The ACA contains many important provisions that will improve access to health insurance coverage and health care for individuals with disabilities, including those with SMI and other psychiatric disorders. Because some provisions have the potential to expand access to coverage, the ACA is a significant step toward breaking the link between eligibility for Social Security disability benefits and public health insurance. This step may weaken the incentive to forego employment and remain on Social Security disability benefits to retain health insurance coverage. Similarly, because the ACA extends medical coverage to those who heretofore have been ineligible for or unable to purchase coverage, it also has the potential to increase access to employment services and supports in a number of ways.
In January 2014, provisions of the ACA that allow states to expand their Medicaid programs went into effect. In states that accept this option, low-income and moderate-income residents who do not meet the definition of disability for SSI or SSDI or are otherwise ineligible for Medicaid will be able to obtain health insurance. As of January 2014, about half of the states are implementing this expansion. States have the flexibility to provide alternative benefits instead of traditional Medicaid services to individuals newly eligible for Medicaid under the ACA. On the other hand, they also have the option to provide the full package of Medicaid benefits to new beneficiaries and design benefit packages for specific populations, such as individuals with SMI. This option might encourage the expansion of Medicaid-funded employment supports. Additional Medicaid options, such as the option to offer health home services to certain Medicaid beneficiaries, the adoption of ACOs, and enhancements to the section 1915(i) state option for HCBS, might also serve as avenues for the provision of employment services. An individual's access to expanded Medicaid services, however, remains dependent upon the state in which he or she resides.
Other reforms to the private health insurance market are also likely to increase access to health insurance and services for people with mental illnesses. All new individual and small-group plans are required to offer mental health and substance use disorder services and comply with federal parity requirements. Prohibitions on pre-existing condition exclusions are also likely to offer individuals with pre-existing psychiatric disorders and other disabilities improved access to coverage, and restrictions on annual and lifetime limits are important for those with high health care costs. Though private plans are somewhat unlikely to cover a full range of employment services, increased availability of health insurance and consistent access to appropriate care are critical to a person's ability to maintain health and secure and retain employment.