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About Mental Health

New federal mental health laws have led to gains in some areas, but patients with severe mental illness still face hurdles in accessing care, results of two new studies published online December 15 in Psychiatric Services show.

The first study, conducted by Peter Lee Phalen, a doctoral student in clinical psychology at the University of Indianapolis, in Indiana, showed that patients with moderate mental illness benefited from passage of sections of the Affordable Care Act (ACA), but not those patients with serious mental illnesses.

Using data from the National Health Insurance Survey, Phalen looked at rates of health insurance coverage and utilization, as well as affordability of mental health services and satisfaction with health coverage and healthcare from 2013 to 2014.

In many states, public health insurance was mandated to expand on January 1, 2014, “so many people suddenly had access to public health care,” Phalen told Medscape Medical News. In addition, access to health insurance “exchanges” meant that people could obtain more affordable healthcare, he said.

Peter Lee Phalen

From a nationally representative sample of more than 35,000 adults aged 26 to 65 years, Phalen compared changes in rates among those in moderate and severe psychological distress and those in no or low psychological distress.

He used a proxy for mental health called the “K6,” which measures psychological distress. A cutoff score of 13 has been well validated to discern people with a psychiatric disorder that severely affects their functioning, he said. “It maps really well, so severe psychological distress and severe mental illness can be roughly equivalent.”

For moderate mental illness, he used a cutoff of 5, which represents people with psychological distress that seems to affect functioning but “doesn’t map as well to mental illness.”

The study showed that the rate of health insurance coverage increased among people with no or low psychological distress and among those with moderate psychological distress, but there was a statistically significant greater increase among people with moderate psychological distress.

“Massive” Improvement

The percentage of persons with moderate psychological distress who were able to find an affordable healthcare plan significantly increased by 15.7 percentage points in comparison with those with no or low psychological distress, after adjustment for covariates that included income, education, race, sex, age and unemployment status (95% confidence interval [CI], 1.6 – 29.8). Phalen described this improvement as “massive.”

“The gap completely closed; there was about a 15-point gap, and in just 1 year, that gap became statistically insignificant; so that’s huge, and that’s great,” he said.

Among people in moderate psychological distress, there were statistically significant net increases in healthcare coverage (6.3%; 95% CI, 3.3 – 9.4), rates of acquisition of public health insurance (4%; 95% CI, 1.4 – 6.8), and subjective improvement in healthcare coverage compared with the previous year (4.4%; 95% CI, 2.3 – 6.4). There were also significant net decreases in reported difficulty obtaining affordable healthcare coverage (–17.7%; 95% CI, -30.2 to -5.2) and worries about paying for costs associated with possible accidents or serious illnesses (-4.6%; 95% CI, -7.6 to −1.6).

People in serious psychological distress did not fare as well. For those patients, there were significant net changes in healthcare coverage, utilization of mental health care, degree of difficulty in obtaining affordable healthcare coverage, or affordability of mental health care.

The absence of measurable improvements in this group suggests that they may face unique barriers that limit the extent to which they benefit from recent changes in public health policy, said Phalen.

Among the barriers are costs associated with transportation and taking time off work, and lack of awareness of where to go for help. In addition, there are still “extensive administrative and bureaucratic barriers” to accessing care, which represent “hurdles that can be incredibly prohibitive or just discouraging,” he said.

“The health insurance system in the United States is expensive, complicated, and, frankly, demoralizing. It’s difficult for anyone to navigate, and psychological distress makes it even harder,” Phalen added.

But those with severe psychological distress did show increases in satisfaction with healthcare, perceived improvements in their healthcare coverage in comparison with the previous year, and decreased concerns about paying for healthcare.

A “big caveat” to this research, said Phalen, is that public insurance was not expanded in all states, and he was unable to distinguish between those states that did and those that did not expand Medicaid. He believes that improvements for the severely mentally ill were seen only in those states in which Medicaid coverage was expanded.

Better Coverage for Children

The second study used administrative databases from Optum, which contracts with facilities and providers to serve customers, to assess the impact of the Mental Health Parity and Addiction Equity Act (MHPAEA).

Passed in 2008, the MHPAEA is the most far-reaching and comprehensive parity law to date, according to the authors, led by Amber Gayle Thalmayer, PhD, who was with Optum at the time of the study but is now a research assistant at the Institute of Psychology, University of Lausanne, Switzerland.

Dr Amber Thalmayer

“The Parity Act was trying to get insurers to cover behavioral health in the same way they cover normal medical concerns, to stop making a distinction,” Dr Thalmayer told Medscape Medical News.

For the study, the investigators used data from 2008 to 2013. The plans they included in their study covered millions of Americans and were diverse in terms of employer size, employer industry, and medical plan type.

The researchers looked at both “carve-in” and “carve-out” plans. A carve-in plan is one in which behavioral healthcare coverage is included with the medical coverage; in a carve-out model, mental health care and substance abuse treatments are handled by a specialty provider and are not included with the main policy.

Before passage of the Parity Act, many healthcare care plans had maximums – or quantitative treatment limits (QTLs) – for such things as the number of inpatient and outpatient treatment days per year for behavioral healthcare. This term refers to both mental health care and substance abuse and so would include treatment for alcoholism.

After accounting for overlap in limit types, the study found that before the Parity Act, 89% of regular carve-out plans and 77% of carve-in plans limited outpatient visits, and 66% of regular carve-out plans and 73% of carve-ins limited inpatient days.

But by 2011, virtually all plans had dropped QTLs on behavioral healthcare (P < .001). There was more complete removal of QTLs in carve-out plans than in carve-in plans.

The elimination of QTLs was consistent across plans and happened shortly after enactment of the law. “It is reasonable to conclude that this large effect would not have occurred in the absence of this legislation,” write the authors.

Including both carve-in and carve-out plans increases the generalizability of the findings, the investigators say.

One of the most meaningful effects of the MHPAEA, according to Dr Thalmayer, is improved insurance protection for children and adults with depression, bipolar disorder, or psychosis. Prior to passge of the Parity Act, patients with these conditions “might have been hitting their limits,” she said.

Dr Thalmayer noted that some insurance plans had limits for both medical and behavioral healthcare and so did not have to change those limits.

“If they have that limit on the medical side, then legally they are allowed to have it on the behavioral health side.”

Peter Lee Phalen has disclosed no relevant financial relationships. Dr Thalmayer was a contractor for and received salary from Optum, United Health Group.

Psychiatr Serv. Published online December 15, 2016. Phalen study, abstract; Thalmayer study, abstract

Pauline Anderson December 19, 2016