Yesterday, the U.S. electorate cast their votes in the 2014 Midterm elections. Elections, of course, mean course correction in the direction of US politics. Sometimes this correction is minor, but yesterday’s midterm elections cast a long shadow over mental health care in the United States.

I will not discuss all the minutia of the recent changes to healthcare legislation. However, a series of changes that began under President Bush, and accelerated under President Obama, have laid the groundwork for a very different, and much improved, system of care for mental and behavioral health. Let’s review:

Improved Coverage

First, tucked away in the 2008 stimulus package (Troubled Asset Relief Program or TARP) was a major update to the  Mental Health Parity Act the so-called Mental Health Parity and Addiction Equity Act. This piece of legislation mandated that any health insurance coverage for mental health and substance abuse issues must at least be as complete as coverage for surgical procedures. This law was a direct response to a number of insurance policies including coverage for these issues so scant, that it was virtually nonexistent, thereby making mental health care unattainable for a multitude of Americans.

Second, a key provision of  the 2010 Patient Protection and Affordable Care Act (aka “Obamacare”) mandated that any policy that was to be included in the health insurance exchanges include coverage for mental health care. Building on the Parity Act, this act added adequate coverage for mental health issues for estimated 62 million Americans. While this was a monumental improvement in access to care, it still does not illustrate the full scope of progress.

Value-based Care and Mental Health

Also included in “Obamacare” was a change in healthcare funding from fee-for-service to the so-called value-based purchase model. This change came along with other measures focused on improving care effectiveness, such as the Hospital Readmission Reduction Program (HRRP).

In the traditional payment model, every action in healthcare had a price, and the cost of a patient’s path through the system was the tally of these different actions. This seemed fair. After all, the billable actions were likely performed by humans, whose time needed compensation, and likely used some expensive tool or drug with its own cost. However, it neither included incentives for effective care delivery, nor for ensuring that the care actually improved the patient’s condition. Sure, doctors want to help patients, but the healthcare system’s financial structure was not aligned with outcome improvement.

Value-based purchasing, which pays care providers for improving key metrics; bundled payments, where a fixed fee is paid for a full care episode (e.g. from taking in a pregnant mother in labor to releasing her and her newborn child from care); and other provisions all share one common aspect: they reward hospitals for improving the effectiveness of their care provision and punish those that don’t.

Now, I just spent a few paragraphs talking about medical care delivery, but these provisions have profound effects on the role of mental and behavioral health within medical care. See, one-in-three medical patients have a co-occurring mental or behavioral health condition. The startling fact is that those with co-occurring mental and medical conditions cost the system 65% more than patients without and are 32% more likely to be re-hospitalized. A flareup in depressive symptoms often heralds (and likely contributes) to disengagement from care. For most complex chronic conditions, such as Diabetes or COPD, this dramatically increases the already expensive cost of treatment. For example, if one third of the 26 million US diabetes patients suffer from a co-occuring depression, $32 billion of the nation’s $176 billion cost of diabetes care is directly attributable to untreated depression.  Under value-based payments, we finally began removing this unnecessary cost from the U.S. healthcare system.

In all, issues of mental health (ie: depression) and behavioral health (ie: addiction) significantly complicate and increase care costs. Luckily, this increased in access to care, along with the health systems’ realization of the impact of mental health on their bottom line, has stirred new interest in funding for the provision of effective mental and behavioral health care for patients in medical care. Once, health systems began contracting with therapy groups, behavioral health followup services began getting reimbursed, patient began seeing the benefits.


Now that voters have elected a Senate that will join the House in trying to override the president, the fear is that they will make a strong push to undo the PPACA (“Obamacare”), putting this progress in jeopardy. If the senate and the house succeed in reversing course on Obamacare, they will revert our healthcare system back to a payment model where mental health was ignored. After all, when a single ER visit can rake in a six-figure fee-for-service, a dose of cancer medication can cost more than an average monthly income, there is little incentive for optimizing care that costs $125 a session. In the fee-for-service model, mental and behavioral care is judged based on direct care costs, not on how it impacts the success of related medical conditions, and if Obamacare is repealed completely, or if a partial repeal is carelessly managed, much of the progress made toward bringing needed attention to the mental health of the American people will be undone.