Secretary of Health and Human Services Kathleen Sebelius visits the Eisner… (Arkasha Stevenson / Los…)
WASHINGTON — When President Obama pledged this week to strengthen the nation's mental health system to help reduce gun violence, he also implicitly acknowledged that a gap remains in his signature effort to guarantee Americans access to healthcare.
Two landmark laws — including the sweeping 2010 health law — have been enacted since 2008 to improve mental health treatment. But the Obama administration is still writing rules for both measures that will change how insurers deal with millions of Americans who suffer from mental illness and addiction.
That unfinished task has proved extremely fraught, as administration officials struggle to find a balance between the mental health needs of patients and concerns that more government mandates will inflate insurance premiums or complicate implementation of the president's healthcare law.
"There have been difficult issues to deal with," Kathleen Sebelius, the secretary of Health and Human Services, acknowledged Friday in an interview.
Obama this week directed Sebelius' department to quickly complete the regulations that will direct insurers to cover more mental health services. When the 2010 Affordable Care Act is fully implemented next year, millions of Americans stand to gain access to such care for the first time.
Nationwide, more than 45 million adults suffered from some mental illness in 2011, according to an annual survey by the federal Substance Abuse and Mental Health Services Administration. About 11 million had a serious illness, and of those more than 40% did not get care.
Among the biggest barriers to treatment have been cost and limits placed on care by insurance companies.
In 2008, President George W. Bush signed legislation that ended differences in the way health plans treat medical benefits and benefits for people who suffer from mental illness or substance abuse. No longer could health plans charge higher co-payments or deductibles for mental health services or place tighter limits on the number of therapy visits they would cover.
The protections in the Mental Health Parity and Addiction Equity Act applied only to health plans offered by large employers, however. Obama's health law is slated to extend those protections in 2014 to plans offered by small employers and to insurance that Americans buy on their own.
The Obama administration also made it clear this week that Medicaid, which together with the Children's Health Insurance Program covers more than 65 million mostly poor Americans every year, will also have to offer equivalent mental health benefits.
"This was a giant step forward," said Carol McDaid, a lobbyist who has been working for nearly two decades to expand protections for the mentally ill.
It remains unclear how the Obama administration will resolve a debate over how much information insurance plans must reveal about the way they structure their mental health and medical benefits.
For example, insurance companies sometimes require prior authorization for some treatments, or they may limit provider networks or require patients to undergo less costly treatments first.
But companies do not typically disclose these practices in detail, which can make it difficult for patients to know if insurers are treating mental health benefits differently than medical benefits.
"The consumer is at a complete loss," said Julie A. Clements, deputy director of regulatory affairs at the American Psychiatric Assn., a leading advocate of more information for consumers.
The insurance industry has resisted more disclosure, however, arguing that outlining these limits would be extremely complicated and unhelpful to consumers.
"We supported the Mental Health Parity Act, and our members are committed to implementing it in the best way for patients," said Robert Zirkelbach, a spokesman for America's Health Insurance Plans, an industry trade group. "But comparing a treatment plan for a patient with a mental health condition to one with a medical condition is not as simple as just comparing co-pays."
Sebelius said Friday that the administration would issue final regulations later this year.