ACA led to huge rise in behavioral health coverage

After the Affordable Care Act (ACA) designated behavioral health as one of 10 essential health benefits, which insurers were required to cover, access to treatment and services rose significantly from 2013 to 2014, according to a study published July 9 in Health Affairs.

Health plans immediately moved to make mental health and substance use services, collectively known as behavioral health, coverage available once the requirements were set in stone.

“By 2014 the proportion with behavioral health coverage had increased to be equal to or close to the proportion with medical/surgical coverage, because plans had made significant reductions in exclusions for behavioral health,” Alexander Cowell, senior research economist at nonprofit research institute RTI International, and researchers wrote.

However, the ACA requirements did not dictate which services had to be covered, and insurers could provide coverage in parity with physical health benefits, including medical and surgical treatments.

“Federal guidance on these benefits did not specify which behavioral health services insurers must include in their plan offerings,” the study authors wrote. “Insurers thus can decide which behavioral health treatment services to cover, as long as they cover them at parity with medical/surgical treatments.”

From 2013 to 2014when the requirements went into effecta smaller proportion of individual and small-group plans covered mental health or substance use care compared to medical and surgical care in 2013. By 2014, the proportions were the same, according to the study, which analyzed 78 individual and small-group plans from 2014 and 60 plans from 2013.

The level of coverage also increased from 2013 to 2014, with a smaller proportion of plans requiring coinsurance for an initial in-network visit for inpatient, outpatient and emergency room department visits year to year.

The essential health benefit requirements remain in effect in 2018, and without the ACA mandate, many insurers would likely drop these benefits to lower overall costs and stake out healthier enrollees, according to the study.

“If essential health benefit requirements were to be removed and mental health and substance use coverage becomes similar to that in 2013, as many as 20 percent of the plans in our sample would not cover these conditions,” Cowell et. al wrote.

People with mental health conditions and substance use disorders tend to have disproportionately high healthcare services utilization and spending, and meaning they're more likely to be dropped from health plans without the essential health benefit requirements.

“Insurers could limit behavioral health coverage to reduce the cost of care and attract healthier enrollees,” Cowell et. al wrote. “Taken together, these requirements may be essential for the stability of the individual and small-group markets."