Reducing Cost of Behavioral Health Services is Not Enough
Austin Tolentino 
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Approximately one in twenty adults in the US suffer from a serious mental illness (SMI) such as schizophrenia, bipolar disorder, or major depressive disorder. Yet barriers to accessing behavioral health services, including mental health care and substance use treatment, remain high.
The National Survey on Drug Use and Health revealed that 26% of adults with mental illness (13.3 million) perceived an unmet need for behavioral health services in 2019. Of these adults, 54% were living at 200% of the Federal Poverty Level or less. Among the reasons why they did not receive mental health services that year, 43% reported they could not afford the cost.
People with SMI who rely on Medicare have faced higher out-of-pocket costs for behavioral health services compared to Medicare coinsurance costs for medical and surgical care. In 2008, the Medicare Improvements for Patients and Providers Act (MIPPA) introduced parity by gradually reducing the coinsurance fee rate for behavioral health care from 50% in 2009 to 20% in 2014. Because the behavioral health services gap is more prevalent among low-income households, such a cost reduction may be more impactful for more vulnerable populations.
The change in policy provided a compelling setting for researchers to measure whether cost is a key barrier preventing patients from receiving behavioral health services.
Dr. Vicki Fung and colleagues studied the association between the coinsurance fee reductions and behavioral health care use and spending among beneficiaries with low income. The study relied on Medicare claims data from 2007 to 2016 for a nationally representative sample of 793,275 lower-income Medicare beneficiaries with SMI. They compared outcomes before and after the MIPPA reductions between beneficiaries who fell within the 135% Federal Poverty Level (FPL) and were eligible for the cost reduction (the study group), and beneficiaries who fell within the 100% FPL limit who did not experience MIPPA reductions because of their eligibility for full cost-sharing subsidies, or in other words free care (the control group).
The authors found that total out-of-pocket costs for those in the study group decreased on average from $135 in 2009 to $65 in 2015. There was, however, no significant difference in the use of behavioral health services or money spent on such services between the MIPPA and free care beneficiaries. This suggests that while MIPPA may have been a step in the right direction to alleviate financial burdens especially for adults with low-income, more comprehensive policy interventions must be considered to address the non-financial barriers faced by this population.
Even with the meaningful reduction in cost, the remaining balance due may still prove to be a financial barrier itself for people with low income. In terms of non-financial barriers, there remain opportunities to improve both the supply and demand for behavioral health services. Given the current scarcity of specialty behavioral health care professionals in the US, especially in rural and low-income regions, policymakers will need to reckon with not only distribution issues but also challenges in incentivization for behavioral health care practitioners who do not accept Medicare, network commercial insurance, or Medicaid payments.
On the patient side, policymakers must consider barriers posed by the attitudes and awareness held by people with SMI, particularly regarding their perceived unmet need for treatment, the stigma around receiving behavioral health care, and their distrust in practitioners. The larger context of COVID-19, racial injustice and inequities, and widening inequality in the US amplify the urgency for more comprehensive and innovative policy solutions to improve the low levels of behavioral health services use by a high-need population of people with serious mental illness.
Fung, Vicki, Mary Price, Andrew A. Nierenberg, John Hsu, Joseph P. Newhouse, and Benjamin L. Cook. 2020. “Assessment of Behavioral Health Services Use Among Low-Income Medicare Beneficiaries After Reductions in Coinsurance Fees.” JAMA Network Open 3, no. 10: https://doi.org/10.1001/jamanetworkopen.2020.19854.
Key substance use and mental health indicators in the United States: results from the 2018 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration (SAMHSA). 2019. https://www.samhsa.gov/data/report/2018-nsduh-annual-national-report.
