What does the Patient Protection & Affordable Care Act (ACA) mean for mental health services?
As a consumer, there are several things you need to know about “minimum essential benefits,” mental health parity, deductibles, and preexisting conditions.
The catchphrase “Minimum Essential Benefits” refers to the ACA mandate that, moving forward, health insurance policies cover basic health care services that were previously optional. The ACA is clear that mental health care, including substance abuse treatment, is a minimum essential benefit. So what are the implications of this provision?
- As of mid-November, 2013, it remains unclear whether this mandate will be delayed for a year or more. Why? Many individual and small business health insurance policies are being cancelled because they are “catastrophic,” i.e., bare minimum, and do not meet the “minimum essential benefits” criteria. However, problems remain with signing up for coverage on www.healthcare.gov, so millions of people are left in the lurch–they are losing their current health insurance policy, but are having trouble signing up for insurance on the healthcare exchanges. To try to address this problem, President Obama has asked health insurance companies to extend their catastrophic policies so no one loses coverage. However, many health insurance companies say they can’t make this change so late in the game. Additionally, some states have enacted laws that won’t allow the continuance of catastrophic policies. So, right now, no one really knows if catastrophic policies will become a thing of the past.
- If you have a health insurance policy through your employer, and your employer’s policy is “grandfathered,” i.e., no changes to the policy have been enacted since the 2010 signing of the ACA, “You may not get some rights and protections that other plans offer,” according to healthcare.gov’s post on grandfathered plans. Are minimum essential benefits such as mental health care one of the “rights and protections” that may not be available? Perhaps. I searched healthcare.gov exhaustively for specific information about grandfathered plans and mental health care, and couldn’t find a direct answer. So, my guess is that if the issue is not specifically mandated, then insurance companies and employers may not fully cover mental health benefits in grandfathered plans, in the interest of cost containment.
- If your employer is “self insured,” then your employer can opt out of certain “minimum essential benefits” such as mental health care. Here’s the reference on healthcare.gov.
“Mental Health Parity” was originally enacted in 1998 and was intended to ensure mental health services were covered by insurance companies similarly to medical issues. There were many exceptions & exclusions to the law, and it was not diligently enforced. The second round of “Mental Health Parity” became law in 2008, but once again, exceptions and work-arounds rendered it ineffective.
In November, 2013, Health & Human Services Secretary Kathleen Sebelius announced new regulations that once again seek to provide coverage for mental health services at the same level as coverage for medical issues.
- Theoretically, this should eliminate separate deductibles, out of pocket limits, and limitations on coverage for mental health services. The specifics of the mental health regulations are spelled out here–206 pages! However, it remains to be seen whether there are loopholes or whether the regulations will be evenly enforced. A provision of the ACA that limited annual out of pocket limits has already allowed exceptions through 2014 for policies that use “more than one benefits administrator,” which often applies to pharmacy and mental health benefits. Mental health benefits should be excluded from these exceptions on out of pocket limits, but we’ll have to wait and see how the regulations are enforced.
- Exclusions to mental health parity (verbatim from healthcare.gov) include:
- Plans offered by small employers that are self-insured (these are plans that don’t buy insurance from an insurance company, but pay for employees’ health care costs themselves; they may use a health insurance company to manage claims and payments)
- Plans offered by employers that can show the federal government that the parity requirements have caused such a significant increase in plan costs that they qualify for a one-year exemption
- Plans offered by state and local government employers that are self-insured and choose not to apply the parity requirements, as long as they properly notify the federal government
- Plans that are grandfathered (generally those that have not changed their plan terms since March 2010)
- Retiree-only plans
- If catastrophic policies remain in effect (see above), then mental health benefits are unlikely to be covered at all in these policies.
To underscore the uncertainty regarding mental health parity, I quote healthcare.gov: “Do job based plans include mental health parity protections? Some of them do.”
A key provision of Obamacare (ACA) is that individuals with preexisting conditions, physical or mental, cannot be denied the opportunity to purchase health insurance. Further, those with preexisting conditions cannot be required to pay higher premiums and policies cannot be cancelled.
- This is good news for individuals who previously sought mental health care and were subsequently denied the opportunity to purchase health insurance because of their “preexisting condition.” You can no longer be denied the opportunity to purchase health insurance! And your marketplace health insurance policies can’t raise premiums or cancel policies if you decide to use your mental health benefits or become seriously ill, which was a risk with individual policies in the past.
One final relevant point about Obamacare and mental health coverage: To quote healthcare.gov: “Can I keep my current mental health provider? Possibly.”
- If you’ve ever invested time, money, and energy into mental health care, then you know that “providers” are not interchangeable! The therapist or psychologist you’ve been working with knows you, your history, challenges, and strengths. Starting over is not a small thing. As insurance companies are managing costs, they are “containing” their networks, i.e., fewer providers are included in-network. This does not mean that you can’t see a therapist or psychologist that is “out-of-network,” but you may pay more out of pocket than with in-network providers. And in-network providers often agree to accept lower reimbursement, which may dilute the quality of care.
In summary, Obamacare is intended to make mental health care affordable and accessible to every American citizen. However, such an ambitious goal is going to have bumps along the way and soundbites don’t accurately describe the reality. If you have comments, questions, or additional insights, please share!
The Nobel Prize winners in Medicine were announced this week, and I was thrilled to hear that one of the awardees is neuroscientist Dr. Thomas Sudhof! While at UTSW Medical Center (my doctoral alma mater!) Dr. Sudhof studied synaptic transmission–how brain cells communicate via chemicals.
During my postdoctoral training in neuropsychology, one of the first things I learned is:
Neurons that fire together wire together.
To oversimplify: Our brain cells communicate with one another via synaptic transmission–one brain cell releases a chemical (neurotransmitter) that the next brain cell absorbs. This communication process is known as “neuronal firing.” When brain cells communicate frequently, the connection between them strengthens. Messages that travel the same pathway in the brain over & over begin to transmit faster & faster. With enough repetition, they become automatic. That’s why we practice things like hitting a golf ball–with enough practice, we can go on automatic pilot.
Psychologists have long known that negative thought processes follow this same pattern–the more we think about, or “ruminate,” on a negative thought, the more entrenched the thought becomes. Negative and traumatic thoughts also tend to “loop”–they play themselves over and over until you do something consciously to stop them.
The more these negative thoughts loop, the stronger the neural pathways become, and the more difficult it becomes to stop them! This is why thoughts that cause depression, anxiety, panic, obsessions, and compulsions can become so difficult to combat. And along the way, these thoughts stir up emotional as well as physiological reactions.
Psychotherapy, regardless of the orientation, attempts to stop this process.
For example, psychodynamic therapy “processes” the thoughts, or attempts to digest the thoughts in a manner such that such the useful parts are kept and the harmful parts are discarded. Cognitive behavioral and rational emotive therapies attempt to interrupt this loop with techniques such as cognitive restructuring and thought stopping.
As we advance our understanding of neurobiology, we better understand the physiological underpinnings of negative thoughts, why they are so hard to get rid of, and why various therapies work–they effectively change the brain. A fairly new form of therapy (researched for 25 years now) is a type “reprocessing” therapy called EMDR.
EMDR involves bihemispheric processing of disturbing thoughts–in other words, EMDR stimulates both left brain & right brain processing of thoughts, memories, and behaviors that cause distress. I’ve studied EMDR since its inception, and scientific studies consistently show that this therapy is effective, and in certain situations, can provide quicker symptom relief than other forms of therapy.
With modern technology (SPECT scans & fMRI’s), along with advanced understanding of neurotransmission, we’re able to see the changes in the brain brought about by EMDR and other types of therapy–it really works!
The speed of symptom relief with EMDR does not negate the usefulness of other types of psychotherapy–traditional therapies build coping skills, enhance self-understanding, and can identify and repair any “missing parts” of personality organization such as the ability to connect with others. What EMDR provides is more immediate symptom relief and a mental release from negative “loops” in the brain.
In light of all the solid research underscoring the importance of neurobiology’s role in psychotherapy, I owe it to my clients to formally train in EMDR. Later this month, I’ll travel to Chicago to begin my training.
Congrats to Dr. Sudhof and all the other Nobel Prize winners!
If you would like to understand in more detail how and why neurons that fire together wire together, read my more detailed article here.
An aside–the picture with this post is one I took of a redbud tree in winter–notice how the branches of the tree mimic the the shape of nerve cells in the brain. If you find this repetition of pattern in nature as fascinating as I do, you may want to learn more about fractal geometry! Here’s a very easy read on the subject–Introducing Fractals: A Graphic Guide.
In a follow-up to my post Finding Flow, here’s a sampling of activities that might help you find your flow:
- Physical activities such as sports, yoga, dance, and martial arts
- Outdoor challenges such as hiking
- Music–writing, playing, mixing
- Art–painting, sculpture, mixed media, pottery
- Photography
- Woodworking
- Do-It-Yourself projects, such as home improvement
- Working with animals
- Gardening
- Cooking and baking
- Software development/coding
- Scrapbooking
- Writing
- Needlework–sewing, knitting, cross stitch
- Horseback riding
- What you do for work (hopefully!)
Remember that “flow” activities are not interchangeable with “leisure” activities. For example, visiting with a friend is a healthy leisure activity, but does not induce flow. That’s because a flow activity:
- Is useful and challenging, which makes it intrinsically rewarding
- Helps you progress toward a goal
- Provides feedback to help gauge the effectiveness of your efforts
And flow activities require some sort of action! Passive leisure activities won’t help you find your flow.
We all need time to zone out but, just like too much sugar in your diet is bad for you, too much passive leisure time isn’t optimal! In fact, some passive leisure activities produce the opposite of “flow”–similar to a state of mild depression! Watching television is one of these passive leisure activities–there can be a lift in mood if it’s a favorite show and you watch in moderation. But if you watch mindlessly, your brain falls into a trance-like (alpha wave) state, only without the benefits of alpha wave during sleep or meditation–only negative effects, similar to depression. So keep passive leisure activities to a minimum. :)
Please share your suggestions for flow activities!
What is “flow” and why is it important for happiness?
First, let me explain what “flow” is. “Flow” involves both an activity and a state of mind.
When you’re in a “flow state of mind”:
- You lose track of time
- You’re totally engrossed in what you’re doing
- You’re not consciously thinking about yourself–in other words, you’re totally un-self conscious
- You’re working toward a goal
If this sounds a lot like mindfulness, you’re right! The key difference is a “flow activity” and working toward a goal.
A “flow activity”:
- Is useful and challenging, which makes it intrinsically rewarding
- Helps you progress toward a goal
- Provides feedback to help gauge the effectiveness of your efforts
(Examples of flow activities in the next post–Flow Activities!)
According to Mihaly Csikszentmihalyi, the author of Flow: The Psychology of Optimal Experience, a flow experience involves “deep concentration, an optimal balance of skill & challenge, and a sense of control and satisfaction.” You can watch Dr. Csikszentmihalyi’s TED Talk here: Flow: The Secret of Happiness.
The key to flow is finding the optimal balance of skill set and challenge–you shouldn’t be overly frustrated, but the challenge shouldn’t be too easy, either.
A flow activity involves the development of a skill set, such that the challenge of the activity evolves over time as your skill set improves. In this way, flow activities lead to growth and discovery.
So why is flow an important component of happiness?
Dr. Csikszentmihalyi’s original research involved studying happiness using the “Experience Sampling Method,” or ESM. Using ESM, Dr. Csikszentmihalyi found that people are happiest when they are fully absorbed in the activity at hand. Further, happiness is enhanced when the activity is optimally challenging.
This research was revolutionary in that it was the first time scientists asked people throughout the day, “How happy are you right now and what are you doing?”
Using ESM, the researchers were able to correlate happiness with the activity at hand, rather than simply asking, “What makes you happy?” As you know from Dr. Gilbert’s research (read my post Finding Happiness), human beings are poor predictors of what truly makes us happy. It turns out the activity was not as important as feeling fully immersed and optimally challenged.
By finding your flow activities and regularly engaging in a flow state of mind, you’re building happiness into your everyday life.
Flow is more important for overall happiness than the things we often think will make us happy, such as a vacation, nicer home, new car, winning the lottery, etc.
Seven Steps for Finding Flow:
- Set goals. Setting goals recognizes the challenges involved in reaching the goal.
- Understand the challenges involved. Understanding the challenges suggests the skill set required to reach your goal.
- Develop your skill set. Part of developing your skill set is monitoring feedback.
- Monitor feedback and adjust your efforts and goals as indicated. As your skill set increases, you should increase the challenge at hand to remain in a state of flow. Accordingly, your overall goal is fluid and can be redefined over time.
- Become immersed in the activity–focus and concentrate, ignoring distractions. Focus is a skill set in itself and you may have to work on this. It’s important to stay consciously focused in the moment, on the task at hand, to enjoy a state of flow.
- Engage in your flow activity on a regular basis. This is necessary to build your skill set and attain meaningful progress toward your goal. Your sense of accomplishment as you progress toward your goal is an important component of flow.
- As you progress toward your goal, think about the meaning and usefulness of the flow activity. How does the flow activity harmonize with other goals or values in your life? An important aspect of flow is that the process is just as important, or even more important, than the final product, in terms of happiness. Nonetheless, it’s important that there’s meaning in what you’re doing. For example, if your goal is to become a scratch golfer, you may harmonize this goal with your value of self discipline and hard work. Or, if your goal is to learn to knit, this may harmonize with your goal of giving handmade gifts to others.
Flow activities may include music, a hobby, movement (sport or fitness), writing, study, art, what you do for work, etc. For more hands-on suggestions, check out Dr. C’s second book, Finding Flow: The Psychology of Engagement with Everyday Life.
By identifying your “flow activities” and cultivating a “flow state of mind,” you’re not only building happiness but emotional resilience. When times are good, flow enhances your sense of satisfaction and well being. When times are tough, flow activities provide a sense of purpose and productivity, even though you’re struggling emotionally. So get started today!
What goals and skill sets do you want to cultivate?
“Positive Psychology” is the scientific study of resilience, optimism, and emotional well being. In other words, the science of happiness!
Today, I want to share some of the key insights of this research.
The first thing you need to know is that the strongest predictor of happiness is having something meaningful to do.
Mihayli Csikszentmihalyi, a Hungarian psychologist, wrote about the importance of meaningful activity in a book called “Flow.” While the concept of productivity contributing to happiness has been around for centuries, Csikszentmihalyi was the first to research and define this phenomenon.
Flow is defined as being totally engaged in an activity, often to the point that you lose track of time.
The activity is challenging, meaningful, and usually requires some degree of creativity or problem solving. When you finish working on the project, you feel a sense of accomplishment and achievement.
But, the process is just as important, or maybe even more important, than the outcome!
Because “flow” is such an integral part of happiness, I’ll devote my next post, “Finding Flow,” to this topic.
The relatively new field of “Positive Psychology” builds on the concept of “flow” and examines the core components of a happy, fulfilling life.
If you’re looking for a “recipe” for happiness, consider these 7 ingredients from pursuit-of-happiness.org:
- Relationships
- Caring
- Exercise
- Flow
- Spiritual Engagement & Meaning
- Strengths & Virtues
- Positive Thinking: Optimism & Gratitude
If you want to learn more, read about Flow and Happiness here, or about the science of Positive Psychology here.
The second thing you need to know about finding happiness is that we are generally poor predictors of what will make us happy!
Research shows that what we think will bring happiness–a new car, a vacation, winning the lottery–does not tend to have a lasting effect on our overall happiness. Human beings are excellent at “acclimating,” or getting accustomed to a situation. So we may experience a temporary boost in happiness when something fortunate happens, but fairly quickly, we are back at our “baseline” level of happiness. Dan Gilbert, Ph.D., writes about this in Stumbling on Happiness, or you can watch his TED Talk here:
GQ Magazine published a great article–“The Luckiest Village in the World“–about tiny Sodeto, Spain, where all the residents (except one) chipped in and won El Gordo, the largest lottery in the world. After the initial elation, the villagers tended to be as happy, or unhappy, as they were before. In fact, the good fortune increased the stress level (and decreased the happiness) of many of the villagers. And the one resident who did not participate in the lottery? He turned out to be one of the happiest at the end of the year! As Michael Paterniti, the GQ journalist, notes:
“Even as luck provides certain comforts while others still suffer, it doesn’t really change you.”
The flip side of Dr. Gilbert’s research on happiness is that, just as improved circumstances don’t usually lead to lasting increases in happiness, we are also surprisingly good at adapting to hardship. So, the things we think would make us miserable often do not significantly impede our happiness over the long haul.
Dr. Gilbert’s research dovetails nicely with the findings of Positive Psychology–it’s finding something meaningful to do, more so than the circumstances, that makes us happy.
Good fortune, a vacation, or a new possession brings only temporary happiness; likewise, we can weather misfortune if we have meaningful activity in our lives.
For help integrating the 7 ingredients of happiness into your life, sign up for the Daily Shoring 90 Day Series!
