King v. Parity
Sometime between Thursday and next Monday, the U.S. Supreme Court will issue its decision in what could be the final legal challenge to the Affordable Care Act. Pundits, politicians and legal scholars are holding their collective breath as we wait to find out if the Court will strike down the federal subsidies that help millions of Americans purchase health insurance from healthcare.gov.
But I’m on the edge of my seat for a different reason. Because there’s something else at stake in King v. Burwell, something no one is talking about.
Health policy experts have covered at length why the loss of subsidies could result in 6.4 million Americans losing access to affordable coverage. If the Court rules against the ACA, I have no doubt that Congress and the states will figure out how to address their constituents’ loss of coverage in some way, shape or form. With an election year fast approaching, not to act would be politically disastrous.
The question weighing on my mind is: what will that coverage look like? And will it include the mental health and addiction parity protections that were embedded throughout the ACA?
Prior to the ACA, consumers with pre-existing conditions could be denied insurance, or offered coverage that excluded the key services they needed to manage their health. This was especially problematic for Americans living with addiction or mental health conditions because so many plans either didn’t cover those services or imposed such burdensome restrictions that it was nearly impossible for consumers to access needed care. This lack of access to adequate health insurance contributes to the average seven-year lag time between first onset of symptoms and initiation of treatment. Without access to comprehensive, affordable care, people living with serious mental health and addiction conditions may experience major deterioration of their health, irreversible cognitive declines (often leading to disability), loss of employment, incarceration, homelessness, and more. Many of these could be prevented with timely, comprehensive treatment – something that has traditionally not been available through most commercial insurance products.
Our nation’s long march toward parity began with the passage of a limited Mental Health Parity Act in 1996, dealing with lifetime and annual benefit caps under employer-sponsored plans. It continued in 2008, when the Mental Health Parity and Addictions Equity Act imposed broader parity requirements on most large group health plans and Medicaid managed care plans. With the passage of the Affordable Care Act in 2010 (and the subsequent implementing regulations), comprehensive parity protections now extend to Americans insured through group plans, individual plans, Medicaid managed care and the Medicaid expansion.
Parity has ushered in a new era for behavioral health care. The vision of parity is a simple one: that all individuals will be able to access the services they need, when they need them. But all of this could be at risk if the Supreme Court decides in favor of the plaintiffs in King v. Burwell this month.
Among the options on the table if the federal exchange falls are a number of proposals that would permit states to launch and regulate their own ACA-like marketplaces – without the consumer protections embodied in the health law. Without the ACA’s parity protections, millions of Americans could suddenly find themselves subject to a patchwork of widely variable state parity laws. These laws differ substantially in terms of what types of benefits they cover, which types of plans are affected, and what coverage standards are required. Before the advent of national parity standards, depending on where you lived, you might find that parity applied only if you had a certain type of condition, or only if you were enrolled in the state employee benefit plan. Some states’ concept of “parity” is so limited, it hardly merits the name. And two states had no parity laws on the books at all.
Consumers should not be at the mercy of geographic happenstance when it comes to their ability to access needed mental health and addiction care. King v. Burwell is a turning point in the evolution of our nation’s health care system not just because of the massive loss of coverage that could result, but because it could set us back years on our path towards ensuring that all Americans have equal access to mental health and addiction care. For their sake – and for their families, friends, neighbors and communities – I hope the Court will rule to uphold the federal exchange subsidies.