Where the Affordable Care Act fits into the gun control debate

Since the tragic shooting at Sandy Hook Elementary School, the debate surrounding gun violence, gun control, and mental health has gained renewed prominence. Last month, President Obama laid out proposals to reduce gun violence which include increasing access to mental health services.  The affordable access to these services has been a constant barrier to some Americans in need of treatment. There have been multiple pieces of bipartisan legislation introduced since the Connecticut shooting, addressing the need for increased access and training in mental health services. Starting January of 2014, the Affordable Care Act (ACA) will help to reduce barriers to mental health services by increasing access to mental health benefits.  Embracing the implementation of the ACA will be one solution to preventing another tragic mass shooting. 

The ACA allows states to expand Medicaid coverage to working individuals with income levels up to 133 percent of the Federal Poverty Line (FPL). The expansion of Medicaid will potentially cover 13.4 million uninsured people with mental and behavioral health conditions. In addition to Medicaid expansion, employers with more than fifty full time employees will now be required to offer affordable health insurance.The act also establishes insurance marketplaces for individuals who are not Medicaid eligible and don’t have access to affordable health insurance through their employer.  Individuals with income levels up to four times the FPL will be eligible for premium tax credits to purchase insurance through the marketplace.

Insurance companies will be required to offer “qualified health plans” through the insurance marketplaces. While qualified health plans have not been specifically defined as of yet, they must all provide “minimum essential benefits” as defined by the ACA. Mental health services are included under the minimum essential benefits. With access to health insurance through Medicaid, an employer, or the insurance marketplace, individuals will be guaranteed the same level of mental health benefits as medical and surgical benefits.

In addition to the ACA, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) exist to ensure parity in mental health benefits. The MHPAEA aimed to create “parity” by eliminating historical differences in group health insurance coverage for mental health and substance abuse benefits and medical/surgical benefits. Getting mental health parity legislation passed and implemented has been a long and difficult journey. Efforts in achieving mental health parity date back 50 years, starting when President John Kennedy called for parity in mental health benefits for federal employee health insurance plans.

In 1997, Senators Pete Domenici from New Mexico and Paul Wellstone from Minnesota succeeded in getting the Mental Health Parity Act passed. The legislation required group health plans with fifty or more employees that offered mental health benefits to apply the same lifetime and annual dollar limits to mental health coverage as those applied to coverage for medical and surgical benefits. Efforts to improve the legislation continued for more than a decade. It wasn’t until the passage of the MHPAEA did true parity between mental health and medical/surgical benefits begin to occur.

However, there are several limitations to the MHPAEA and ACA. The MHPAEA doesn’t require employers to offer mental health benefits. The ACA requires insurance plans sold through the insurance marketplaces to offer mental health benefits, but exempts employers who already provide affordable health insurance to their employees from offering mental health benefits if they are not currently offering the benefits. Also, when the Supreme Court ruled on the constitutionality of the ACA, the Court gave the states the option of expanding Medicaid. As of mid-February, only 21 states and the District of Columbia have decided to expand Medicaid in compliance with the ACA. As a result, those individuals who are unable to receive coverage under Medicaid will be unable to access affordable health insurance which will include mental health benefits.

Now that the gun control debate is back in the national spotlight and President Obama has committed his administration to working on solutions to curb gun violence, the MHPAEA and the ACA are two mechanisms that will ensure individuals will have access to mental health services. Both Congressional Senators from Oklahoma, Tom Coburn and Jim Inhofe agreed with President Obama’s efforts to increase mental health services as one solution to preventing gun violence. In her State of the State address, Governor Mary Fallin, emphasized the need for more resources to be put towards the Department of Mental Health and Substance Abuse Services to assist children and their families who suffer from emotional disturbances.

Unfortunately, Governor Fallin has failed to take the extra vital step in getting uninsured working Oklahomans access to needed health insurance including mental health benefits by refusing to accept federal funds to expand the Medicaid program in Oklahoma. The full implementation and acceptance of the ACA will demonstrate the country’s willingness to ensure individuals are getting the mental health services they need and hopefully avert the next tragic mass shooting.