Imagine a woman in an emergency room—let’s call her Rebecca. Last month Rebecca lost her job, and this week she got evicted. To deal with the stress, she’s been having a few drinks every night. Last night, she had one too many, and wound up cracking her head against the windshield of her car. The ER doc stitched the cut across her face and referred her to a social worker, who is helping her get into a substance abuse program and gave her listings for some low-rent apartments.
How many of these services should Rebecca’s health insurance pay for?
Rebecca has at least three needs: medical care, substance abuse treatment, and affordable housing. Traditionally, health insurance only covers medical care, but both substance abuse and a lack of housing can directly impact Rebecca’s ability to be healthy. Besides the obvious negative physical effects of drinking too much, struggling with an addiction could keep Rebecca from eating well or taking medicines on the schedule prescribed by her doctor. Without a home, Rebecca will have nowhere to cook healthy meals or sleep soundly at night, and might even face exposure to extreme weather.
For someone like Rebecca, both of these non-medical factors negatively influence health, and both of them could be remedied with access to appropriate mental health and social services. A growing movement among health care providers and policy makers is pushing for health insurance to include coverage for the services needed for health that go beyond the purview of medicine.
Calls to reform coverage for mental health and substance abuse are already loud and clear. Mental health has long been cast as something separate from physical health, and insurance plans have often failed to cover services such as regular visits to a psychologist or prescriptions for psychiatric drugs. When plans did include coverage for mental health, insurers commonly charge patients more for their mental healthcare than for their physical healthcare.
Insurers neglected mental health coverage for a variety of reasons. Because patients with mental health needs often require expensive services over a long period of time (for example, someone with schizophrenia may need daily medication her entire life), insurers might engage in “risk selection,” purposefully not offering a set of services in order to deter those patients that need them from enrolling in their plans. For more socially or politically sensitive subjects, such as counseling for transgendered individuals or patients with addictions, stigma alone might be enough to keep insurers from providing coverage.
New rules enacted under the Affordable Care Act seek to level the playing field for mental health care and substance abuse treatment. First, the ACA establishes mental health as one of the ten Essential Health Benefits, meaning that every insurance plan must provide coverage for services needed to diagnose and treat mental health conditions. Second, the Mental Health and Addiction Equity Act (the requirements of which are being implemented through the ACA) requires “parity” in coverage of mental and physical health needs. This means the insurer can’t place limitations or requirements on mental health services that are more onerous than those placed on physical care, such as requiring an individual to pay seventy-five percent of the price of psychiatric drugs but only twenty percent for other prescription drugs. By establishing mental health as an Essential Health Benefit and introducing requirements for parity, the ACA aims for mental health services to be viewed and treated the same way as medical services for physical health.
In addition to increasing coverage for mental health, a growing movement is pushing for the inclusion of social services that directly enable health. These services, known as the “social determinants of health,” include stable housing, gainful employment, and access to healthy food and clean air. The “social determinants” approach essentially considers any variable that might interfere with a person’s health to be relevant to their health care, extending the concept of “health care” to a holistic vision of health well beyond the walls of a hospital or clinic.
The greatest challenge for this movement lies in getting insurance companies and policy makers to pay for social services that fall outside the traditional scope of the health care system.
In Illinois, a new Medicaid initiative seeks to do just that. Pending approval from the federal government, Illinois will use Medicaid funding to address many of the social determinants of health that negatively impact low-income patients. The proposed program builds on existing models of integrated care organizations which provide patients with a wide range of services, including primary care, mental health, and social services – all covered by state and federal funding. For the first time, Medicaid managed care plans will also be incentivized to offer housing support for patients with mental health and substance abuse disorders.
Altogether, it seems difficult to name a variable that does not affect health, a problem well illustrated by Rebecca’s trip to the emergency room. Rebecca needed medical treatment as a result of excess drinking precipitated by anxiety brought on by being evicted as a result of losing her job. Maybe she lost her job because she was replaced by someone with more education; maybe she took too many days off to care for a relative.
Exactly where along the causal chain of Rebecca’s problems the responsibility of health care providers and insurers should end is difficult to pin down. Traditionalists hold that health insurance is for medical expenses only. Advocates of the “social determinants” approach find themselves caught in a never-ending web of complex, interacting factors, where solving one problem often exposes or creates another. In reality, no single entity, private or public, can be responsible for arranging every facet of an individual’s life.
In the end, perhaps the best judge of when needs have been sufficiently met is the patient herself. The aim, after all, is to provide the patient with the support she needs to meet the challenges to health brought by the circumstances of her own life. As appreciation for the interrelationship of mental health, social conditions, and physical health grows, so too does the argument for public and private insurers to expand coverage to include a full continuum of services extending well beyond medicine.