Almost one of five adults in America — just under 50 million people — are currently living with a mental illness. People with mental health conditions are at significantly higher risk for other health problems and complications, including substance use. Annual U.S. mental health spending is more than $200 billion.
A decade after passage, there is ample evidence the Affordable Care Act (ACA) significantly increased insurance coverage in the United States and enhanced access to affordable health services, including mental health. Before the law, mental health care could be particularly inaccessible for patients in individual or small-group health plans, as well as for the uninsured.
Through a combination of coverage expansions and access provisions, the ACA addressed many, but not all, of these barriers. We conducted a literature review to examine the effects of the ACA on mental health care and highlight future research and policy priorities.
Before the Affordable Care Act
There were more than 48 million uninsured people when the ACA passed; people with mental illness are more likely to have low incomes and to be uninsured. Leading up to the ACA, the Mental Health Parity Act of 1996 and the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) required all large-group employer insurance plans to cover mental health services at the same level as medical and surgical services, if they offered them. This is known as “parity,” and means that there cannot be greater cost-sharing or other limitations for mental health services.
However, those parity laws did not apply to individual and small-group plans and underwriting protections through HIPAA were insufficient, as were state laws. Depending on the type of plan, insurers in those two markets could screen patients for mental health history and use that information to deny coverage, exclude and cap mental health services, increase premiums and cost-sharing, and restrict access to drugs.
After the Affordable Care Act
The ACA addressed these problems by pairing coverage expansions with access to mental health care. Efforts to expand coverage, including allowing young people to stay on parents’ plans until age 26 and expanding the Medicaid program, led to a drop in the number of uninsured to 30.4 million by 2018.
The ACA also guaranteed access to mental health services within individual, small-group (fully insured), and Medicaid expansion plans by mandating that they cover 10 essential health benefits, including mental health and prescription drugs. It applied the MHPAEA parity requirements to these plans, and required all plans (including large-group) to cover preventive services like mental health screenings at no cost. Individual and small-group plans also must meet provider network adequacy standards.
Finally, the ACA ended annual and lifetime benefit caps and eliminated medical underwriting in the individual and small-group markets. Plans can no longer deny coverage or impose cost barriers because of preexisting mental health conditions.
Through a survey of the literature, we investigated the impact of these reforms:
- Coverage. People with mental health conditions were more likely to have insurance as a result of the ACA. One study found that Medicaid expansion was associated with greater coverage improvements among low-income adults with depression; another showed improvements in states that had expanded as well as those that did not (but lower uninsured rates in expansion states). Studies also have shown increased coverage for young adults with mental health conditions and increased mental health benefits in individual and small-group plans.
- Access. Access has improved for mental health patients, with studies showing increased treatment and decreased unmet mental health needs because of cost. One study found that living in a Medicaid expansion state was associated with a greater decline in cost-related access problems for low-income adults with depression; multiple studies have shown improved overall access for lower-income adult populations in Medicaid expansion states. The dependent coverage provision has generally been associated with greater mental health access improvements for young adults.
- Outcomes. Outcomes data are emerging, but preliminary. Multiple studies found that living in a Medicaid expansion state was associated with relative reductions in poor mental health days for low-income, childless adults. Medicaid expansion also has been associated with reduced severe psychological stress, while other studies have not found improvements. Several studies have reported modest relative improvements in self-reported mental health for young adults under the dependent provision, compared to older control groups. Another study showed lower out-of-pocket spending for young adults with mental health or substance use conditions.
The Affordable Care Act has improved access to mental health care in just 10 years, but remaining gaps require further attention. We must focus future research on: disparities in the mental health care of racial and ethnic minorities; the significant mental health care burden of justice-involved populations and the lack of increased treatment; and suicide rates, which have continued to climb.
Moreover, coverage gains have stalled. The Trump administration has loosened restrictions on non-ACA-compliant plans that could deny mental health care, and supports overturning the ACA, which would put millions of people with preexisting mental health conditions at risk.
While the ACA mandated mental health coverage for individual and small-group plans, large-group plans are still not subject to that requirement and coverage parity enforcement varies by state. Studies and reports also have flagged mental health network adequacy issues; 113 million people currently live in areas with a shortage of mental health providers.
Moving forward, state and federal policymakers have tools available to protect and build on this progress. These range from expanding Medicaid in the remaining 14 states, or otherwise filling the Medicaid coverage gap, to extending mandatory essential health benefits to the large-group employer market and eliminating non-ACA-compliant plans.