Since passage of the Affordable Care Act (ACA), the US has seen a dramatic expansion of insurance coverage for mental health and substance use disorder treatment. The health law sparked broader access to these behavioral health services both by giving states the ability to expand Medicaid coverage to more low-income adults, and by giving teeth to existing mental health parity laws. Today, meaningful coverage of mental health and substance use disorder (SUD) is real for millions more people.
Californians recognize the value of this coverage. In a statewide Berkeley IGS poll supported by CHCF and released today, three in four respondents said that mental health and SUD treatment not only can help people live healthy and productive lives, but that it is “very important” for insurance plans to cover this treatment. Support for coverage of behavioral health care crosses all demographic and regional subgroups, including all ethnic groups and age brackets. It has bipartisan support as well, with 59% of Republicans and 86% of Democrats telling interviewers such coverage is “very important.”
Medicaid is the single biggest payer for mental health treatment and is playing a much larger role in covering substance use disorder treatment. In California, of the approximately 4 million people in the Medi-Cal expansion group, an estimated 450,000 have a substance use disorder. The American Health Care Act (AHCA) passed by the House last month, and the Senate’s current efforts, pose a threat to this coverage. The AHCA would phase out the ACA’s enhanced funding for the Medicaid expansion and cap federal Medicaid spending. Under the bill, California stands to lose $24 billion by 2027. It would face painful cuts to eligibility or benefits — or both.
This is particularly alarming amid an opioid epidemic in which certain California counties have overdose death rates among the highest in the nation.
Repeal of the ACA wouldn’t affect only people who receive Medicaid. The House bill would allow states to waive “essential health benefits” requirements, allowing insurers to exclude coverage for a variety of services or to charge higher premiums if those services are included, according to a report from the Urban Institute. Before the ACA was enacted, people who purchased their own insurance and those covered in small businesses were at great risk of having mental health disorders excluded from coverage. Coverage of behavioral health services in the individual market was extremely limited: One-third of people had no coverage for SUD, and nearly 20% had no mental health coverage. The coverage that did exist was typically very limited.
The survey shows that not only do people value mental health and SUD coverage in the abstract, they’re also aware that they have it and they’re ready to use it. CHCF has been tracking consumer understanding of behavioral health coverage since the ACA first took effect. In today’s poll, two in three respondents said their health plans covered mental health and SUD services, a 5 percentage-point increase from a similar CHCF-sponsored poll in 2014. Only 47% of people with Medi-Cal, however, said that they were covered for mental health treatment even though these services are in fact covered by the program.
The survey also found that people were open to seeking behavioral health treatment if needed (66% for a mental health condition, 65% for drug use problems). Twenty-two percent reported that they or a family member had sought treatment for a mental health condition within the last year.
Stigma and access gaps remain, but this survey shows that Californians know recovery happens and treatment works — and they care about maintaining access to these vital services.
Catherine Teare is associate director of CHCF’s High-Value Care team, which supports policies and care models that align with patient preferences, are proven effective, and are affordable. She leads the foundation’s work on behavioral health care, including behavioral health integration in primary care and behavioral health interventions for high-cost populations. She also manages projects related to the county role in health care delivery and oral health care.
Catherine has worked at CHCF since 2011 and previously led the organization’s efforts on enrollment in public programs, with a particular focus on consumer experience. Before joining the foundation, she worked as a consultant for safety-net health care providers, foundations, and local government, providing research and policy analysis in the areas of health care financing and delivery, public and private health insurance programs for children, adolescent health, reproductive health, HIV, and youth development. She also worked as director of policy for Children Now and as a health policy analyst for the National Center for Youth Law. She received a bachelor’s degree in English from Yale College and a master’s degree in public policy from the University of California, Berkeley.