But the ACA aims to change that by including behavioral health as one of 10 essential benefits that plans must cover in order to be sold on the ACA marketplaces.
So why aren't people flocking to therapists? People are still learning how to use their new plans. And "there is still a lot of stigma" attached to mental illness, Kleven said.
Caregivers say the main reason people aren't clamoring for care is Pennsylvania's reluctance to expand Medicaid, leaving a gap where no subsidized or free insurance is available.
"The main issue is the Medicaid gap," said Joseph Rogers, chief advocacy officer for the Mental Health Association of Southeastern Pennsylvania. "If you don't have private insurance and you are not poor enough to be on Medicaid, it is very difficult to get behavioral-health services because not enough people provide it on a sliding-scale basis."
Rogers said many people that his group helps have serious challenges, from schizophrenia to major depression. Though some work part-time, most can't hold a full-time job. So they can't get covered at work and don't earn enough to qualify for a tax-credit subsidy in the marketplace.
"We know that there are people falling through the [Medicaid] hole," Rogers said. "If you have private insurance and have enough to pay some co-pay, you are probably going to be able to see somebody. But those people who don't have money are not going to get the care, and that is disappointing."
Seeing a therapist regularly can be costly. If one even takes insurance, co-payments can be $25 to $45 a visit. With sessions scheduled weekly, that adds up quickly.
"It does kind of become a trade-off," Rogers said. "Do I pay the electric bill or do I get some counseling?"
No one expected the health law to fully solve the behavioral-health or substance-abuse problem. Including them as essential coverage, however, has helped focus attention, says Sanjay Nath, director of the Institute for Graduate Clinical Psychology at Widener University.
"For Health and Human Services and the president to put their weight behind the epidemic of substance abuse and have it listed together with mental health is a major shift in policy," Nath said. "One of the areas the ACA is going to change the most is substance abuse."
In the past, Nath said, many substance-abuse services - rehabilitation, detoxification, and residential/transitional care - were "carved out" and had stricter rules for use.
Though the ACA makes coverage of substance-abuse treatment essential, it does allow states to choose what insurance will cover, Nath said. Pennsylvania has adopted substance-abuse coverage for in-patient and residential care. And Nath said there were signs other states would follow suit.
The ACA also reinforces earlier laws requiring behavioral-health services to have similar payment rates as medical and surgical practices. Nath hopes that in five years, both fields will be on par.
"If you go back a decade," he said, behavioral health "had separate co-pays, separate policies, separate contract for behavioral health with worse coverage typically than physical health care. That era is over, and that is a huge relief."