Mental Health and the ACA

In the wake of the shootings in Newtown Connecticut, it has been encouraging to hear so many calls for attention to improving mental health services in the U.S. Like oral health, mental health is a poor step-sister in our nation's behemoth health care system, mostly on the outside, shouting for attention, and having to settle for second class.

So it's good to hear voices saying we have to do better.

Here's a question: regarding U.S. mental health policy, what's the most important and consequential federal legislation ever signed into law?

Answer: the Affordable Care Act, also known as the ACA and Obamacare. Hardly anyone appreciates the enormous advance in mental health policy created by the ACA, and it's true.

Really. Permit to me to explain.

First, go the actual text of the law right here. When you get there, go to Title I and look for section 1302. Take a look, please. Section 1302 defines "essential health benefits," those services which every single health insurance policy, beginning on January 1 2014, must include and cover to qualify as health insurance in the United States. There are ten listed services, and number five is:

"Mental health and substance use disorder services, including behavioral health treatment."

Today, and until 1/1/2014, the inclusion of mental health services in health insurance is optional. Many states, not all, require it - but those state mandates don't apply to the majority of large employers who self-insure. In 2008, Congress passed a law to require "parity" or equality of treatment for mental health care - but that law only applies to employers who choose to offer mental health services, not to those who don't, and doesn't apply to employers with 50 or fewer workers.

The ACA changes all that, and that's not all. As David Mechanic explains in a 2012 article in the journal Health Affairs:

"The Affordable Care Act, along with Medicaid expansions, offers the opportunity to redesign the nation's highly flawed mental health system. It promotes new programs and tools, such as health homes, interdisciplinary care teams, the broadening of the Medicaid Home and Community-Based Services option, co-location of physical health and behavioral services, and collaborative care. Provisions of the act offer extraordinary opportunities, for instance, to insure many more people, reimburse previously unreimbursed services, integrate care using new information technology tools and treatment teams, confront complex chronic comorbidities, and adopt underused evidence-based interventions." One could make the case that the 1963 Community Mental Health Centers Act, signed by President John Kennedy, was more consequential. It's fair argument, either way. I say the ACA.

I do have a hunch that some people now talking about the need to focus on mental health in the wake of the Newtown tragedy are really trying to turn the conversation away from the need for more effective gun control.