Wednesday, January 18, 2017

Making America Suffer Again

In December 2015, Mary Giliberti, CEO of the National Alliance on Mental Illness, wrote a call to action. Her message was to those “who believe in the importance of mental health services and supports” to be better advocates for mental health reform in 2016. The year just ended, but I’d like to answer that call.

Since 2009, Republicans have waged a ceaseless war on President Obama’s signature policy achievement, the Affordable Care Act (a.k.a. Obamacare). So far, all efforts to repeal the law have been unsuccessful because President Obama currently occupies the White House. But that will soon no longer be the case. It’s probably safe to say that Obamacare is toast.

That’s truly a shame, and not just because millions of Americans will needlessly suffer without health insurance. Repealing Obamacare will have overwhelmingly negative effects on many groups of people, but one group that will be disproportionately punished is the mentally ill. That’s because repealing Obamacare is very bad mental health policy, and even worse economics.

On mental health policy, Obamacare represents the largest expansion of mental health and substance abuse services in a generation. It also encourages greater coordination and integration of mental and physical health services, expands health insurance coverage to more people with mental disorders, and improves mental health coverage and access to care. While Obamacare is far from an elixir, never before has a piece of federal legislation addressed mental health policy on such a comprehensive scale.

Lest you think these investments aren’t all that necessary to begin with, consider the following: according to the National Institute of Mental Health, approximately 1 in 5 American adults suffer from mental illness, 1 in 25 suffer from a severe mental illness, and 1 in 5 American children will suffer from a severe mental illness at some point in their lives. Approximately 10 percent of American adults either live with schizophrenia, bipolar disorder, or had at least one major depressive episode this past year. In 2010, the Global Burden of Disease study found that mental disorders were the leading cause of years lived with disability (23%), accounting for approximately 7.4 percent of disability-adjusted life years (DALYs) (DALYs measure lost years of disability-free life).

One of the main ways Obamacare works to address these troubling statistics is by giving teeth to the federal mental health parity law established by the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. Historically, health insurers have had an incentive to avoid enrolling people with mental health issues because they tend to cost more. That’s because people with mental disorders typically use both mental and physical health care services more than the average person. So many insurers discouraged the mentally ill from enrolling in their plans by charging them higher premiums or imposing higher cost-sharing requirements (e.g., deductibles, copayments, or coinsurance) for mental health services.

In response, Congress passed the MHPAEA, which requires that physical and mental health care services have equivalent cost-sharing requirements in health insurance plans. The problem is, many insurers easily side-stepped the law by simply not offering mental health coverage at all. Obamacare rectifies this by classifying mental health and substance abuse treatment as one of the ten “essential health benefits” that insurers are required to cover. Of course, repealing Obamacare means we’re right back to square one.

And that brings me to the economics.

Mental health parity laws are fundamentally important from a policy and humanitarian perspective, but they also have considerable economic benefits. For example, recent evidence from economist Martin Andersen suggests that parity laws may improve the wages and hours worked of moderately distressed individuals. This is consistent with the previous findings of economist Matthew Lang, who shows that parity laws are effective at combating the effects of depression, and Ernst Berndt and his colleagues, who show that those treated for clinical depression are more productive on-the-job.

Given this evidence, it’s not all that surprising that independent studies conclude that failing to adequately address mental health issues has a profoundly negative impact on economic growth. Indeed, a recent report by the World Economic Forum and the Harvard School of Public Health ranked mental health conditions as the top driver of lost economic output (35%) among all non-communicable diseases. This means that failing to address mental illness comes at incredible economic cost—more so than cardiovascular diseases, and more so than cancer, chronic respiratory diseases, and diabetes combined.

In summary, then, repealing Obamacare would do a lot of irreparable harm to a lot of people, particularly the mentally ill. Even simple economics says it shouldn’t happen. Yet here we are.

There are some who say that Republicans will never go through with this, that repealing Obamacare simply wreaks too much havoc. For the country’s sake, I hope they’re right.

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