than youwould think it would be in the mental health and substance abuse arena.

The 2008 Medicare, the NIPA improvement billhad in it a provision to get rid of that which I believe in fact, if I remember right, cameout of Pete Stark’s office, I’m pretty sure.

Harold Pollack: Now, why was it so discriminatoryin Medicare? Do you know why it was set up that way? Keith: It probably had to do with the stigmaof these conditions at the time.

Also, these are very, as you know, very weak constituencies.

There are people like Ted Kennedy, God bless him, who really passionately identified, caredwith seriously mentally ill people, but most people don’t identify with this population.

Most people are scared of them.

Most people don’t want to stand up for them.

I assume, like all Congresses, they were alsoasking: “How much does this cost? How do we limit things?” Said, “Let’s cut the mentalhealth and substance abuse.

” Maybe someone said, “We’re going to be paying for psychoanalysisfor all these people.

We don’t want to pay for that.

” I don’t know how it came about,but I’m just sort of betting because those have been the generic processes that havetended to underfund care for those two populations.



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