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Medicaid Expansion
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An Investment in States' Mental Health

By Joel E. Miller
AMHCA Executive Director & Chief Executive Officer

Health Insurance—The Pass-Key to Our Healthcare System

Mass shootings by individuals with a history of mental illness—particularly the tragedy in Newtown, Conn., and most recently at the Navy Yard here in Washington, D.C.—have sparked legislative debates and public conversation about mental health in the United States. 

One positive result of the discussions is a growing awareness of the drastic effects of the sustained budget cuts that have strained the publicly run state mental health systems across the country. In the aftermath of the shootings, many congressional and state politicians and policymakers promised to take steps to fix America’s broken mental-health delivery system. 

It hasn’t happened yet. 

Many decision-makers do not recognize that the burden of mental illness in the United States is incredibly significant due to increasing numbers of uninsured people with mental health conditions, as well as an underfunded mental health system. The lack of health insurance coverage keeps people with mental illness from obtaining needed services and treatments as well as follow-up care. Whole families and communities suffer needlessly because of it. Health insurance coverage is the pass-key to our healthcare and mental-health delivery systems.

Read the full “Dashed Hopes” report, which includes additional tables and graphics

Access individual state press releases and fact sheets

AMHCA members and AMHCA state chapter officials should use these materials to engage their state media, policy-makers, and other decision-makers on the importance of opting in to the New Medicaid Expansion Program in 25 states that so far have refused to participate.
  Enter the New Medicaid Expansion Program. This program, part of the Affordable Care Act (ACA), addresses both the growing problem of uninsured people with mental health conditions and state mental budget problems. Expanding Medicaid through the ACA in all states would represent a significant step toward keeping those promises to fix the mental health system.

AMHCA’s recently released report—“Dashed Hopes, Broken Promises, More Despair: How the Lack of State Participation in the ACA Medicaid Expansion Will Punish Americans with Mental Illness”—makes the compelling case that uninsured people with mental illness is a profound policy and societal problem that can be addressed though the New Medicaid Expansion Program.
Geography Is Destiny—And It Shouldn’t Be

Unfortunately, 25 states that could address this problem in a significant way refuse to participate in the new Medicaid program. The New Medicaid Expansion Program is a voluntary program that’s part of the ACA. Uninsured citizens with a mental illness who experience the misfortune of residing in those 25 states will see their hopes dashed because they will not be able obtain health insurance coverage—that they are eligible for under the ACA—due to a policy decision by their state’s lawmakers. 

We believe the decision of those 25 states not to participate in the Medicaid Expansion is misguided, alarming, and a dangerous stance.

Major Findings From AMHCA’s “Dashed Hopes” Report Include:
  • Nearly 7 million uninsured people with mental illness are
  • eligible for health insurance coverage in all 50 states under the new Medicaid Expansion Program. (See Figure 1, adjacent.)
  • This group of uninsured people represents about 15 percent of all uninsured people in the United States.
  • Nearly 4 million uninsured people with a serious mental illness (SMI), in serious psychological distress (SPD), or who have a substance use disorder (SUD), are eligible for health insurance coverage through the New Medicaid Expansion Program in 25 States that have refused to participate in the program. (See the map at the end of this article.)
  • This group represents 55 percent of all uninsured people with major mental health disorders who are eligible for coverage under the New Medicaid Expansion.
  • Over 75 percent (2.7 million adults) of all uninsured people with a serious mental health condition or substance use disorder, who are eligible for coverage in the 25 non-expansion states (3.7 million), reside in the 11 Southern states that have rejected the Medicaid Expansion. (See Figure 2, below right.)
  • In Texas and Florida alone, more than a million uninsured people with serious mental health and substance abuse conditions are eligible for coverage under the New Medicaid Expansion Program. However, Texas and Florida officials have said they will not participate in the initiative, therefore leaving their most vulnerable citizens without health insurance, even though it would be paid for in full by the federal government for the first three years of the progr
  • am, and at 95 percent  in 2017 and 90 percent going forward.
Overall National Findings Include:
  • More than 10.6 million who are uninsured and eligible for coverage under the Medicaid Expansion program live in the 25 states that have rejected the Expansion.
  • Nearly 8 in 10 of all uninsured persons who are eligible for health insurance coverage under the Medicaid Expansion effort (10.6 million) reside in the 11 Southern states that have refused to participate in the new coverage program.

So not only will we see millions of people with a diagnosed mental illness denied coverage, but millions more will be left uncovered—many who may have an undiagnosed mental health condition and many others who could benefit from comprehensive benefits that include mental health and substance use services.
Key Characteristics of the Medicaid Expansion Include:
  • Specifically, 53 percent of all uninsured adults who are eligible for coverage through the Medicaid Expansion are between the ages of 18 and 34. (See Table 1.) The vast majority of mass shootings by young adults with mental illness are in this relatively narrow age category.
  • Over one third of the uninsured population with a serious mental illness in the states of California, Texas, and New Mexico are Hispanic residents, and are eligible for health coverage under the Medicaid Expansion program.
  • The majority of uninsured people with substance use disorders have a high school education or less, are white males between the ages of 18 and 34—and are eligible for health coverage under the Medicaid Expansion program.
Raising the Visibility of Mental Health Through Expanded Coverage

The decision made by the 25 “left behind” states not to participate in the Medicaid Expansion will commit millions of their fellow citizens who are suffering with a mental illness to poor health, more poverty, and more despair. Their dreams of receiving affordable health insurance and healthcare will be dashed. 
Passage of the ACA was a major milestone in long-standing efforts to ensure access for all Americans to appropriate, high-quality, affordable mental healthcare and prevention and treatment services, as part of overall healthcare.

Many of the most prominent features of the ACA were instrumental in establishing the centrality of overall mental health services within the overall healthcare delivery system—such as the designation of mental health and addiction services as one of the 10 categories of essential health benefits (EHB).

As originally conceived, this designation as an essential health benefit provides a comprehensive range of covered prevention and treatment services. These include early identification and screening in primary care, through early inter-ventions and acute treatment, through chronic care-management activities, including case management, both in person and over the phone and Internet. 

Under our current mental health—and overall healthcare system—we wait until young adults with severe mental health conditions become very sick and have suffered serious consequences before treating them. Yet delayed treatment is associated with incomplete and prolonged recovery.

What better way is there to dramatically reduce stigma, discrimination, and outright rejection that have kept people from seeking help than to open the “Coverage Door” to those with mental illness so it is treated like any other illness? That is exactly what the ACA’s Medicaid Expansion Program does if all states participate in the initiative. 

Moreover, the legislation transforms an expanded Medicaid program from one that in the past targeted specific groups of people—such as pregnant mothers and children living in poverty—to a much more comprehensive health insurance program open to all individuals living at or under 138 percent of the Federal Poverty Level. The Medicaid Expansion would provide a significant safety net for now left out “in the coverage cold.” 

Keeping Promises

The promises that policymakers made to address the needs of people with mental illness after the terrible tragedy in Newtown, Conn., will go unfulfilled if they oppose the Medicaid Expansion in their states.
There is no practical or financial argument for governors and legislators in the 25 states that have rejected the Medicaid Expansion to continue refusing to participate in the program:

  • Long-term care for people with the mental health conditions represents a large plurality of expenses by the state programs. The Medicaid program and the federal government would pick up a significant percentage of these costs, which the states are currently paying for.
  • Those currently uninsured in community mental health centers, whose expenses are being absorbed entirely by the states, will be shifting to Medicaid under the new legislation at a significant matching rate.
  • By not opting into the Medicaid Expansion, states will continue to face higher costs associated with unnecessary use of emergency departments and hospitals by people with mental illness who go there as a last resort. States will also face continued demands on their criminal and juvenile justice systems, social service agencies, and related programs due to lack of available mental health services.

The Medicaid expansion is a win-win-win for currently uninsured people with mental health conditions, for state budgets, and entire state economies. 

Don’t miss this opportunity to help uninsured people with a mental illness gain coverage through the new Medicaid program. It’s the right thing to do, and though virtue is its own reward, in this case it will also result in bringing more clients into your practice. 

Here Are Some Ways You Can Help Turn the Tide Toward Acceptance of Medicare Expansion in Your State

We urge AMHCA leaders, all AMHCA members, and grassroots advocates to work together with other healthcare groups and to meet with state officials in the non-expansion states to reconsider their positions on the Medicaid Expansion.

Use the data in this report to document the number of people in your state who are eligible for coverage under the Medicaid Expansion to show how it would help your community. 

You can help make the Medicaid Expansion a reality by:

  • Contacting your elected officials at the state level;
  • Writing a Letter to the Editor or a guest column in your local media, and
  • Creating or joining state campaigns and grassroots efforts to inform residents and policymakers about the benefits of the New Medicaid Expansion Program.

The New Medicaid Expansion Program has the capacity to help states redirect funds from jails, prisons, and crisis-driven services, such as traditional homeless shelters and hospital emergency departments, into community-based programs and evidence-based treatments.

We can and must improve mental health services in our country; ensure quality, safety, and adequate oversight; and improve access to recovery-based care. 

The new Medicaid Expansion initiative is good for people with mental illness, their families—and the states in which they live.

MAP: Number of Uninsured Adults With Serious Mental Health and Substance Use Conditions Eligible for Coverage in the 25 Medicaid Non-Expansion States

Note: All grahpics in the article are drawn from the “Dashed Hopes”  report 
and were created by Devall Advertising.