From the very first days of the U.S. health insurance system, the stigma of mental illness was formally codified into benefit design. Both public and private insurers provided inferior coverage for mental health care, if they even provided it at all. For decades, this was not remotely controversial. Labor unions were quite happy to trade “mental for dental” when negotiating fringe benefits for their workers, politicians suffered no electoral consequences for passing insurance legislation that discriminated against people with mental illness, and families who needed better health benefits for mentally ill loved ones were typically too ashamed to speak up. But thanks to brave advocates, inspiring bipartisan political leadership and cultural changes in perceptions of mental illness, dramatically improved mental health insurance coverage has at last arrived on the American scene.
Three laws have transformed the landscape of mental health insurance policy in the span of only a half-decade.
In 2008, a sweeping reform of Medicare passed which righted an injustice that had plagued the program since its inception. Medicare originally covered outpatient mental health and addiction treatment at a far lower rate (50%) than other outpatient care (80%). The backbreaking 50% outpatient co-pay effectively prevented most enrollees from accessing outpatient mental health care. The 2008 law phased this payment disparity out over time, eliminating it entirely as of January 1, 2014. Medicare now covers 80% of outpatient mental health care costs, which is good news for its 50 million current enrollees and the 150,000 new enrollees it gains each month.
Also in 2008, Congress passed and President G.W. Bush signed the Wellstone-Domenici Mental Health Parity and Addiction Equity Act. Named for its two leading Senatorial advocates (interestingly, the proudly liberal Paul Wellstone and the staunchly conservative Pete Domenici) the law requires companies with more than 50 employees as well as Medicaid managed care plans to make their offered mental health benefits comparable to those for other illnesses. These parity protections apply to over 100 million Americans.
The 2010 Affordable Care Act aka “Obamacare” went even further. It extended parity protections to individuals who receive insurance from small businesses and to those who purchase it in the individual market (e.g., on a state or federal health insurance exchange). It also defines mental health as an essential health care benefit that all plans it regulates must offer. Last but not least, the law of course also provides insurance to the uninsured population, which has a high rate of psychiatric disorders. Over 60 million Americans will receive improved mental health insurance coverage because of the provisions of the Affordable Care Act.
Although enormous work remains necessary to implement these laws, they together bring the U.S. closer than it has ever been to providing mental health treatment on demand. Coping with mental illness is never going to be easy, but at least mental health policy is now directed at making the process easier rather than harder.
This post originally appeared at the PLOS Blog Mind the Brain