The Health Insurance Reform Bill and Psychiatry: A “Huge Step Forward”

The health insurance reform bill Congress passed and President Obama signed has a number of small, psychiatric-targeted provisions, but their significance probably pales beside the first-time insuring of somewhere above 30 million Americans-some of whom will visit psychiatrists for the first time in their lives. The new Health Insurance Exchanges that will start in 2014 and that will serve about 22 million of these people will offer policies that include mental health coverage. That mandate is clear, although the bill, called the Patient Protection and Affordable Care Act (HR 3590), does not specify the breadth of that coverage, except to make clear that Exchange policies must adhere to the Wellstone-Domenici law. That law mandates that insurance policies apply the same deductibles, copays, annual and lifetime limits, and other features equally to physical and mental health coverage.

Nick Meyers, director of government affairs for the American Psychiatric Association (APA), said the bill is “by any standards a huge step forward.” He added, “Between 2008 when the Wellstone-Domenici Act was passed and 2010 and the passage of health care reform, there has been mandated a very, very significant improvement in mental health coverage.” However, he acknowledged that the efforts of the APA and other mental health groups fell short with regard to efforts to get the mental health coverage mandate within Exchange policies applied to policies offered outside the Exchange, particularly to employer policies. “Is the bill everything we wished for,” asked Meyers rhetorically? “No, it is not.”

Another 10 million Americans will become eligible for health insurance and mental health care through the Medicaid program, whose umbrella the Patient Protection Act widened to cover families and individuals with incomes up to 133% of the poverty level.

However, legal challenges threaten those coverage expansions. A number of state attorney generals have filed lawsuits arguing the Patient Protection bill forces new Medicaid coverage mandates on the states without providing them with the funds to pay for that medical care. The state of Virginia has filed a separate lawsuit on a different issue, alleging that the Patient Protection bill’s mandate that all individuals purchase Exchange health insurance policies, or pay a fine, violates the Constitution.

The quick eruption of these 2 legal challenges underlines the fact that the new health coverage for the heretofore uninsured was the big provision in the bill, and the most controversial one too. But there are numerous small provisions, some affecting psychiatrists uniquely, others affecting them along with all other physicians.

In the first category is the provision extending a 5% increase in the payment rate for outpatient psychotherapy in Medicare until the end of calendar year 2010. This 5% increase was instituted in the Medicare Improvements for Patients and Providers Act of 2008. Initially, it was good only for the remainder of calendar year 2008 (the bill passed that July). It was extended by Congress through calendar year 2009. The Patient Protection bill extends the 5% bonus through calendar year 2010.

That is particularly good news for psychiatrists. All physicians have been slated for a baseline 21% reduction in fees in calendar year 2010 because of the Sustainable Growth Rate (SGR) formula Congress imposed years ago. This was intended as a way of calculating year-to-year updates in the conversion factor, the dollar figure that is multiplied against the relative value units (RVUs) for each CPT code, to come up with the Medicare fee for each medical service in a given year. That SGR has yielded negative updates for years, which Congress has then set aside. This year the SGR yielded a 21% reduction in all RVUs. That was scheduled to go into effect on April 1, and hopes that the Patient Protection bill would delay that move and, more important, reform the SGR, were dashed, at least for now.

Coming back to provisions with a psychiatric or mental health tint, there are a number of them in the Patient Protection bill. The bill includes an authorization to create a national network of centers of excellence for the treatment of depressive disorders, which was the brainchild of Sen Debbie Stabenow (D-MI), who introduced that concept last October with her ENHANCED Act (S 1857), which was incorporated into the Patient Protection bill. The Substance Abuse and Mental Health Services Administration (SAMHSA) will be asking for applications from which it will designate up to 30 centers of excellence for depressive disorders. The grants would be made to institutions of higher education or to public or private non-profit research institutions that develop, implement, and disseminate evidence-based interventions that emphasize primary prevention, early intervention, and treatment of, and recovery from, de-pressive disorders. The bill authorizes $100 million for each of the fiscal years 2011 through 2015 and $150 million for each of the fiscal years 2016 through 2020. However, Congress will have to appropriate funds each year as part of the appropriations process for SAMHSA. Given the yawning federal deficit, those annual appropriations may or may not be forthcoming.

Another psychiatric-tinged health care reform provision allocates $75 million over 3 years for a demonstration program that will allow states to apply to the Department of Health and Human Services for federal matching funds to pay for emergen-cy care for Medicaid patients ages 21 through 64 at freestanding psychiatric hospitals. Medicaid does not pay for that coverage at general hospitals or state mental hospitals, nor will it as a result of this provision. The term “emergency medical condition” applies to someone who, in the bill’s words, “expresses suicidal or homicidal thoughts or gestures, if determined dangerous to self or others.”

The good news is that the $75 million will be made available from Medicaid funds; it will not, like the depressions centers, have to be appropriated separately. However, states that apply for funding will have to pay for 25% to 50% of the care of those individuals at the freestanding psychiatric hospitals-of which there are about 250 in this country, according to Mark Covall, President/CEO, National Association of Psychiatric Health Systems. Given the financial stress states are under generally, and their coming obligation to cover people at 133% of the poverty level, many states will not apply for this demonstration program, Covall conceded. However, states are paying 100% for care of this population at state mental hospitals, whereas they would only pay 25% to 50% of the costs at a freestanding hospital under this demonstration.