Medicaid expansion programs vary in mental health benefits
Coverage for mental illnesses and substance abuse disorders in state plans and proposals to cover the uninsured generally involve Medicaid expansions, parity, limited coverage, or minimal or no benefits.
A report by the National Alliance on Mental Illness (NAMI) and the National Council for Community Behavioral Health care says people with mental illness and substance abuse disorders are prevalent in the uninsured population. More than 25% of uninsured adults have a mental illness, substance abuse disorder, or co-occurring disorder, according to data from the 2005 and 2006 National Survey on Drug Use and Health. And one-third of people with mental illness, substance abuse disorders, or both who are under the federal poverty level are uninsured.
"Not having insurance is a significant roadblock for people with mental illness and/or substance disorders," according to the report. "Almost 80% of people with these disorders who needed mental health treatment but did not receive it cited cost as the reason. Underinsurance also is a problem, with 34% of insured people who had unmet mental health needs indicating that cost was a barrier to seeking treatment."
The two groups say the consequences of untreated or undertreated mental illness, substance abuse disorders, and co-occurring disorders can be quite severe. Nearly one-fourth of all stays in U.S. community hospitals involved depression, bipolar disorder, schizophrenia, and other mental health or substance abuse disorders. Two-thirds of the U.S. homeless population are adults with chronic alcoholism, drug addiction, mental illness, or some combination of the three. And 16% to 23% of jail, state, and federal prison inmates have a serious mental disorder, and adults with serious mental illnesses die 25 years sooner than those who do not have a mental illness.
"Given the health and economic consequences of untreated mental illness and substance abuse disorders, along with the high prevalence of those conditions in people who are uninsured, states that do not include benefits for their residents will fail to address significant treatment needs of a considerable percentage of the uninsured, leaving them to suffer poor health and economic distress," the report asserts.
NAMI director of public policy and advocacy Mary Giliberti tells State Health Watch that historically people with mental health problems have been treated differently than those with physical health problems. "They were isolated into asylums or state hospitals that were separate from the health care system and offered little treatment," she says. "Also, mental health has been seen as a state responsibility rather than as part of the health system."
Several states are moving toward universal coverage and working to ensure that their lowest income residents have access to a full array of services funded under their traditional Medicaid program. For example, the report says, Maine, Massachusetts, Vermont, and Maryland expanded coverage to low-income populations such as childless adults and parents of poor children, and Illinois proposed a similar expansion.
A sizeable number of states have included parity in coverage between mental illness and/or substance abuse disorders and physical health conditions in their benefit package to cover the uninsured. But many states only provide parity for a limited set of mental health conditions such as "serious" or "biologically-based" mental illnesses and exclude substance abuse disorders. In these laws, serious mental illnesses typically include schizophrenia and other psychotic disorders, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, and panic disorder. The authors say that most of the implemented programs and state proposals seeking to cover all residents include a parity requirement, but many don't include treatment for substance use.
State programs in the limited coverage category impose limits on the number of visits or covered costs for mental illness and substance abuse treatment that are not imposed on other health conditions. States with limited coverage include Pennsylvania, New York, Rhode Island, Oklahoma, and Maryland.
States that provide minimal or no benefits for mental illness or substance abuse disorders often target small employers, and cost is a primary factor in coverage decisions. Healthy New York and Pennsylvania's adultBasic program provide the least benefits, specifically excluding mental illness and substance use treatment from coverage.
The two groups say a number of recommendations arise from their observations and analysis:
1. Parity for mental illness and substance disorders is an important component of health care reform efforts seeking to meet the needs of uninsured people. The inclusion of parity for serious mental illness or substance abuse in almost all of the state initiatives striving for universal coverage indicates a growing consensus to include these disorders as part of health care reform efforts. The need to address parity issues is particularly urgent in light of the high percentage of uninsured adults with substance abuse and co-occurring disorders.
2. Parity by itself does not ensure access to a broad array of services necessary to treat mental illness and substance use disorders. Most states also have addressed the scope of benefits, utilization management, cost-sharing, and provider availability in their health care reform initiatives.
3. To improve health outcomes, several states have included mental illness and substance use disorders in chronic care management and wellness initiatives.
4. States would benefit from access to information regarding efforts to address mental illness and substance use disorders in state programs to cover the uninsured.
5. To facilitate stakeholder input and informed decision making, health care expansion initiatives should clearly define the scope of benefits for mental illness and substance use disorders and specify whether people with those disorders are included in all parts of the reform effort.
Ms. Giliberti says the organizations believe that parity is important in benefit packages, but they also would like to see programs with a wide array of services available as part of the parity. She notes there are some federal bills pending dealing with parity and says any federal health care reform effort has the potential to offer people mental health and substance abuse benefits.
Download the report at http://healthcareforuninsured.org/.
Coverage for mental illnesses and substance abuse disorders in state plans and proposals to cover the uninsured generally involve Medicaid expansions, parity, limited coverage, or minimal or no benefits.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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