As of 2014, the Affordable Care Act mandates for the first time that insurance plans on the health care exchange, as well as Medicaid, must include mental health and substance use disorder services.
Philadelphia’s Treatment Research Institute, along with the the Legal Action Center and Truven Health, received a $1.35 million grant from the Conrad N. Hilton Foundation to document whether this mandate is implemented for young people up to the age of 25.
“Adolescence is widely known to be the at-risk period,” said Abigail Woodworth, vice president of public affairs for TRI. “But there’s very little attention being paid to our current prevention and early intervention infrastructure to this particular age group.”
According to the National Council on Alcoholism and Drug Dependence, young people who use drugs and alcohol before the age of 15 are five times more likely to develop an addiction than those who wait until 21.
Woodworth said there are a lot of barriers, particularly in the area of addiction prevention. For starters, training on substance abuse for doctors isn’t mandatory in most medical schools. And because there are shades of gray between substance use and addiction, the mechanisms to identify problems early were not established before prevention could be paid for through insurance reimbursement.
Only in the case of severe addiction did insurance potentially cover medical care.
“It’s the equivalent of saying to a diabetic patient, ‘You will not have any coverage until you’re in a diabetic coma,'” said Woodworth.
TRI and the others anticipate these and other barriers, so the point of the study is really to “hone in and map what the problem is,” she said. And because of the ACA and Mental Health Parity and Addiction Equity Act, “we now can address it.”
Getting to mental health parity
In 2008, the Mental Health Parity and Addiction Equity Act took a stab at placing mental health treatment on the same level as physical health care.
But that law only requires employers who choose to offer mental health services in their insurance plans to cover mental health and substance abuse treatment as thoroughly as they cover physical health. But the law offered little mechanism for enforcement; by giving the employers the choice to not cover mental health at all, it effectively didn’t mandate coverage.
Then in 2010, the Affordable Care Act “gave the Parity Act teeth,” said Woodworth. Still, parity remains slippery in the face of many different classes of insurance (Medicaid, private, employer). Woodworth anticipates seeing mental health coverage disparities in classes of insured persons.
Kathleen Noonan, co-director of the Children’s Hospital of Philadelphia’s PolicyLab, said they’re also following how the ACA will affect levels of care for mental health and substance use in adolescents, among other areas.
The states themselves create “benchmarks,” their own individual definitions of a qualified plan, of approximately what a silver level plan on their marketplaces should offer. There is substantial variation among these plans, in both duration and level of treatment provided, Noonan said.
Proving disparities by documenting these benchmarks is one way to bring about long-overdue enforcement of the Mental Health Parity and Addiction Equity Act, she said.
Between 6 million and 10 million people getting health insurance through the ACA this year will have untreated mental illnesses or addiction, according to the U.S. Substance Abuse and Mental Health Services Administration.