Kenneth osiezagha

COMMENTARY

Remaking the American Health Care System: A Positive Reflection on the Affordable Care Act

with emphasis on Mental Health Care

Babatunde Ogundipe, MD, MPH Farzana Alam, MD

Lalitha Gazula, MD, MPH Yetunde Olagbemiro, MD, MPH

Kenneth Osiezagha, MD Rahn K. Bailey, MD, DFAPA

William D. Richie, MD, DFAPA

Abstract: Health care reform under the Patient Protection and Affordable Care Act (PPACA, ACA) of 2010 may be the most significant health care- related legislation enacted since the establishment of Medicare and Medicaid several decades ago. Over two years ago the U.S. Supreme Court upheld the constitutionality of the individual mandate of the Patient Protection and Affordable Care Act. This legislation has emerged as a significant and ambi- tious undertaking for all levels of the U.S. government. With the need to accommodate the estimated 30 million people projected over time to become newly insured it is increasingly important to understand the necessity of reform, how the legislation has been interpreted and implemented to fit the goals of the federal, state, and local governments, and what the potential benefits and consequences of changing the system are, in particular, as it relates to mental health care.

Key words: Health care, health reform, Affordable Care Act, health insurance, state- based health insurance marketplaces, mental health care.

Under the Obama Administration health care reform has become a reality through two separate pieces of legislation designed to improve the structure of health care delivery and the quality of health care. These include: (1) The Patient Protection and Affordable Care Act of 2010 (PPACA, or ACA), and (2) The Health Care and Educa- tion Reconciliation Act of 2010 (HCERA). Focused on cost containment and improved access, these two legislative acts define changes made within the health care system and have the potential to affect other important facets of United States (U.S.) society both politically and economically.

The authors are affiliated with Meharry Medical College. Please address correspondence to William D. Richie, MD, DFAPA; Meharry Medical College, 1005, Dr. D.B. Todd Jr. Blvd., Nashville, TN 37208; wrichie@mmc .edu; (615) 327‑6823.

50 Remaking the American health care system

The Patient Protection and Affordable Care Act was designed to extend insurance coverage through an expansion of Medicaid, as well as through state- run marketplaces (exchanges) for health insurance supplemented by tax relief for middle- income par- ticipants who qualify for assistance.1 The Patient Protection and Affordable Care Act has provided federal funding to enable states to expand the availability of Medicaid to people who previously did not qualify (either because they had too high an income or were single, non- disabled adults). Those individuals under 133% of the federal poverty level are now eligible for Medicaid in states that have chosen to expand. Many states, however, have not yet accepted this offer from the federal government resulting in gaps where the poorest of the uninsured are remaining uninsured while those who have somewhat higher incomes have been able to purchase insurance on the federal health insurance exchange.2 In an effort to increase participation of healthy people in both Medicaid and the newly created exchanges a critical piece of the mechanism, known as the individual mandate, requires citizens to carry health insurance. In effect, this means that citizens who are uninsured must either sign up for Medicaid or if they earn too much to qualify for it, must purchase health insurance for themselves. Failing to purchase their own insurance would result in a tax penalty. Provisions also exist for the enforcement of penalties on employers with 50 or more full- time (or full- time equivalent) workers who do not provide health insurance coverage for their employees. Originally set to begin in 2014, the employer mandate has been delayed until 2015/ 2016.1

The health insurance marketplaces established through the Patient Protection and Affordable Care Act were set up so that small businesses and individuals could compare plans and purchase private insurance coverage that covers all the “essential health benefits,” including services in: ambulatory care, emergency room, mental health, substance use disorders (counseling and psychotherapy), laboratory studies, rehabilitation, maternity/ newborn care, prescription drugs, preventive medicine/ wellness, pediatrics, and hos- pitalization.3,4 More details are available at the federal government’s website for the program, https:// www .health care .gov/ what- does- marketplace- health- insurance- cover.