The Politics of Mental Health

When Coronavirus came onto the stage in March of this year it was the working poor who were impacted the most. They led precarious lives prior to Covid, largely living check to check before Corona disrupted life as we knew it. The working poor has been disproportionately affected by these disruptions. Things like child care, exposure at work, time off work, and loss of job place benefits (if they had any) have left many of these Americans struggling to make ends meet.

But who are the working poor?

They’re individuals who were in the workforce at least 27 weeks out of the year, but whose income falls below the federal poverty line (FPL). 100% of the FPL is currently set at $26,200 for a family of 4, or households making $2,183 a month.
And this poverty doesn’t strike everyone equally. Women are more likely to be among the working poor. And a person of color has more than double the likelihood of being impacted by poverty than their white neighbors.

Many in this vulnerable group are one paycheck away from unpaid bills, debt collectors, and bankruptcy. And a huge portion of the average household expenses, including the working poor, is medical debt.

Healthcare is expensive no matter what income bracket you’re in, but that is especially true in America. In 2019 the US spent about $11,100 per person on healthcare, compared to under $2,000 in 1970’s America.
This is also more than twice the global average of other first world countries, at a rate of $5,287.
And even with the higher spending, we are not seeing better outcomes. In some areas like life expectancy, infant mortality, and unmanaged diseases (like diabetes), America falls to the bottom.

1 in 5 adults in America is living with mental illness. That’s around 50 million people…300,000 of those are in Arkansas alone. 3 out of 5 adults with mental health issues do not receive treatment for them. Many do not receive treatment for their mental health needs due to lack of access and affordability. Mental health has become a luxury for those that can afford it. And that can be life-impacting and potentially deadly for millions of Americans.

People with mental illness are more susceptible to self-medicating and have higher rates of substance abuse issues.  Arkansas currently ranks 36th in the country for access to mental health services. The barriers that prevent people from receiving adequate mental health services also contribute to there being a disproportionate number who are struggling with addiction. Arkansas ranks 8th in the country for overall drug use and addiction rate. And anyone from Small Town Anywhere, USA understands the impacts this can have on communities. 

 
America also has the highest suicide rates among 11 other nations. This higher rate of suicide is contributed to a lack of mental health screening, inadequate investment in social services, and the inability of many people to pay for mental health treatment. Arkansas ranks 9th in the country as having the highest suicide rate.

Arkansas, we obviously have a problem.

The rising costs of healthcare and the rising threats of COVID-19 have amplified already precarious situations for millions of American households. This has many people barely hanging on economically, as well as mentally and emotionally.

The Affordable Care Act was implemented to decrease some of those barriers to access.

Since passing the ACA

Since the passing of the Affordable Care Act (ACA) the number of people with insurance coverage and access has increased. Before ACA 48 million people were uninsured. After the passage of the ACA that number has dropped to 30.4 million in 2018.

The Affordable Care Act mandated insurance cover the 10 essential health benefits, including mental health, prescription, and preventive services. It also eliminated pre-existing medical conditions as a barrier to coverage. Mental health and substance abuse services are among the ten essential health benefits that must be covered by insurance offered in the exchanges and by all new products sold in the individual and small-group markets. After the ACA passage insurance was required to cover mental health coverage the same as medical and surgical coverage. This is known as “parity,” and means that there cannot be greater cost-sharing or other limitations for mental health services.

Access to coverage has increased for millions of Americans, especially the young adults in our country. Since the passage of the ACA in 2014, the uninsured rate has declined sharply. The number of uninsured Americans, ages 19-64, declined from 24% in 2013 to 14% in 2015. As of writing this, the national rate has declined even further to the current rate of 12.5%.

How other states have implemented the ACA

Arkansas chose a private option. With this option, the Federal Marketplace provides coverage to Medicaid expansion enrollees. This program is dubbed the AR Works Program, and so far it’s seen much success in delivering quality healthcare options to the citizens of Arkansas. Arkansas saw one of the top ten declines in uninsurance rates in the country, down to 8.5%, beating the national average.

250,000 Arkansasans are on AR Works, and almost 900,000 are served by the Medicaid program. 

AR Works covers adults earning at or below 138% of the federal poverty level (FPL) $17,609 individual and $36,153 family of 4. But the program helps more than just the working poor.

There are scaled subsidies available for incomes between 139%-400% FPL or between $17,736 and $51,040 for an individual, and $36,418-$104,800 for a family of 4. The Medicaid expansion and premium tax credits help moderate-income people afford health insurance they could not afford prior. This has increased healthcare access for millions of Americans, improving financial security, health outcomes...and ultimately saving lives.

If ACA is overturned

If the ACA is overturned, states that signed onto the Affordable Care Act won’t see coverage go away immediately, as it will take a while for the wheels of legislative change to turn. But states that opted for a private option, like Arkansas, will see their coverage end shortly after the ACA is undone. Eventually, it will impact everyone, with 20 million people losing coverage nationally. 

It will also disproportionately affect POC. 1 in 10 nonelderly black, and 1 in 10 nonelderly Hispanic will lose their coverage, compared to 1 in 16 white people.

The state will also bear the burden of the repeal, by shouldering the uncompensated and unpaid medical costs of those without coverage and means to pay. In a pandemic, this can be an especially heavy burden for state and local governments to shoulder. Since the passage of the Affordable Care Act, uncompensated care costs have dropped by 57% as a share of hospital budgets. This has lifted much of this burden on the under-insured or the uninsured. It has also helped to keep rural hospitals and community-based providers open and running. 

Healthcare coverage and COVID

An estimated 5.4 million American workers lost their health insurance from February through May, one study finds. Nonprofit Kaiser Family Foundation estimates that about 27 million in total are at risk of losing coverage during the coronavirus pandemic, and could be left struggling with COVID-19 or other illnesses along with a lack of income that can make paying medical bills nearly impossible.

In Arkansas, it is estimated that 169,000 Arkansans lost their job-based healthcare coverage during the past 6 months due to COVID-19. It is also estimated that 56% of those Arkansans are eligible for Medicaid coverage, and another 28% will be eligible for marketplace coverage with premium tax credits. The Kaiser Family Foundation estimates that four out of five Americans who lost their employer health insurance are eligible for help through the Affordable Care Act or Medicaid, but many do not know about it.

The ACA may be just what rural, southern areas like Arkansas needs to stay afloat during this difficult time, both in physical and mental health. But what does the future hold for programs like AR Works? How will the state shoulder the excess burdens of its newly uninsured? And there are even more questions if the ACA is overturned.

Will COVID-19 become a pre-existing condition? If the ACA is repealed pre-existing conditions will no longer be required coverage by insurance companies. Will individuals currently receiving coverage for mental health care no longer have access to it? Will people who feel ill not seek treatment because a doctor’s visit is one more bill than they can pay? Will this cause a surge in COVID cases as sick people do their best to make ends meet?

There are more questions than answers when it comes to this. And unfortunately, the path forward is far from clear. 

https://www.cbsnews.com/news/covid-pandemic-health-care-25-million-risk-losing-coronavirus/

https://wallethub.com/edu/drug-use-by-state/35150/

https://www.mhanational.org/issues/ranking-states

https://www.healthsystemtracker.org/indicator/spending/per-capita-spending/

https://www.healthcare.gov/coverage/what-marketplace-plans-cover/

https://www.commonwealthfund.org/blog/2020/aca-10-how-has-it-impacted-mental-health-care