InvisALERT Solutions – ObservSMART

Mental Health in Health Care Reform: High Hopes but Big Battles Ahead

Federal health care reform promises health coverage for most of the 50 million American citizens and documented immigrants who are currently uncovered. This will include coverage of mental health and substance abuse treatment. It also promises improved quality of physical and behavioral health care, which is much to be desired given the fact that the World Health Organization (WHO) ranks the health system in the United States 37th in the world.

Unfortunately, realizing these promises will be far from easy because of the great complexity of the health care system that is envisioned and because of the tremendous political effort that will be needed to fight off conservative attacks designed not only to reverse health care reform but also to roll back Medicaid and Medicare.

Under the provisions of The Affordable Care Act (ACA), as it is known, over 32 million Americans who do not have coverage soon will. In addition, the ACA assures that coverage will be in effect when people need it most by forbidding refusal to cover pre-existing conditions or termination of coverage for people who develop a condition requiring substantial medical care.

Health care reform also includes specific benefits for people with mental or substance use disorders, who at best have had coverage for treatment of these disorders far more limited than coverage for physical disorders. At last federal law provides full “parity,” requiring (1) that coverage include mental and substance abuse conditions and (2) that it be equal to coverage of physical health conditions.

In addition, health care reform calls for improvements in quality of care, including integrated delivery of primary physical health care and behavioral health care, as well as an emphasis on health and mental health promotion. Goals include increased identification of mental and/or substance use disorders in primary care settings, access to good behavioral health care for those who need it, access to good physical health care for people with serious behavioral health problems, and changes in behavior and lifestyle so as to combat the obesity epidemic and promote physical and mental health generally.

In short, more people with mental disorders will have health coverage. They will have coverage regardless of when their disorders began. Their coverage will be equal for mental and physical conditions. They will be more likely to be identified as needing treatment and to get treatment through primary health care. Those with serious psychiatric disabilities will be more likely to get good physical health care. Everyone will benefit from preventive interventions and “wellness” initiatives.

Specifically, The Affordable Care Act provides:

  • More extensive eligibility for Medicaid and State Child Health Insurance. An additional 16 million people will become eligible.
  • Improved coverage of medications and preventive care by Medicare
  • A mandate that all employers provide health and behavioral health coverage, except some small employers, who either will get subsidies to provide coverage or whose employees will be eligible for help to purchase coverage.
  • A mandate that all individuals have coverage, which they will purchase themselves if they are not covered by a governmental or employer-based health plan.
  • The establishment of State health insurance marketplaces (called “exchanges”) where individuals can purchase insurance (including coverage of mental health) at prices that reflect the benefits of purchasing by a large group and through which plans will be guaranteed to provide what they promise.
  • Extensive health insurance reforms outlawing refusal to cover pre-existing conditions or people who develop serious medical conditions after they are enrolled in a plan. Reforms will also guarantee “transparency”, i.e., that you get what you pay for as well as prices that reflect health risks in your community, and more.
  • Efforts to increase integration of health and behavioral health service delivery through structures called “patient-centered medical homes”, “health homes,” and “accountable care organizations,” and more.

Implementation of these provisions will be exceedingly difficult because they are so complex and require the coordination of state and federal governments as well as numerous state and federal agencies.

In addition, it will not be easy to develop true integration of physical and behavioral health care. The rhetoric of integration is promising, but the requirements that are emerging to translate rhetoric into reality leave much to the imagination. For example, the criteria for recognition as a “medical home” that have been issued by the National Commission of Quality of Care (NCQA) are purposely vague so as to allow innovative approaches to integrated treatment. Avoiding over-regulation is important, of course; but it will also make it easy for organizations to pay lip service to the goal of integration while doing little in reality.

Both with regard to cooperation needed among governmental agencies and the degree of communication and coordination needed to achieve integration of physical and behavioral health care, the principle that “collaboration is an unnatural act carried out by non-consenting adults” will surely be at work here.

Beyond these inherent difficulties is the sad fact that health care reform has become the major symbol of the differences between the political parties. Democrats by and large support health care reform so as to provide access to decent health care to as many people as possible. Republicans by and large oppose health care reform as a symbol of government intruding into the private realm, of the federal government trampling the rights of the states, and of profligate spending.

Specifically, Republicans have proposed massive cuts to Medicaid and Medicare spending by reducing who and what they cover. Some have gone far beyond overturning the Affordable Care Act with proposals to turn Medicaid into a block grant program and to turn Medicare into a voucher program. Federal health coverage would no longer be an “entitlement”. This would create substantial risk that federal health insurance coverage would not be inadequately funded. In fact, it would no longer be insurance at all because a person with Medicaid and/or Medicare who was in medical need would not be guaranteed coverage once the money allotted to their state or to them as individuals ran out.

Behavioral health services are particularly at risk in the conservative assault on federal health spending. Medicaid has become the single largest source of funding for mental health services, and over the past 30 years or so it has moved past the medical model of reimbursable services to include much more of what people with serious mental disabilities need—outreach, housing, rehabilitation, case management, etc. A return to using Medicaid to pay only for medical model services in medical settings would be a disaster for people with the greatest need of help in order to live in the community.

In addition, behavioral health services are technically “optional” services under Medicaid. Unfortunately, this makes them sound as if they are not really important to people and makes them a tempting target for cutting. In fact, “optional” in this context simply means that—under current law—it is permissible for states to be in the federal Medicaid program without covering behavioral health services. Despite the legal option, all states currently use Medicaid to pay for mental health services. Eliminating the federal share of Medicaid for behavioral health would undoubtedly result in a vast reduction of behavioral health services throughout the United States.

So, we all have to be ready to fight to preserve both the provisions of health care reform and federal behavioral health benefits that were available prior to health care reform. The good news is that all of the mental health advocacy organizations are in the battle already, and they have been effective. (It may be that vouchers for Medicare are already off the table.) The bad news is that unless there is a political shift in Congress after the next election, the battle for decent behavioral health services in the United States has just begun.

Michael B. Friedman is Founder and former Director of the Center for Policy, Advocacy, and Education of the Mental Health Association of New York City. He currently teaches at Columbia University’s schools of social work and public health. His writings are collected at, and he can be reached at

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