On March 23, 2010, President Barack Obama signed into law HR 3590, better known as the Patient Protection and Affordable Care Act (PPACA), to enact health care reform across the country. The bill has generated heated debate in regard to the government's role in providing health care coverage (1), with reactions ranging from enthusiasm that the bill facilitates affordable care to concerns that the bill does not lower costs enough or increase the supply of primary care physicians (2).
Important changes in mental health care that are mandated in the PPACA have received less attention. In this Open Forum we raise questions about the effect of state fiscal crises on impending reforms and how conceptualizing health care either as a commodity or as a right has an impact on care for persons with serious mental disorders.
The PPACA mandates that insurance companies cover mental health and substance use disorders. At the state level, the PPACA will stimulate coverage for services by enrolling individuals with mental or substance use disorders in state health insurance exchange programs, resulting in risk pools with and coverage purchased from a network of insurers;
• permitting state plans to provide home and community services to individuals who would otherwise need hospitalization;
• allowing states to seek service and training grants for psychiatric emergencies, child and adolescent conditions, and postpartum depression and psychosis;
• increasing prospective payments to hospitals for inpatient services;
• expanding preventive clinical services through school-based health centers; and
• developing community-based, multidisciplinary teams through state grants for integrating primary care and mental health (3).
The PPACA may expand and improve services for persons with mental illness, but thorny issues remain. First, the PPACA largely relies on states to implement key provisions even as they experience fiscal crises that threaten services. Ongoing shortfalls in state revenue and increasing demand for state services, such as Medicaid, during the recession will lead to nationwide state budget deficits totaling nearly $300 billion between fiscal years 2009 and 2012, which the federal government hopes to partially offset with $87 billion in Medicaid relief that ends in 2011 (4). Nonetheless, states may struggle with early reforms, such as covering childless adults under Medicaid, changing Medicaid drug rebates, providing long-term community care, and establishing high-risk insurance pools until state exchanges become operational in 2014. To worsen matters, state governors who reject federal assistance as reflective of "Washington spending" may prioritize personal politics over public health care and exacerbate the coverage crisis (5). Varying state commitments could consequently widen disparities in services despite the federal government's clear interest in prevention and treatment of mental illness.
Second, the PPACA emerged from a more expansive plan that moved toward universal health care, and perhaps for that reason the law contains elements that favor the two seemingly contradictory positions of health care as a right or as a commodity. Each stance directly affects provision of services. Below, we define and present both sides.
The argument that health care is a commodity proposes that the marketplace govern demand, supply, and the cost of health care, with consumers (patients) rationally selecting options suited to individual needs. Society as a whole benefits as costs decline through market competition, quality improves through competitive advantage, and the types of services offered undergo revision on the basis of allocation of demanded resources. The clearest examples of the PPACA's market-driven reforms are the state insurance exchanges, in which the state essentially creates the marketplace, and the prospective payments to inpatient units, in which hospitals compete for resources on the basis of services.
In contrast, the argument that health care is a right posits that health care is a need and not a choice and that profit motives undermine the physician-patient fiduciary relationship. It also posits that the government should regulate standards of care that could be vulnerable to compromise as insurers attempt to minimize costs and that the government should act to reduce the information asymmetry that precludes patients from behaving as informed consumers. Society as a whole benefits through the health and productivity of all citizens, effective curbs on market greed, and strict regulations on the quality of care. The clearest examples of the PPACA's rights-driven reforms are provisions requiring insurance companies to cover mental and substance use disorders, grants designated for key mental disorders, programs aimed at prevention, and requirements that all individuals whose income is above a certain level purchase insurance.
Provisions in the PPACA hold much promise for coverage of services for persons with serious mental illnesses, but certain elements cause concerns that should be addressed sooner rather than later. For example, the law leaves it up to each state to determine the scope of benefits offered in Medicaid and other state health plans. If health care budgets are subject to fiscal politics now, what protections are in place to ensure that benefits in state-determined plans will remain intact from one year to the next? Also, what external standards ensure that high-quality services will be provided when hospitals and community organizations compete for state grants? In addition, what happens to coverage when people move between states if the states differ in service provisions? By assuming that state marketplaces will maximize coverage, the PPACA leans toward treating health care as a commodity rather than as a right.
Furthermore, commoditized coverage could be reduced for people with the most serious psychiatric disorders. Indeed, the PPACA does not cover about 6% of the nonelderly adult population, including undocumented immigrants (2% of the nonelderly population in 2019), people eligible for Medicaid who do not enroll, and people who opt out of insurance either because it is not affordable or they prefer to pay the cheaper penalty fees (6). Insuring undocumented immigrants may be a highly controversial political battle, which we do not address here. However, if poorer households and younger adults do not enroll because they perceive the costs of insurance to exceed their current disease burden, the Obama Administration may experience setbacks in its preventive focus on substance abuse, early-onset disorders, and women's mental health.
In a broader sense, those who consider health care a commodity rather than a right often overlook discrimination against ill individuals by insurance companies concerned about profits (7). Domestic and international examples of mixed public-private health care systems reveal that private insurers often spend to exclude people with existing conditions and have substantially higher administrative costs than government programs (8). People with mental illness have long faced discrimination in medical and nonmedical spheres of life. Although the PPACA reinforces mental health parity, it is unclear how state exchanges would encourage people with very low incomes and young people to obtain insurance.
Fortunately, remedies exist. We suggest that the Secretary of the Department of Health and Human Services, along with the state directors of Medicare and Medicaid, monitor coverage for persons with mental illness across all states. Benchmarks for coverage and minimum services should be specified, with clear incentives and disincentives outlined. Consequences can also be established, such as requiring states that fail to meet performance goals to take federal loans to meet shortfalls. The distribution of federal aid as loans rather than as grants may allay politicians who worry about the national deficit. Private institutions may have the luxury of cherry-picking patients and services, but when states slash funds for people with mental illness, especially in harsh economic times, it signals an ominous trend.