Even as access to behavioral and mental healthcare expands under health reform, there may still be gaps in both public and private insurance, researchers said in a new Health Affairs study.
Lack of adequate treatment for people suffering from mental and behavioral health disorders, addiction and substance abuse has long been a problem, especially for low-income Americans most at risk. In 2005, according to the National Comorbidity Survey, three out of five adults with a mental health disorder did not receive care from either a general provider or a mental health specialist.
It's possible not all of those people actually need treatment; some skeptics argue that depression, for instance, is overdiagnosed and anti-depressants over-prescribed. But those with more severe mental illnesses, like schizophrenia, are more likely to face obstacles to treatment, and even those with less-severe conditions have had trouble finding or affording treatment, according to Kathleen Rowan, University of Minnesota health policy doctoral student, and colleagues writing in Health Affairs.
In the National Comorbidity Study, from 2005, almost half of all respondents with mood, anxiety or substance use disorders who said they needed treatment cited cost or being uninsured as reasons for not getting treatment. Rowan and colleagues, two University of Minnesota professors, wanted to find more recent data, just as the Affordable Care Act's essential health benefits bring mental health treatment options to more people.
Reviewing data from the Integrated Health Interview Series, a part of the National Health Interview Survey, they found that between 2000 and 2010 there was a "modest but significant" increase in the prevalence of mental health disorders among working age adults, for both the insured and uninsured.
The percentage of U.S. adults diagnosed with moderate mental health problems increased from 3.7 to 5.1 percent between 2000 and 2010, with the prevalence of both moderate and serious mental health problems being "significantly higher" among the publicly insured, including TRICARE military members, and lowest among those with commercial insurance.
Insurance coverage "varied significantly by level of mental health problems," they found.
For Americans with moderate mental health problems, public insurance coverage increased from 25 percent to 35 percent between 2000 and 2010, while private coverage fell. In 2000, almost half of all Americans diagnosed with a moderate mental health disorder were covered through private insurance; by 2010, that number fell to 40 percent.
Between 2000 and 2010, the number of Americans with serious mental health problems -- defined as a functional impairment that limits one or more major life activities -- covered by public insurance increased from 43.5 percent to 47.3 percent, while the number covered by private insurance fell from 36 percent to 26 percent, Rowan and colleagues found.
In part, those findings reflect a slight decline in the prevalence of employer-sponsored insurance during the last decade, and they also reflect the fact lower-income Americans who rely on Medicaid are more likely to suffer from behavioral and substance abuse problems -- a reason why Medicaid is the single largest payer for mental health services in the U.S. In 2010, about 33 percent of adults receiving Medicaid are estimated to have had a mental or behavioral health disorder, with 11 percent meeting the criteria for severe mental illness.
Meanwhile, treatment rates for people with severe mental illnesses are estimated to be the lowest for the uninsured and the highest for those with public insurance, "while those with private insurance fall in between."
Between 2000 and 2010, about 20 percent of those with moderate problems and 44 percent of those with serious problems accessed speciality mental health care, and public insurance programs covered a majority of them -- almost 50 percent of those with moderate disorders and almost 70 percent of those with serious disorders.
Medicaid, the main insurer for mental health services, provides "some protection against barriers to care" for low-income Americans, Rowan and colleagues wrote. But today, with at least 21 states so far deciding not to expand Medicaid eligibility, some of the nation's most at-risk populations may go on living with mental, behavioral and substance use problems untreated.
And even for Medicaid beneficiaries elsewhere, it remains to be seen how much impact the ACA has in expanding access. "The devil now lies in the details of the rules, regulations, and implementation," said Rowan and colleagues.