Members in exchange plans struggle to access mental health care: study

Lack of providers pose big challenges for marketplace plans. (Getty/KatarzynaBialasiewicz)

The limited provider participation within Medicaid and in health insurance marketplaces poses barriers for people with behavioral health needs, according to a new study.

The study, backed by Project HOPE and published in the May issue of Health Affairs, compared employer-sponsored insurance, Medicaid and Affordable Care Act (ACA) marketplace coverage for people with psychological distress. The results showed a greater difficulty in accessing healthcare for those in distress versus those without distress, regardless of insurance.

And while Medicaid enrollees were more likely to use care and less likely to experience financial strain than those with private insurance, people with marketplace coverage were more likely to experience barriers across all domains. Despite gains from the ACA, as of 2016, of the 44.7 million adults with mental illness, only 43.1% had received treatment within the past year.

And the biggest barrier is access, according to the study. Marketplace plans had a 10.6% lower availability for primary care appointments, and Medicaid had a 25.1% lower availability than employer-based insurance. Plus, mental and behavioral health specialists had a lower participation rate in marketplaces and Medicaid plans.

In addition, those with mental and behavioral health needs tend to be lower-income and have a lower insurance literacy than those with stable jobs and mental health.

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“There were several things that were surprising in the data, the first of which is that, regardless of insurance type, adults with psychological distress had worse measure of health care access,” Ryan McKenna, assistant professor of health management and policy at the Drexel University Dornsife School of Public Health and an author of the study, told FierceHealthcare. “I was also surprised at the magnitude of the disparity in outcomes that existed for adults with psychological distress covered by the marketplaces relative to those covered by Medicaid.” 

For all three outcomes, marketplace enrollees reported the most difficulty accessing the system, then those with Medicaid followed by people with employer-sponsored insurance. Specifically, 1.26% of those with marketplace coverage and 9.31% of those with Medicaid reported trouble finding a provider in the past 12 months, versus 4.65% of those with employer-based health.

Similarly, enrollees in marketplace plans and Medicaid had more difficultly getting accepted as a new patient versus those with private insurance. And the largest disparity was having insurance accepted by a provider: 16.22% of people with marketplace plans, 12.19% of those with Medicaid and 4.68% of those with employer coverage.

However, Medicaid enrollees were more likely to use healthcare than employer-covered people or marketplace enrollees and were also less likely to experience financial barriers in accessing care relative to marketplace enrollees, which could be one of the reasons for the differences between the use of care for these groups.

Some of these discrepancies could possibly be alleviated by increasing transparency into marketplace plans and, therefore, helping enrollees make better informed decisions. However, there is still the issue of provider participation, which is primarily a state-level policy issue.

McKenna warns that several challenges lie ahead regarding marketplace plans and mental health. The first is encouraging behavioral health provider participation within exchange plans.

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“Without sufficient provider buy-in, the effect of parity will be weakened (if individuals cannot access an in-network provider),” McKenna said. The second obstacle is how policymakers can work to make provider participation and network breadth more transparent so that at the time of plan selection, consumers can be better informed. 

After concluding the study, McKenna says he was left with additional questions. The first question was a need to look into how the outcomes considered in the study would vary by type of insurance (PPO, POS, HMO). Secondly, McKenna was left wondering what were the differences in the outcomes or quality of treatment that were experienced across insurance types.