Q&A: If upheld, ACA ruling would ‘undermine’ behavioral health integration efforts

Key takeaways:

• About 40% of behavioral health visits take place in primary care.
• Healio spoke with the president of the AAFP about how the recent Affordable Care Act ruling may impact behavioral health integration.

A federal judge in Texas recently ruled that a mandate of the Affordable Care Act requiring employers and insurers to cover certain preventive services recommended by the U.S. Preventive Services Task Force at no cost is unconstitutional.

Plaintiffs of the case, Braidwood Management v. Xavier Becerra, had wanted an insurance option that excluded or limited coverage of various services, including contraceptives, HPV vaccination, HIV pre-exposure prophylaxis and screenings and behavioral counseling for drug use and sexually transmitted diseases, since “neither they nor their families require such preventive care,” and that compulsory coverage violates their religious beliefs.

Although the ruling has been appealed, experts argue that it could still threaten access to important preventive health services, many of which have played a significant role in ongoing efforts to integrate behavioral health in primary care settings.

Speaking to Healio, Tochi Iroku-Malize, MD, MPH, MBA, FAAFP, the president of the American Academy of Family Physicians, discussed how the ACA ruling may impact progress toward behavioral health integration over the long-term.

Healio: Which behavioral health preventive services will be impacted by the ruling?

Iroku-Malize: To start off, for us at AAFP, we’re disappointed in this because it jeopardizes the equitable, affordable access to these particular types of evidence-based preventive services to millions of people, which is necessary for them.

I want to highlight that importance because as family physicians, this is what we do. We provide this preventive care. The preventive care is not just the behavioral health aspect, but it’s other things like vaccines, recommended testing or counseling that are necessary to keep the people in our communities healthy.

Eliminating the ACA requirements to cover these services recommended by the USPSTF with no cost sharing could result in millions of patients losing their free coverage of screenings for mental health conditions, as well as those counseling services that we are offering.

I also need to stress that there's an impact on health equity here, because this will affect access to mental health screenings and counseling for people who are in underrepresented areas. Those who face financial barriers and cannot afford the out-of-pocket costs that would be associated with screenings for mental health conditions will be hit hardest.

We have patients who are waiting 3 to 6 months to get appointments with physicians who are going to help with their mental health issues. This is just an extra layer to it. Without that free coverage, we're worried that the ruling will prevent these patients from seeking needed mental health services.

People will say this is just for those who have more severe behavioral health issues. But think about it. We have patients with depression and anxiety, women who have postpartum depression, and screenings for children with mental health needs. We’ve seen that these numbers have gone up since COVID. There’s a lot more anxiety and depression amongst these populations.

Healio: Last year, we talked to you about the progress being made towards integrating behavioral health in the primary care setting. Could the ruling impede that effort?

Iroku-Malize: Absolutely. This ruling would undermine that progress of the behavioral health integration that we’ve worked so hard for, and it also restricts access to care in a number of ways. If the rule is upheld, it would no longer cover essential screenings, like the postpartum screenings that we do when a patient comes in who just delivered. For youth in elementary school, middle school and high school who have emotional or behavioral health problems like anxiety and depression, the ruling will restrict access to that.

Creating barriers to these screenings prevents our ability to accurately diagnose what’s going on with them, and ultimately utilize that behavioral health integration piece where we're working together in our primary care settings to provide those services. Then ultimately, patients’ ability to access treatment is impeded, because now we can’t provide services they need and help them make progress on their condition.

More importantly, we already have an existing equity gap. For many, this loss of coverage will place preventive care out of their reach financially, and patients are going to potentially say, ‘You know what, this may not be a priority for me.’ That’s concerning.

Healio: What kinds of responses should be made to address potential barriers?

Iroku-Malize: With regards to behavioral health and how physicians and patients should be looking at this, we know that about 40% of the visits for depression, anxiety and other behavioral health issues are seen by primary care physicians because that’s the physician who patients go to.

I'm going to say to the patients: Continue to go to your primary care physician regardless. We’re going to figure out how to do this. We are family physicians. We are well prepared in terms of our education to provide mental health services, and we’ll play a vital role in trying to improve that access, quality and outcomes of mental health care.

We are usually the first point of contact for patients who are navigating the health care system, and many people with mental health issues will be diagnosed and treated in our settings. We know that, yes, there are going to be these challenges to integrating behavioral health into primary care, like the shortages of the mental health providers, the lack of payments for these visits that are complex and involve mental health screenings and treatment — and now with it not being covered at all, that’s an issue.

These challenges will be amplified if the patients aren’t able to access mental screenings with their family doctor any more due to these financial or other perceived barriers. So, as an academy, we’re calling on lawmakers, insurers, health plans and sponsors to ensure that patients can continue to get these high-value essential preventive services without cost-sharing.

For physicians, I’m saying to stay engaged. Don’t give up. Continue to do the best you can with the resources that you have. Continue to use your education that you have in terms of helping patients with mental health needs. Utilize the resources available in your communities as best as possible and continue to advocate to ensure that we can continue this very much needed service.

Reference:

• Braidwood Management Inc. et al. v Xavier Becerra et al. https://storage.courtlistener.com/recap/gov.uscourts.txnd.330381/gov.uscourts.txnd.330381.113.0.pdf. Accessed March 30, 2023.