All the months that Teresa McConnell went without treatment for depression, she basically was homebound.
"I could barely go to the store," said the 50-year-old Irondequoit woman, who also has a disability. "I didn't want to be around people."
Health benefits from her former job had run out, and she said she was going broke trying to cover the cost of medication. Your whole world is totally different. Without treatment, therapy and medication, you live in a depression. There's no help for you. It's just a sad world. It's lonely."
The Patient Protection and Affordable Care Act is supposed to fix that problem by putting mental health on par with physical health. Mental health and substance abuse disorders together are one of the 10 essential benefits required in new individual and small group plans.
Starting in 2014, those plans have to cover your broken heart just as they would your broken leg. Under the copious regulations, co-payments, co-insurance and other forms of cost-sharing have to be the same for mental health services as for medical/surgical care. The number of visits also has to be equal.
Nationally, one in four adults experiences a mental health disorder in a given year. Among 13- to 18-year-olds, one in five has a serious mental health condition in a particular year, according to the National Alliance on Mental Illness. "This is a disease like everything else," said McConnell, who signed up for a plan but had received free help through the mental health clinic at Spiritus Christi Church. "It needs to be insured."
As with other insurance provisions, some in the field have expressed concern about being able to meet demand. Having mental health among the essential benefits is meant to expand access and further reduce the stigma associated with mental illness.
"You don't want to live in your mind," McConnell said. "Being depressed and stressed out and anxious is not a good place to be."
New Yorkers are somewhat familiar with mental health parity because of Timothy's Law. The legislation took effect in 2007 and required group plans that offered inpatient benefits to cover in- and outpatient mental health services for children and adults.
Now the ACA is broadening the idea and taking it nationwide by requiring every individual and small group plan to cover services for the 10 essential benefits.
But the law doesn't impose a cookie-cutter approach. The way in which plans cover essential benefits can vary by state because each one sets its own benchmark. In New York, there is no limit on inpatient or outpatient services for mental/behavioral health or substance abuse. But plans may not be required to cover all types of mental health services or conditions, according to the National Alliance on Mental Illness. Drug plans also may vary.
However, large employers who self-insure don't have to offer all of the essential benefits, such as mental health. If they do, they must comply with the law, according to Tom Flynn in the Rochester office of Mercer, a global human resources firm. Because mental illness treatments can take time, some proponents of parity questioned whether the law truly put mental health on the same level as physical health.
"We're talking co-pay parity," said Christine Wagner, executive director of St. Joseph's Neighborhood Center. "But I'm not sure we're talking diagnosis treatment parity."
Wagner cited the chronic physical condition of diabetes. She said many patients eventually can cut back on office visits.
"If you have a diagnosis of depression, that requires weekly or biweekly visits for six months. Even for some depressions that are short term, you're talking a whole lot more money than people can afford. … There's still a point at which people make the 'can I afford it or not' decision."
Chris Etsler, director of Patient Financial Services at Unity Health System, acknowledged that cost for a mental health diagnosis can add up quickly. She said that rules limiting out of pocket expenses should help ease some of the financial stress. However, that maximum can vary based on policies at the bronze, silver, gold or platinum level.
"The challenge is how do we educate people on what their options are and so they make the best determination," said Kimberly Knapp, director of mental health services for Unity Behavioral Health.
John Tauriello, counsel of the state Office of Mental Health, said the ACA's expansion of mental health coverage can provide early treatment that potentially can prevent lifetime involvement in the mental health system.
As with other insurance provisions of the ACA, some people have expressed concern about whether the health care system can handle the influx.
NY State of Health requires plans to have a "robust" network of mental and behavioral health providers. Lisa Sbrana, counsel for NY State of Health, didn't define "robust."
She said her agency performs quarterly reviews of networks to make sure there are adequate numbers of providers for the estimated number of people expected to use the services per county. "There's not an exact ratio. The plan has to show that if there are 1,000 people coming in, they can meet the needs of those folks."
Monroe County has a rate of 31 mental health counselors per 100,000 residents, according to a 2013 report by the Center for Health Workforce Studies at the University of Albany's School of Public Health. There were 27 psychiatrists, 42 psychologists and 217 social workers (some of whom do mental health counseling) per 100,000.
Elisa DeJesus, vice president of the Family Services Division of the Ibero-American Action League, questioned whether there were enough providers, particularly for minorities.
DeJesus said Ibero had not done a study on the number of culturally competent providers. State officials say that plans are required to have interpreters, but DeJesus went further.
"Behavioral health issues are very difficult. Things you talk about with people you don't know. You feel more comfortable if you see there are people that understand your culture."
Full equality between mental and physical health may rest with another aspect of Obamacare — reimbursement reform.
Dr. Eric Caine, chairman of the Department of Psychiatry at the University of Rochester School of Medicine and Dentistry, said that as payment shifts from fee for service to rewards for quality, mental health becomes more important.
"If someone's got diabetes and depression or heart disease and depression, it's very clear now that if you don't treat the depression effectively, you're not going to be able to treat the diabetes or the heart disease effectively."
PSINGER@DemocratandChronicle.com
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