Mental Health the game-changing legacy of the affordable care act

By Jen Snow

Each year, elected Representatives in the House and the Senate introduce thousands of bills in the U.S. Congress. A small percentage of those bills are passed and signed into law by the President. Some of those laws have a very local impact - like laws that rename a neighborhood post office in honor of a local hero. Fewer of those laws have a national impact - like laws that modify how you file your taxes each year. Even fewer become landmark laws that revolutionize an industry and have an everyday impact on millions of Americans. The Affordable Care Act (known as ACA or "Obamacare") is one of those once-iin-aalifetime laws

In 2010, the ACA was signed into law as the most significant expansion of health care coverage since the enactment of Medicare and Medicaid in 1965. The law had wide-reaching implications for the entire U.S. health care industry, and profound implications for mental health. Most importantly, ACA had a direct impact on NAMI members across the country.

The Benefits Of The ACA

Here are the key ways the ACA improved health insurance coverage for people with mental health conditions.

Insurers Can't Deny Coverage To People With Pre-EExisting Conditions

Mental illness is poised to become the most common pre-existing condition nationwide.

Before the ACA, some health insurers routinely denied coverage to people with mental health and substance use disorders.

People, like Timothy, a programmer who explains, "the first job I worked had an insurance company that reserved the right to refuse health insurance to anyone with health problems. So, they refused health insurance to me because of my psychiatric disorder." Thanks to the ACA, people with mental illness cannot be refused coverage.

Mental Health & Substance Use Disorder Services Must Be Covered Benefits

Before the ACA, some health insurers could choose not to cover mental health and substance use disorder services or apply annual or lifetime limits on these services. ACA requires coverage of mental health and substance use disorder services in most health insurance, without annual or lifetime limits on these services. ACA also extended the protections of the Mental Health Parity and Addiction Equity Act (MHPAEA) to individual and small group plans so people can't be charged higher cost-sharing for mental health services than they do for other medical services.

"Because of the Affordable Care Act, [my son] has been able to see a psychiatrist," says Lilian, whose son was diagnosed with schizophrenia at age 21. "Without the Affordable Care Act, none of this would be possible."

Health Care Is More Affordable For Millions

Before the ACA, people seeking private health insurance were often priced out of coverage. As the result of Medicaid expansion, tax credits to purchase private health insurance and limits on deductibles and copays, the number of people who don't get mental health treatment because of the cost has gone down by one-third.

"Even though I'm highly educated, I do have a history of psychosis," mental health advocate Joy says. For the past few years, she has only been able to work temp jobs that provided little to no health care. "Without the Affordable Care Act, health insurance just wouldn't have been available to me."

Young Adults Can Stay On Their Parents' Health Plans Through Age 26

Before the ACA, young adults were frequently uninsured because their parent's plans no longer covered them, and they could not afford separate coverage. With the ACA, young adults can remain on their parent's plan up to the age of 26, even if they no longer live at home. This is a crucial extension, since 75% of all cases of lifetime mental illness begins by age 24

When young adult Maggie experienced a mental health crisis, she was job searching and didn't have employer health coverage. "Because of ACA, I'm alive," she says because she was covered on her parents' health insurance plan and could get the intensive and lifesaving care she needed.

There have been many additional benefits of the ACA. Specifically, thanks to the ACA: lMore people with serious mental illness are using mental health services and fewer people are delaying or skipping necessary care.

People with mental health conditions are more likely to have insurance and less likely to report unmet need due to cost of mental health care.

Young adults with mental health conditions are now more likely to be insured and receive outpatient services. People are experiencing positive changes in their mental health, including fewer poor mental health days and increased access to care.

People are less likely to skip medications due to cost and more likely to seek regular care for their ongoing health conditions while reporting improvements in their overall health.

NAMI In Our Fight

Even though the ACA has been law for more than a decade, there have been more than 2,000 legal challenges filed in state and federal courts contesting part or all of the ACA. The most recent challenge involves the ACA requirement that most private insurance plans cover recommended preventive care services without cost sharing. NAMI will continue to fight against these challenges because we cannot go back.

Here are some ways you can join the NAMI community in this vision: Join our #Act4MentalHealth advocacy network.

lYour story matters. Share how the ACA has helped you or a loved one.

lSign a petition to tell policymakers to support mental health. We cannot go back to a time when health insurance was unavailable, inaccessible and discriminatory for people with mental health conditions. Instead, we must look forward and work to build on the successes of the ACA. We will not stop until all people with mental health conditions have accessible, affordable and comprehensive health care.

Jen Snow is the National Director of Government Relations and Policy at NAMI

By Patrick Neustatter, MD

The joy of having students at the Moss Clinic (we have a lot of pre-med students working as scribes) is that it provides an opportunity to corrupt them.

Well, maybe "corrupt" is not quite the right word. But it gives me a chance to introduce the heretical idea that the information we use to practice evidencebased medicine may not be quite as golden as they will be led to believe in medical school

The Holy Grail Evidence-based medicine is considered the holy grail. The ultimate in what we should strive for.

It means your doctor is making decisions on how to manage your case, based on the evidence derived from the plethora of clinical trials that are published in one of a zillion different medical journals.

This is what medical students are taught. Look at the studies - or some slightly more convenient distillation of the studies in the form of clinical guidelines. Many doctors don't question this, but the studies are not so inviolable as you might think.

Heresy

I didn't really question the validity of these published studies - which are nearly always peer reviewed before publishing - until I came across an eyeopening book, Ending Medical ReversalsImproving Medical Outcomes, Saving Lives, by Hematologist/Oncologist Vinayak

K Prasad MD, MPH, and Professor of Medicine at the University of Chicago, Adam S. Cifu MD, published in 2015.

They tell how they have studied, and "struggled with, " what they call medical reversals - that a lot of established practices are shown to be of no benefit to patients - and these outmoded treatments are continued, "sometimes for decades."

They give innumerable examples (including an appendix of 146 studies published in the New England Journal of Medicine between 2001 to 2010 that contradicted accepted practice).

Stuff like a study of arthroscopic surgery to repair torn meniscus (cartilage)in the knee followed by physical therapy showed that physical therapy alone was just as effective

In diabetes - a major risk factor for vascular disease like heart attacks and strokes - the dogma is that the tighter the control the better. But they cite a study where tighter control showed no benefit to risk of dying from cardiovascular disease - and in fact people in the intensively treated group had a higher allcause mortality.

They warn any study should be Randomized Controlled (RCT), as opposed to an observational, cohort, or case control one. It should not use a "surrogate end point" - where you measure some easier metric like blood cholesterol level instead of much harder to assess, atheroma in arteries, as an indicator of the risk of heart disease for example.

They also warn, whoever is performing the study - which is nearly always a drug company - can have major influence on the results by how the study is designed and reported.

And drug companies can have a major influence on supposedly objective treatment guidelines - like Eli Lilly providing 90% of funding for the creation of guidelines for treating septic shock Surprise, surprise, the guidelines recommended an antibiotic they make. The Take Home

I was certainly never taught anything other than "base your treatment on the evidence." Nothing about critically assessing the evidence.

I have to admit to a certain joy in debunking medical dogma - and sharing these heretical ideas with students. Including one that really messes with their heads that "half of what we are taught in medical school is wrong" - it's just no one knows which half.

This possibility that the evidencebased information your doctor is using to decide on what treatment or tests you should have could be out of date, is a bit unnerving.

This is real "emancipated patient" stuff Your doctor's claim that "this is the way it's always been done" may not be good enough To play safe you must get in there and do your own research

Patrick Neustatter, MD is the Medical Director of the Moss Free Clinic