Mental Illnesses May Soon Be the Most Common Pre-Existing Conditions

The coronavirus pandemic has killed over 200,000 Americans, left millions unemployed, and resulted in widespread social isolation. The pandemic has understandably also affected the country's mental health. In a recent KFF survey, more than half of adults in the United States reported that their mental health had been negatively impacted due to worry and stress about the coronavirus.

Meanwhile, a case that Republican states have taken to the Supreme Court and backed by President Trump threatens to repeal the Affordable Care Act (ACA). When the ACA is knocked over, mental illness can become one of the most common pre-existing conditions.

Before the pandemic began, in the first half of 2019, just over one in ten adults (11%) reported symptoms that were compatible with a diagnosable anxiety or depressive disorder. However, by July 2020 that number had risen to 40% (Figure 1).

Figure 1: Proportion of adults reporting symptoms of anxiety and / or depressive disorder, January-June 2019 vs. July 2020

With the sharp rise in people reporting symptoms of anxiety and / or depression, mental illness in adults is comparable to obesity in prevalence.

Before the ACA, the decision on an existing condition in the individual insurance market was largely up to the insurers. There were some terms that could almost always be refused, which meant that insurers would not offer coverage if they weren't required to. Examples of removable conditions include heart failure, newer cancers, and diabetes to name a few.

Other conditions, such as depression, may have resulted in a rejection in some cases or an offer with higher rewards and / or exclusions in other cases. For example, according to a drawing manual before ACA Humana, a person with severe depression who included hospitalization would be denied coverage, while a person with depression who received counseling and no medication would be charged a premium 10 to 20% higher. For other insurers, the recent use of some drugs to treat mental illness, such as Abilify, Lithium, and Clozapine, was another reason to deny individuals coverage under the ACA. If an individual did not report any mental illness or medication during their application process, possibly due to stigma, an insurer who discovers this may later cancel the individual's coverage.

Some people who experience symptoms of anxiety or depression during the pandemic may not meet criteria for diagnosis or may still need to receive diagnosis or treatment. Whether or not a diagnosis was already made, many individual market plans did not include mental health and substance abuse disorder services or medication for participants before the ACA had to cover essential health benefits such as mental health.

Providers are encouraged to provide routine screening for depression for adults and adolescents, which could help many get the treatment they need, but may also leave them with a diagnosis on their medical records. With the ACA banning insurers from discriminating against people with pre-existing medical conditions, people with new symptoms of mental illness and other illnesses no longer have to worry about what an insurer might discover in their medical records. That is, assuming that the full protection of the ACA continues to be required by law for people with pre-existing conditions.

Although his administration is advocating in court that pre-existing condition safeguards with the rest of the ACA be lifted, President Trump has promised to continue taking safeguards but has not released a replacement plan for it. The Republican "Repeal and Replace" plans, which were supported by President Trump in 2017, would have obliged insurers to include people with pre-existing conditions in their plan. However, in order to lower premiums, states were allowed to relax the essential health benefits of the ACA, such as mental health care. This could mean that insurers are offering insurance to people with mental illness but not paying for their mental health care.

President Trump has also supported the expansion of so-called short-term plans (which can now be extended for up to three years). These plans provide insight into coverage under the ACA when insurers are no longer required to provide the essential health benefits of the ACA. When analyzing these plans, we found that more than half of the short-term plans had no coverage for mental illness at all, meaning that even if coverage was offered to a person with a mental illness, their plan would not pay for mental illness Health treatment. Over a third of these plans would not pay off for substance use treatment. Because short-term plans can deny coverage to people with pre-existing medical conditions, even insurers that cover mental health care may not offer cover at all to people with severe mental illness. In a post-ACA scenario where a hypothetical replacement plan prohibits insurers from refusing coverage but does not oblige them to provide essential health benefits, the benefits covered could be even tighter.

The protection of people with pre-existing conditions in the ACA goes far beyond the prohibition of refusing insurance cover to insurers. Not only do insurers need to provide coverage for people with common pre-existing conditions such as depression or anxiety, they also need to cover treatment.