19 – Health Policy and Population Health in Behavioral Health Care in the United States




Abstract




The treatment of behavioral health disorders is impacted by the many complexities and challenges inherent in the United States health care system. Patients and their families struggle with limited access, availability and affordability of treatment, inadequate insurance coverage, and a fragmented system of care. To better understand these issues, this chapter provides an overview of the US health care system, with a focus on coverage and financing of behavioral health care; describes current challenges within the system; and highlights emerging solutions to improve behavioral health delivery and outcomes.





19 Health Policy and Population Health in Behavioral Health Care in the United States


Kirstin Beach and Bruce Schwartz



Introduction


The treatment of behavioral health disorders is impacted by the many complexities and challenges inherent in the United States health care system. Patients and their families struggle with limited access, availability and affordability of treatment, inadequate insurance coverage, and a fragmented system of care. To better understand these issues, this chapter provides an overview of the US health care system, with a focus on coverage and financing of behavioral health care; describes current challenges within the system; and highlights emerging solutions to improve behavioral health delivery and outcomes.



Health Care in the United States



The US Health Care System in the International Context

The US health care system has a mixed model of insurance coverage and of service delivery, with public and private sources of insurance and public and private health care providers. Unlike many countries in the Organization for Economic Cooperation and Development (OECD), the US does not have universal health care coverage.


While it lacks universal health insurance coverage, the United States spends far more on health care than any other nation. In 2017, total health spending per capita in the United States was $10,209, in comparison to $4,826 in Canada and $8,009 in Switzerland. When including social services and health care spending, the United States is much closer to the OECD average, highlighting the relative underpayment in the social services sector in the United States; 28.8 percent of US GDP is spent on social services and health care, compared to the OECD average of 21.4 percent of GDP (OECD, 2017). While the root cause of high health care spending is the subject of debate, it is clear that the United States is deriving less value for these expenditures than other OECD countries. Utilization of medical and hospital services is not the main driver of high health care spending, as patients in the United States do not use these services at a notably higher rate than patients in other nations. For example, Americans have an average of four physician visits annually compared to the OECD median of 6.5 visits (Squires, 2015). Lack of price control is likely a key driver of US spending compared to other nations (Anderson et al., 2003).



Sources of Coverage in the United States

The US health care insurance system is a patchwork of group health plans that are most often offered through employment arrangements, government-sponsored health insurance for defined populations, and non-group markets from which individuals to purchase coverage. In total, these insurance sources cover 91 percent of Americans, leaving more than 27 million individuals uninsured (OECD, 2017). Further, there is significant variability in benefits across insurance products, making it difficult for patients and providers to understand and obtain needed medical services, especially for behavioral health care. The largest sources of coverage are employer-sponsored health insurance (ESI), Medicare, and Medicaid.



Employer-Sponsored Health Insurance

In the United States, unlike many high-income countries, employment plays a major role in health care insurance coverage. More than 150 million Americans are covered by ESI, making it the largest source of coverage in the United States (Collins, Gunja, & Doty, 2017). This form of insurance was enabled by the Employee Retirement Income Security Act (ERISA) of 1974, which established minimum standards for retirement, health, and other welfare benefit plans. Employer-sponsored insurance receives preferred tax treatment, which encourages private businesses to provide it to employees. Employer and employee contributions for employer-sponsored insurance are excluded from income and payroll taxes, costing an estimated loss of approximately $250 billion in federal tax revenue annually (Congress of the United States Congressional Budget Office, 2013).


The cost of ESI has steadily grown faster than wages, concerning employers and employees alike. The growing ESI costs have led many employers to increase the amount employees must contribute for coverage through larger contributions to the premium and insurance plan designs that result in larger out-of-pocket costs and high deductibles for employees. For example, those enrolled in high-deductible plans must pay a substantial amount on their health care bills before insurance coverage is triggered. The share of people covered by ESI with deductibles of more than 5 percent of household income grew from 2 to 13 percent between 2003 and 2016 (Collins, Gunja, & and Doty, 2017). As a result, many individuals cannot afford to use their health insurance coverage – a phenomenon referred to as underinsurance – and forgo and delay necessary treatment.


It is also worth noting the variability in the regulation of ESI, depending on the size of the employer and the way the plan is administered. Some ESI plans are subject to state regulation and mandates, while others are subject to lesser federal oversight. This leads to significant variability in what ESI plans are required to cover.



Medicare

Medicare is a federal health insurance program for individuals aged sixty-five and older, as well as individuals under sixty-five with end-stage renal disease (ESRD), and with some disabilities. Medicare covers sixty million people. Traditional, or fee-for-service, Medicare is administered directly by the federal government and offers hospital insurance (Part A); physician services, outpatient services, and other medical services (Part B); and outpatient prescription drug coverage (Part D). Under Medicare Part C, also known as Medicare Advantage, private insurance companies administer the Medicare benefit through managed care programs. There are many notable gaps in Medicare, including long-term care, vision, hearing, and dental coverage, leading many beneficiaries to elect for supplemental insurance coverage (Cubanski et al., 2015).


Medicare is financed through federal taxes and beneficiary premium contributions. In 2016 Medicare accounted for 15 percent of total federal spending, and 20 percent of total public and private health spending in 2015 (US Centers for Medicare & Medicaid Services, 2018). Given the rising costs of health care and expected increases in enrollment due to the aging population, there is increasing concern about the future costs of Medicare.



Medicaid

Medicaid, which currently covers more than 67 million people, provides health insurance for people with low-income. Each state administers its own Medicaid program, which is jointly financed and overseen by the federal government. (US Centers for Medicare & Medicaid Services, 2018). To qualify for Medicaid, individuals must fall below income thresholds and meet categorical eligibility, such as being a child, a parent of an eligible child, or an aged adult. Although states must adhere to some federally mandated categories for eligibility, there is much discretion in designing Medicaid programs, leading to great variability in benefits from state to state.


The Affordable Care Act of 2010 (ACA) intended to expand Medicaid eligibility to all individuals under the age of 65 in households with income up to 138 percent of the federal poverty level. However, a 2012 Supreme Court ruling made the eligibility expansion optional for each state (Klees, Wolfe, & Curtis, 2017). As a result, many states chose not to expand their Medicaid programs. This has significantly hampered the ability of the ACA to reduce the uninsured and has resulted in even greater variability across state Medicaid programs.


Medicaid plays an especially important role in covering patients with serious mental illness. While only 14 percent of the adult population is covered by Medicaid, the program covers 21 percent of adults with diagnosed mental illness and 17 percent of adults with substance use disorders. In most states, individuals are automatically eligible for Medicaid if they qualify to receive Supplemental Security Income, the federal cash assistance program for the aged with low-income, blind, or disabled. Mental illness is a qualifying disability for program eligibility.


There are major differences between the states in Medicaid’s behavioral health coverage and funding for psychiatric and substance abuse services. This especially affects the provision of mental health services as many states do not adequately reimburse the cost of care provided by community mental health clinics or hospital providers. The variability is particularly stark in terms of substance use disorders, where many Medicaid programs do not cover medication-assisted treatment. Further, federal Medicaid funding is prohibited for “institutions for mental disease,” limiting access to residential and inpatient treatment settings (Social Security Act).



Population Health and Mental Health Indicators in the US


Despite high spending, the US generally has poorer outcomes on almost any health measure than other OECD countries. The US life expectancy at birth in 2015 was 78.8, compared to the OECD average of 80.6 (OECD, 2017). This difference may be driven in part by high rates of obesity and poorly managed chronic disease. The obesity rate in the US is 38.2 percent, nearly 20 percentage points higher than the OECD average of 19.4 percent (OECD, 2017).


Mental and behavioral disorders are among the leading causes of disability in the US and the most costly health conditions for adults under sixty-five, along with cancer and trauma-related disorders. Of the top twenty-five leading causes of disability and injury between 1990 and 2016, nine are mental, neurological, or substance use disorders (US Burden of Disease Collaborators, 2018). In 2016, deaths from overdose and suicide in the US exceeded deaths from diabetes (29 per 100,000 population versus 25 per 100,000 respectively) (Rockett et al., 2018).


The prevalence of psychiatric disorders in the US of adults ages 18 or older in 2016 was estimated at 44.7 million (18.3 percent), with a higher rate of occurrence among women (21.7 percent) than men (14.5 percent; SAMHSA 2017). In 2014, it was estimated that 20.2 million adults in the US aged 18 or older (8.4 percent) had a substance use disorder (SUD) and 39.1 percent had a co-occurring mental disorder and SUD. For adolescents aged 12 to 17 years, who had a past year SUD, 28.4 percent had a co-occurring major depressive episode (Park-Lee et al., 2017).



Challenges in Behavioral Health and Service Delivery



Inadequate Behavioral Health Coverage and the Search for Parity


Historically, health insurance, regardless of the source, has covered behavioral health differently than physical health. This lack of parity has meant that patients were often subject to higher cost-sharing for behavioral health services, limits on the number of inpatient and/or outpatient services covered, strict prior authorization requirements, and annual and/or lifetime limits on behavioral health services.


Over time, policymakers attempted to achieve parity for behavioral health care. These efforts for parity began within states. However, state efforts were piecemeal and, because states generally cannot regulate ESI, which is regulated under federal law, the impact was limited (US Department of Health and Human Services Assistant Secretary for Public Affairs [ASPA], 2016).


The first major federal attempt at parity was achieved in 1996 when the US Congress passed the Mental Health Parity Act. This legislation required that any annual or lifetime limits on behavioral health benefits set by large employers be comparable to the limits set on physical health benefits. While this effort was largely effective in addressing lack of parity in annual and lifetime limits on behavioral health, health insurance companies continued to discriminate against psychiatric patients in their benefit design. Notably, four years after the passage of the legislation, among plans that were compliant with the law, 87 percent restricted mental health benefits more than physical health outpatient visits and hospital days (Schwartz, Stein, & Wetzler, 2017).


The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 was passed with bipartisan support to address the shortcomings of the Mental Health Parity Act of 1996 and required that, if mental illness and substance use disorder benefits were offered by ESI plans, then coverage could be no more restrictive than that for physical health benefits. Notably, this law did not require that plans offer behavioral health benefits, nor did this requirement apply to Medicaid or Medicare. In 2009, of individuals insured through ESI, 2 percent had no behavioral health benefits whatsoever and 7 percent had no substance use benefits. Individuals covered by other types of plans had even lower coverage of behavioral health benefits (Frank, Beronio, & Glied, 2014). The Affordable Care Act extended parity protections to additional types of insurance coverage. However, implementation and enforcement of parity protection have been slow, and parity has still not yet been fully achieved.



Inadequate Access to Psychiatric Care


There are insufficient resources in almost all communities to provide access to specialized behavioral care given the prevalence of psychiatric and substance use disorders. The National Survey on Drug Use and Health from 2016 indicated that among the estimated 44.7 million adults with any mental illness, only 43.1 percent received mental health services in the past year (Park-Lee et al., 2017). For the 10.4 million adults with serious mental illness, 64.8 percent received mental health services, and more than 17.7 million adults who needed substance use treatment did not receive specialty treatment (Park-Lee et al., 2017). This data demonstrates the serious shortfall in the availability of behavioral health treatment resources across the United States.


This shortfall in treatment is driven in part by an inadequate supply of psychiatrists. The US Department of Health and Human Services estimates there are approximately 46,000 psychiatrists in the United States with a current shortage of over 6,000 to meet current demand; this shortage is expected to grow to between 14,000 and 31,000 psychiatrists by 2024 (Satiani et al., 2018).


The psychiatrist shortage is compounded by inadequate insurance reimbursement and, therefore, insufficient numbers of psychiatrists participating within insurance networks. The acceptance rate of private insurance and Medicare is significantly lower for psychiatrists (55 percent) than for other physicians (86 to 88 percent; Bishop et al., 2014). As a result, patients access out-of-network behavioral services at a rate of 4.8 to 5.1 times higher than for primary care. (Melek, Norris, & Paulus, 2014). This means that patients who are treated by psychiatrists are subject to higher out-of-pocket costs, even if they have insurance offering behavioral health benefits.


Primary care physicians and pediatricians necessarily become the front-line behavioral health providers for the majority of patients when they present for medical care (Norquist, Regier, 1996; Regier, Goldberg, & Taube, 1978). Depression is one of the most prevalent disorders, and it should be of no surprise that more than 70 percent of antidepressants are prescribed in primary care and are among the most frequently prescribed medications. Although treatment for behavioral disorders most likely occurs in a primary care setting, research demonstrates that enhanced treatment is most likely to occur in a specialty mental health setting as psychiatrists use higher doses of medications, and patients were more likely to continue medication for 90 days or longer (Mojtabai, Olfson, 2008).


The problem of accessing needed behavioral health services extends as well to inpatient psychiatric services. Many communities have seen the loss of inpatient psychiatric capacity driven by inadequate reimbursement, including the impact of overly stringent utilization review from behavioral managed care companies. The US now averages about 11 psychiatric beds per 100,000 population. This is 25 to 30 percent of other OECD countries and below the consensus of 50 beds needed per 100,000 population (Green, Griffiths, 2014; Treatment Advocacy Center, 2016).

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Jul 27, 2021 | Posted by in PSYCHIATRY | Comments Off on 19 – Health Policy and Population Health in Behavioral Health Care in the United States

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