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Double-edged sword of federalism: variation in essential health benefits for mental health and substance use disorder coverage in states

Published online by Cambridge University Press:  06 January 2020

Charley E. Willison Open the ORCID record for Charley E. Willison [Opens in a new window] ,
Phillip M. Singer Open the ORCID record for Phillip M. Singer [Opens in a new window]  and
Kyle L. Grazier
Charley E. Willison*
Affiliation:
Department of Health Care Policy, Harvard University, 180A Longwood Avenue, Boston, MA02115, USA
Phillip M. Singer
Affiliation:
Department of Political Science, University of Utah, 260 South Central Campus Drive, Salt Lake City, UT84112, USA
Kyle L. Grazier
Affiliation:
Department of Health Management and Policy, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI48109, USA
*
*Corresponding author. Email: willison@hcp.med.harvard.edu
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Abstract

The Affordable Care Act requires all insurance plans sold on health insurance marketplaces and individual and small-group plans to cover 10 Essential Health Benefits (EHB), including behavioral health services. Instead of applying a uniform EHB plan design, the Department of Health and Human Services let states define their own EHB plan. This approach was seen as the best balance between flexibility and comprehensiveness, and assumed there would be little state-to-state variation. Limited federal oversight runs the risk of variation in EHB coverage definitions and requirements, as well as potential divergence from standardized medical guidelines. We analyzed 112 EHB documents from all states for behavioral health coverage in effect from 2012 to 2017. We find wide variation among states in their EHB plan required-coverage, and divergence between medical-practice guidelines and EHB plans. These results emphasize consideration of federated regulation over health insurance coverage standards. Federal flexibility in states benefit design nods to state-specific policymaking-processes and population needs. However, flexibility becomes problematic if it leads to inadequate coverage that reduces access to critical health care services. The EHBs demonstrate an incomplete effort to establish appropriate minimum standards of coverage for behavioral health services.

Keywords

Behavioral healthfederalismhealth care reformpolitics
Type
Article
Information
Health Economics, Policy and Law , Volume 16 , Issue 2 , April 2021 , pp. 170 - 182
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Copyright
Copyright © Cambridge University Press 2020

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References

Agency for Health care Research and Quality (1993) Depression in Primary Care, Vol 2: Treatment of Major Depression. Rockville, MD: Department of Health and Human Services Public Health Service Agency for Health Care Policy and Research.Google Scholar
Alexandre, PK, Martins, SS and Richard, P (2009) Disparities in adequate mental health care for past-year major depressive episodes among Caucasian and Hispanic youths. Psychiatric Services 60, 1365–1371.CrossRefGoogle ScholarPubMed
Bagley, N and Levy, H (2014) Essential health benefits and the affordable care act: law and process. Journal of Health Politics, Policy and Law 39, p. 3. Available from: https://www-ncbi-nlm-nih-gov.proxy.lib.umich.edu/pmc/articles/PMC4116669/pdf/nihms600749.pdfCrossRefGoogle ScholarPubMed
Barnett, PG and Swindle, RW (1997) Cost-effectiveness of inpatient substance abuse treatment. Health Services Research 32, 615–629. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9402904.Google ScholarPubMed
Barry, CL (2006) The political evolution of mental health parity. Harvard Review of Psychiatry 14, 185–194. doi: 10.1080/10673220600883168CrossRefGoogle ScholarPubMed
Brunette, M, Drake, RE, Woods, M and Hartnett, T (2001) A comparison of long-term and short-term residential treatment programs for dual diagnosis patients. Psychiatric Services 52, 526–528.CrossRefGoogle ScholarPubMed
Buchmueller, TC, Cooper, PF, Jacobson, M and Zuvekas, SH (2007) Parity for whom? Exemptions and the extent of state mental health parity legislation. Health Affairs (Project Hope) 26, w483–w487. doi: 10.1377/hlthaff.26.4.w483.CrossRefGoogle ScholarPubMed
Cauchi, R (2015) Mental Health Benefits: State Laws Mandating or Regulating. http://www.ncsl.org/research/health/mental-health-benefits-state-mandates.aspx.Google Scholar
Center for Consumer Information and Insurance Oversight (2011) Essential Health Benefits Bulletin. Vol. December. Washington, DC: Centers for Medicaid and Medicare Services.Google Scholar
Centers for Medicare and Medicaid Services (2018) Trump Administration Announces State Relief and Empowerment Waivers to Give States the Flexibility to Lower Premiums and Increase Choices for Their Health Insurance Markets. CMS.Gov Newsroom. https://www.cms.gov/newsroom/press-releases/trump-administration-announces-state-relief-and-empowerment-waivers-give-states-flexibility-lower.Google Scholar
Gelenberg, AJ, Freeman, MP, Markowitz, JC, Rosenbaum, JF, Thase, ME, Trivedi, MH and Van Rhoads, RS (2010) Practice Guideline for the Treatment of Patients With Major Depressive Disorder. American Psychiatric Association Practice Guidelines Committee. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf.Google Scholar
Giovannelli, J, Lucia, K and Corlette, S (2014) Realizing Health Reforms Potential. The Commonwealth Fund, no. Oct: 1–2. http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2014/oct/1783_giovannelli_implementing_aca_essential_hlt_benefits_rb.pdf.Google Scholar
Grace, BAM, Noonan, KG, Cheng, TL, Miller, D, Verga, B and Rubin, D (2014) The ACA's pediatric essential health benefit has resulted in a state-by-state patchwork of coverage with exclusions. Health Affairs 33, 2136–2143. Available from: https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2014.0743.CrossRefGoogle Scholar
Haeder, SF (2014) Balancing adequacy and affordability? Essential health benefits under the affordable care act. Health Policy 118, 285.CrossRefGoogle ScholarPubMed
Health Policy Brief: Essential Health Benefits (2013) Health Affairs May 2nd. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=91.Google Scholar
Institute of Medicine (2006) Improving the Quality of Health Care for Mental and Substance-Use Condition: Quality Chasm Series. Washington, DC: National Academy Press.Google Scholar
Institute of Medicine Committee on Quality of Health Care in America (2001) Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy of Sciences. http://books.nap.edu/catalog/10027.html.Google Scholar
Klein, RW (2009) The insurance industry and its regulation: an overview. In Grace, MF and Klein, RW (eds), The Future of Insurance Regulation in the United States. Washington, DC: Brookings Institution Press, pp. 13–51.Google Scholar
Levitis, J (2017) Changes to State Innovation Waivers in the Senate Health Bill Undermine Coverage and Open the Door to Misuse of Federal Funds. Brookings Institute. https://www.brookings.edu/blog/up-front/2017/06/23/changes-to-state-innovation-waivers-in-the-senate-health-bill-undermine-coverage-and-open-the-door-to-misuse-of-federal-funds/.Google Scholar
National Conference of State Legislatures (2014) State Health Insurance Mandates and the ACA Essential Benefits Provisions. http://www.ncsl.org/research/health/state-ins-mandates-and-aca-essential-benefits.aspx.Google Scholar
Oberlander, J (2017) Repeal, Replace, Repair, Retreat – Republicans’ Health Care Quagmire. New England Journal of Medicine 377, 1001–1003. doi: 10.1056/NEJMp1710391.CrossRefGoogle ScholarPubMed
O'Brien, WB and Perfas, FB (2004) The therapeutic community. In Lowinson, JH, Ruiz, P, Millman, RB and Langrod, JC (eds), Substance Abuse: A Comprehensive Textbook. Baltimore, MD: Lippincott Williams and Wilkins, pp. 609–615.Google Scholar
Olmstead, T and Sindelar, JL (2004) To what extent are key services offered in treatment programs for special populations? Journal of Substance Abuse Treatment 27, 9–15. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15223088CrossRefGoogle ScholarPubMed
Peterson, K, Swindle, R, Phibbs, C, Recine, B and Moos, R (1994) Determinants of readmission following inpatient substance abuse treatment: a national study of VA programs. Medical Care 32, 535–550.CrossRefGoogle ScholarPubMed
Powers, EJ, Nishimi, RY and Kizer, KW (2005) Evidence-Based Treatment Practices for Substance Use Disorders. http://www.apa.org/divisions/div50/doc/Evidence_-_Based_Treatment_Practices_for_Substance_Use_Disorders.pdf.Google Scholar
Reif, S, George, P, Braude, L, Doughtery, R, Daniels, A, and Ghose, S (2014) Residential treatment for individuals with substance use disorders: assessing the evidence. Psychiatric Services 65, 301–312.CrossRefGoogle ScholarPubMed
Schoen, C and Doty, (2011) Affordable care act reforms could reduce the number of underinsured US adults by 70 percent. Health Affairs 30, 1762–1771.CrossRefGoogle ScholarPubMed
Singer, PM (2017) States of Reform: Polarization, Long-term Services and Supports, and Medicaid Waivers. Available from: http://journals.sagepub.com.proxy.lib.umich.edu/doi/pdf/10.1177/0160323X17699526.Google Scholar
State Associations of Addiction Services (2013) Residential Treatment of Substance Use Disorders: Practice Committee Consensus Report. http://www.saasnet.org/PDF/SAAS_Consensus_Report_Residential_Treatment_0413.pdf.Google Scholar
Substance Abuse and Mental Health Service Administration (2013 a) Mental Health Parity and Addiction Equity Act. Accessed November 10. http://beta.samhsa.gov/health-reform/parity.Google Scholar
Substance Abuse and Mental Health Service Administration (2013 b) Mental Health Parity and Addiction Equity Act. http://beta.samhsa.gov/health-reform/parity.Google Scholar
The Center for Consumer Information & Insurance Oversight (2015 a) Essential Health Benefits Standards: Ensuring Quality, Affordable Coverage. https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/ehb-2-20-2013.html.Google Scholar
The Center for Consumer Information and Insurance Oversight (2015b) Additional Information on Proposed State Essential Health Benefit Benchmark Plans. Centers for Medicare and Medicaid Services. Accessed December 1. http://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.htmil.Google Scholar
The Center for Consumer Information & Insurance Oversight (2016) The Mental Health Parity and Addiction Equity Act. Accessed March 1. https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet.html.Google Scholar
The National Center on Addiction and Substance (2016) Uncovering Coverage Gaps: A Review of Addiction Benefits in ACA Plans.Google Scholar
U.S. Census Bureau (2013) Current Population Survey 2000–2013 Annual Social and Economic Supplements. http://www.census.gov/hhes/www/hlthins/.Google Scholar
United Nations Office on Drugs and Crime (2002) Contemporary Drug Abuse Treatment: A Review of the Evidence. New York. https://www.unodc.org/docs/treatment/Review_E.pdf.Google Scholar
Wang, P, Delmer, O and Kessler, R (2002) Adequacy of treatment for serious mental illness in the United States. American Journal of Public Health 92, 92–98.CrossRefGoogle ScholarPubMed
Weiner, J and Colameco, C (2014) Essential Health Benefits: 50-State Variations on a Theme. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf416179.Google Scholar
Willison, C and Singer, P (2017) Repealing the affordable care act essential health benefits: threats and obstacles. American Journal of Public Health 107, 1225–1226.CrossRefGoogle ScholarPubMed
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