Authors: Deb Stein and Jennifer Lav
The Senate Republican-proposed Better Care Reconciliation Act (BCRA) threatens to undo decades of progress and recent giant leaps forward in the provision of mental health services. BCRA will harm everyone who may ever need mental health services by undermining mental health parity. BCRA will also cause states to make deep cuts to the Medicaid-funded mental health services. Last, BCRA will strip coverage from individuals with mental health diagnoses who gained coverage through Medicaid expansion, taking away their opportunity to access any services at all.
BCRA Undermines Mental Health Parity for Everyone
The changes under BCRA put at risk coverage of mental health services for the entire country by allowing states to waive Essential Health Benefits (EHBs), which include mental health services. Insurers could exclude mental health services entirely from private market and large employer insurance plans. Federal requirements for mental health parity only apply when plans offer mental health benefits at all, so requirements for equal treatment of mental health and medical/surgical conditions becomes meaningless if insurers do not cover mental health services. When analyzing the House’s version of the bill, which contained an EHB waiver provision similar to BCRA, the Congressional Budget Office estimated that mental health services were one of the more likely EHBs to be dropped by states. The result is that individuals could spend, on average, $1,525 to $14,023 more on mental health services per year than under current law.
Medicaid Cuts Threaten Mental Health Benefits
Despite Republican claims that states will have more flexibility under BCRA, the $772 billion cut to Medicaid will actually inhibit innovation. For example, every state currently offers some type of mental health rehabilitation services through Medicaid. But innovative Medicaid services such as assertive community treatment, peer support, and employment-related services are optional state services for adults. If states are faced with BCRA’s severe funding cuts, these optional services may be the first to go.
Similarly, Medicaid has also been particularly innovative for children with mental health diagnoses. For example, states have used Medicaid to pilot community-based alternatives to residential treatment. Many of the services offered under Medicaid are generally not available in private health care plans. Medicaid’s mental health services successfully provide care for children in the community and keeps families together.
BCRA Repeals Medicaid Expansion, Stripping Coverage from Millions of Individuals with Mental Health Diagnoses
The Affordable Care Act (ACA) expanded Medicaid to millions of individuals, including 1.3 million with a serious mental health diagnosis. Medicaid expansion has been associated with reducing significant unmet mental health care needs.
By repealing Medicaid expansion, BCRA creates a vicious cycle for individuals with mental health diagnoses. Without expansion, individuals may only become eligible for Medicaid if they demonstrate they are “sick” enough to qualify as a person with a disability. Even those who could qualify for Medicaid may not have access to health care providers to obtain the documentation of disability needed to qualify. This may also keep people with mental health diagnoses out of the workforce because to qualify for Medicaid as “disabled,” an individual generally needs to demonstrate that she cannot engage in substantial gainful employment. Without access to health care, a person with mental health diagnoses may also have difficulty recovering and achieving stability such that consistent employment is feasible.