Au-Yeung, Caroline
Research Fellow

p 612-625-2492
e butle180@umn.edu

New SHADAC Brief Explores National and State Estimates of Gains in Equitable Coverage for Mental Health and Substance Use Disorder under the ACA

A new brief from SHADAC, supported by the California Health Care Foundation (CHCF), examines gains in equitable coverage (i.e., “parity”) for mental health and substance use disorder (MH/SUD) treatment for people in the individual and small-group markets as well as those covered under Medicaid expansion after the passage of the Affordable Care Act (ACA). National and state-level estimates of parity gains for both types of treatment are provided within the brief, and estimates are broken down for the individual market, the small-group market, and the Medicaid expansion population.^[1] These estimates provide important context for policymakers and others engaged in the ongoing debate about repealing, modifying, or replacing the ACA.

Background
Before the ACA, national legislation regarding equitable coverage for MH/SUD treatments applied only to large-group (i.e., employer-sponsored) health plans, as a result of the Mental Health Parity Act of 1996 (MHPA) and the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The ACA extended these MH/SUD parity protections beyond the large-group market to the individual and small-group markets and to Medicaid expansion beneficiaries by making MH/SUD treatments an essential health benefit (EHB). Before this change, coverage and parity for MH/ SUD treatment in these markets were addressed unevenly across states through a patchwork of state laws.

Expanding Equitable Coverage of Mental Health and Substance Use Disorder Treatment under the ACA: Key Provisions

Findings
Mental Health
In total, an estimated 39 million individuals nationwide had health insurance that was subject to the ACA’s expanded MH parity requirements as of 2017. Of these, 12.1 million were enrolled in individual plans, 14.4 million were enrolled in small-group plans, and almost 13 million were newly eligible Medicaid expansion enrollees.

At the state level, California saw the greatest number of individuals affected at approximately 8.6 million. Other states that had high estimates of affected populations included New York with 2.1 million, Florida with 2.08 million*, Texas with 1.9 million*, and Pennsylvania with 1.87 million.

Vermont, which had pre-ACA parity in both the individual and small-group market and had expanded Medicaid in advance of the ACA, was the only state that saw no effect. Other states such as Wyoming*, Alaska, and Delaware, all had affected populations of less than 100,000 (44,000; 67,000; and 80,000, respectively).

Substance Use Disorder
In total, an estimated 36.4 million individuals nationwide had health insurance that was subject to the ACA’s expanded SUD parity requirements as of 2017. Of these, 9.8 million were enrolled in individual plans, 14 million were enrolled in small-group plans, and almost 12 million were newly eligible Medicaid expansion enrollees.

At the state level, California saw the greatest number of individuals affected at approximately 8.26 million, followed by New York (2.09 million), Florida* (1.79 million), Pennsylvania (1.79 million) and Texas* (1.7 million).

Massachusetts, which had pre-ACA parity in both the individual and small-group market and had expanded Medicaid in advance of the ACA, was the only state that saw no effect. Other states such as Delaware, Wyoming*, Maine*, and Alaska all had affected populations of less than 100,000 (12,000; 39,000; 52,000; and 64,000, respectively).

Discussion
Though the ACA mandated access to health insurance coverage with parity for treatment of mental health and substance use disorders for new groups, it is important to note that the expansion of coverage parity legislation does not guarantee access to equitable MH/SUD services unless the legislation is enforced. Responsibility for parity enforcement falls primarily to states, and the nature and extent of enforcement is consequently inconsistent across the country, with many parity violations continuing to occur as state regulators face limitations in their enforcement capacities.

Further Reading
Access and Cost Barriers to Mental Health Care, by Insurance Status, 1999-2010
Kathleen Rowan, Donna McAlpine, and Lynn Blewett

Section 1115 Waivers and ACA Medicaid Expansions: A Review of Policies and Evidence from Five States: May 2016
SHADAC Special Issue Brief

Medicaid Expansion: Comparing State Choices in Alternative Benefit Plan Design
Colin Planalp

To learn more about mental health and state-level estimates for the affected population who report mentally unhealthy days, see our recent blog post, and visit State Health Compare to learn more about the measure and its data sources.

Mental Health and Substance Use Disorder Parity under the ACA: National and State Estimates of Parity Gains as of 2017

July 2019:

In addition to expanding access to health insurance coverage for millions of Americans through subsidized individual market coverage and state Medicaid expansions, the federal Affordable Care Act (ACA) applied Mental Health (MH) and Substance Use Disorder (SUD) coverage and parity mandates to beneficiaries in the individual and small-group markets and to Medicaid expansion beneficiaries. The following brief details the mechanisms by which the ACA applied these mandates and presents national and state-level estimates of the number of people with insurance coverage that must newly provide MH/SUD parity under the ACA. These estimates provide important context for policymakers and others engaged in the ongoing debate about repealing, modifying, or replacing the ACA.  

Background
Before the ACA, national legislation regarding equitable coverage for MH/SUD treatments applied only to large-group (i.e., employer-sponsored) health plans, as a result of the Mental Health Parity Act of 1996 (MHPA) and the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The ACA extended these MH/SUD parity protections beyond the large-group market to the individual and small-group markets and to Medicaid expansion beneficiaries by making MH/SUD treatments an essential health benefit (EHB). Before this change, coverage and parity for MH/ SUD treatment in these markets were addressed unevenly across states through a patchwork of state laws.

Expanding Equitable Coverage of Mental Health and Substance Use Disorder Treatment under the ACA: Key Provisions

 

 

 

 

Findings
Mental Health
In total, an estimated 39 million individuals nationwide had health insurance that was subject to the ACA’s expanded MH parity requirements as of 2017. Of these, 12.1 million were enrolled in individual plans, 14.4 million were enrolled in small-group plans, and almost 13 million were newly eligible Medicaid expansion enrollees.

At the state level, California saw the greatest number of individuals affected at approximately 8.6 million. Other states that had high estimates of affected populations included New York with 2.1 million, Florida with 2.08 million*, Texas with 1.9 million*, and Pennsylvania with 1.87 million.

Vermont, which had pre-ACA parity in both the individual and small-group market and had expanded Medicaid in advance of the ACA, was the only state that saw no effect. Other states such as Wyoming*, Alaska, and Delaware, all had affected populations of less than 100,000 (44,000; 67,000; and 80,000, respectively).

Substance Use Disorder
In total, an estimated 36.4 million individuals nationwide had health insurance that was subject to the ACA’s expanded SUD parity requirements as of 2017. Of these, 9.8 million were enrolled in individual plans, 14 million were enrolled in small-group plans, and almost 12 million were newly eligible Medicaid expansion enrollees.

At the state level, California saw the greatest number of individuals affected at approximately 8.26 million, followed by New York (2.09 million), Florida* (1.79 million), Pennsylvania (1.79 million) and Texas* (1.7 million).

Massachusetts, which had pre-ACA parity in both the individual and small-group market and had expanded Medicaid in advance of the ACA, was the only state that saw no effect. Other states such as Delaware, Wyoming*, Maine*, and Alaska all had affected populations of less than 100,000 (12,000; 39,000; 52,000; and 64,000, respectively).

Discussion
Though the ACA mandated access to health insurance coverage with parity for treatment of mental health and substance use disorders for new groups, it is important to note that the expansion of coverage parity legislation does not guarantee access to equitable MH/SUD services unless the legislation is enforced. Responsibility for parity enforcement falls primarily to states, and the nature and extent of enforcement is consequently inconsistent across the country, with many parity violations continuing to occur as state regulators face limitations in their enforcement capacities.

Further Reading
Access and Cost Barriers to Mental Health Care, by Insurance Status, 1999-2010
Kathleen Rowan, Donna McAlpine, and Lynn Blewett

Section 1115 Waivers and ACA Medicaid Expansions: A Review of Policies and Evidence from Five States: May 2016
SHADAC Special Issue Brief

Medicaid Expansion: Comparing State Choices in Alternative Benefit Plan Design
Colin Planalp

To learn more about mental health and state-level estimates for the affected population who report mentally unhealthy days, see our recent blog post, and visit State Health Compare to learn more about the measure and its data sources.

 

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[1] National estimates do not include a Medicaid expansion breakdown because expansion has only occurred at the state level.

* No Medicaid expansion

Hest, Robert
Senior Research Fellow

p 612-624-5507
e hestx005@umn.edu

Measuring Health Care Affordability with State Health Compare: Trouble Paying Medical Bills

The cost of health care continues to grow nationwide, with U.S. health care spending reaching $3.5 trillion, or an average of $10,739 per person, in 2017.^[1] As these expenditures have grown, the cost of health insurance has grown as well, such that Americans are increasingly enrolling in health plans with large deductibles and other cost sharing in order to avoid the expense of rising premiums. Rising enrollment in these health plans, combined with the ongoing problem of “surprise medical bills” (bills from providers who are out of network unbeknownst to consumers) across all plan types, has increased the health care cost burden for many Americans and has drawn increasing attention to the affordability of health care for consumers.^[2]

Exploring Health Care Affordability at the State Level with State Health Compare

SHADAC’s State Health Compare includes a measure “Had Trouble Paying Medical Bills” that assesses changes and patterns in health care affordability across the country by tracking the percent of Americans that had difficulty paying off medical bills or that were paying off medical bills over time. The measure is available at both the state and national level for 2011-2016 and can be broken down by age and insurance coverage type.

This post highlights states that experienced changes in the percent of residents by age that had trouble paying medical bills between 2015 and 2016 and shows the substantial amount of variation across states on this measure.

Trouble paying medical bills among the states, 2015-2016: Some rate increases, no decreases

Nationally, the percent of nonelderly adults (age 19-64) reporting trouble paying medical bills increased from 29.2% in 2015 to 31.3% in 2016 (2.1 points). This pattern was mirrored among children (age 0-18), who experienced an increase of 2.8 points, from 32.5% in 2015 to 35.3% in 2016.

Eight states experienced statistically significant increases in the share of nonelderly adults reporting trouble paying medical bills between 2015 and 2016, as shown below. Montana had the largest increase at 11.4 points (from 28.0% in 2015 to 39.4% in 2016), followed by Nevada at 10.4 points (from 18.2% to 26.8%), and New Hampshire at 7.4 points (from 26.8% to 34.2%). No state experienced a statistically significant decrease in the percent of non-elderly adults reporting trouble paying medical bills.

Among children, four states saw significant increases in the share reporting trouble paying medical bills, also shown below. The largest of these increases was in Arkansas, which experienced a rise of 18.0 points from 30.2% to 48.2% between 2015 and 2016. No state saw a significant decrease in the percent of children whose family reported trouble paying medical bills.

Among elderly adults (65+), only Alabama and Montana experienced significant increases in the share reporting trouble paying medical bills. Those states saw increases of 8.4 and 7.1 percentage points, respectively. No state saw a significant decrease in the percent of elderly adults reporting trouble paying medical bills.

2016: Large variation across states in percent with trouble paying medical bills

As shown below, there was substantial variation across states in 2016 in the percent that had trouble paying medical bills among nonelderly adults, children, and elderly adults. In general, states with median incomes registering below the national median^[3] tend to have higher shares of residents reporting trouble paying medical bills, regardless of age group, and vice versa.

The percent of nonelderly adults who had trouble paying medical bills ranged from 13.3% in the District of Columbia to 49.0% in Mississippi (a difference of 35.7 points); the percent of children in families that had trouble paying medical bills ranged from 20.6% in New York to 57.8% in Wyoming (a difference of 37.2 points); and the percent of elderly adults who had trouble paying medical bills ranged from 9.6% in New York to 24.2% in Mississippi (a difference of 14.6 points).

Percent That Had Trouble Paying Medical Bills by State, 2016

Nonelderly Adults (Age 19-64)

Children (Age 0-18)

Elderly Adults (Age 65+)

Notes and Definitions

“Had Trouble Paying Medical Bills” is defined as the rate of individuals that had trouble paying off medical bills during past twelve months or were currently paying off medical bills among the civilian non-institutionalized population.

The source of the estimates is SHADAC analysis of NHIS data, National Center for Health Statistics (NCHS). The NHIS sample is drawn from the Integrated Health Interview Survey (IHIS, MN Population Center and SHADAC). Data were analyzed at the University of Minnesota's Census Research Data Center because state identifiers were needed to produce results and these variables were restricted.

Estimates were created using the NHIS survey weights, which are calibrated to the total U.S. Civilian non-institutionalized population for estimates broken down by age, and to the civilian non-institutionalized population age 18 to 64 for estimates broken down by coverage type.

Though SHADAC goes to great effort to produce as many state-level estimates as possible for our measures, due to sample size restrictions many state estimates of this measure are suppressed when broken down by subgroup. Namely, estimates are suppressed if the number of sample cases was too small or the estimate had a relative standard error greater than 30 percent.

Other State Health Compare estimates that use data from the NHIS

Had Trouble Paying Medical Bills is one of eight State Health Compare measures that SHADAC produces using data from the NHIS listed below. State Health Compare is the only source for state-level estimates of these measures.

• Made Changes to Medical Drugs
• Trouble Paying Medical Bills
• No Trouble Finding Doctor
• Told that Provider Accepts Insurance
• Had Usual Source of Medical Care
• Had General Doctor or Provider Visit
• Had Emergency Department Visit
• Spent the Night in a Hospital