For too long a time, there had been significant barriers to accessing behavioral health services for the treatment of mental illness and substance use disorders (SUD). Insurance plans were sold that had no coverage for behavioral health, or had such tight limits on inpatient days and outpatient therapy that they were of little help. Those who were insured found to their dismay that their behavioral health copay or coinsurance was significantly higher than for physical health visits. Annual and lifetime limits were lower for behavioral than for physical health. It was a dismal situation, compounded by stigma and difficulty in locating the appropriate provider and services.
As early as 1978, advocates with the Kentucky Mental Health Association went to Frankfort to seek a remedy. The result was, at best, a toe in the door with a bill requiring insurers to offer a rider covering mental health services at parity or equality with physical health services. It was a hollow victory, as the cost of the rider made it unaffordable for any but the most affluent.
Efforts at the national level to address the situation had met with repeated failures until 1996 with a bill that required parity of annual and lifetime limits for behavioral health. That activity spurred Kentucky advocates to take up the fight and after 18 months of preparation and education, the Kentucky Mental Health Coalition led the charge to pass HB 268 in the 2000 Kentucky General Assembly.
It did mandate behavioral health coverage in all plans, but required parity with physical health if they did. Kentuckians could no longer be charged a higher copay or coinsurance, no longer have arbitrary day or therapy limits, nor different annual and lifetime limits. But the legislation applied only to insurance plans for groups of 50 or more, leaving out those in the individual and small-group markets.
More progress was then made at the federal level with the passage of the Dominici-Wellstone Mental Health Parity Act in 2008. It gave the policy-holder the assurance of parity in all aspects of payment and full access, if the policy included behavioral health coverage. The legislation covered large-group policies and even included the self-insured market. But, once again, those individuals who were covered by small-group or individual plans were excluded from the parity protections.
The Affordable Care Act (ACA) was a game-changer! It laid out the ten Essential Health Benefits and mandated their inclusion in every insurance plan: individual, small group, large group, self-insured and government-provided. One of those ten benefits is the diagnosis and treatment of mental illness and substance use disorders.
That behavioral health mandate resulted in a significant change in Kentucky’s Medicaid program. Before the ACA, Kentucky Medicaid provided coverage for SUD only for pregnant women and youth. With the advent of the ACA, Medicaid Expansion plans were required to include SUD services along with mental health treatment. The Beshear Administration then extended that same coverage to traditional Medicaid members, increasing access to much-needed services for those individuals.
The ACA requirement for behavioral health went beyond mandating services. It accomplished what no legislative efforts at the federal or state level had been able to accomplish. It required that behavioral health services be covered at full parity with physical healthcare. At long last, equality! And with the very successful roll-out of Medicaid expansion and kynect in our state, we now have nearly 500,000 Kentuckians who have coverage, and with coverage, full access to equal physical and behavioral health services.
Equality Short Lived
Equality may be short-lived, as there are significant threats on the horizon. The Governor’s Medicaid waiver proposal would place barriers to maintaining coverage and access that pose a potential threat, particularly to those seeking recovery from SUD. The larger threat is, of course, the potential repeal of the ACA. With it, the mandate for inclusion of behavioral health services and the requirement for parity.
A Harvard Medical School report just released noted that with repeal “61,463 Kentuckians suffering from mental illness or substance use disorder will lose access to critical behavioral health services made available by the ACA.” The number is probably twice that, using the nationally-recognized figure of one in four with a behavioral health issue in their lifetime.
There is no doubt that Kentucky has significant mental illness and addiction issues which need to be addressed. The ACA has demonstrated that access (coverage) and parity are key elements. We’ve had a taste of that promised land and we will fight to stay there!
-Sheila Schuster, PhD, is a licensed psychologist and executive director of the Kentucky Mental Health Coalition.