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By Joel E. Miller, Executive Director and Chief Executive Officer
American Mental Health Counselors Association

Dashed Hopes—or a Second Chance?—for  People With Mental Illness

For the first time, nearly 7 million uninsured Americans with a mental health condition—out of 49 million uninsured Americans—are eligible to receive health insurance coverage and access to non-emergency mental health services. This accomplishment is the result of the New Medicaid Expansion Program of the Affordable Care Act (ACA), which offers more than $800 billion in federal funding to states over the next 10 years to expand Medicaid. 

(Another 6.6 million uninsured people with a mental health condition are eligible for coverage through 16 new state health insurance exchanges known as marketplaces and—for the remaining 34 states that decided not to set up state online insurance marketplaces—through the national marketplace,

So far, 25 states and the District of Columbia have opted to take advantage of the $800 million in federal money to provide, through the expanded Medicare program, overall health coverage and mental health services to adults with incomes of up to 139 percent of the Federal Poverty Level (FPL). The New Medicaid Expansion Program will improve individuals’ mental health, extend thousands of lives, increase economic growth, and strengthen the financial stability of hospitals—on which both rich and poor rely. 

In the aftermath of the Sandy Hook Elementary School tragedy in 2012, many lawmakers of all stripes promised to provide better access to key services for people with mental health conditions, and improve our public mental health systems that are in shambles due to major budget cuts over the last two decades. 

However, a new study that AMHCA released on Feb. 26—”Dashed Hopes, Broken Promises, More Despair: How the Lack of State Participation in the Medicaid Expansion Will Punish Americans With Mental Illness”—shows that 25 states that could improve the plight of people with serious mental health illnesses have refused to participate in the new Medicaid coverage initiative. The result: Nearly 4 million uninsured people with mental health conditions will be locked out of the health insurance system. They therefore will lack access to timely, quality mental health services and a consistent source of care. Nearly 8 in 10 of this group of uninsured people reside in 11 Southern states that have refused to participate in the coverage expansion effort.

If this policy persists, millions of people with a serious mental and substance use condition—or both—will find themselves out in the coverage cold—unable to afford unsubsidized private insurance and also ineligible for both the public safety-net program and subsidies to purchase plans in the ACA marketplaces in their states.

When uninsured people with mental health conditions gain Medicaid coverage, they become healthier and their life expectancy increases, but in states that refuse to expand Medicaid, citizens will see their hopes dashed for a better life and better health. 

From an ethical point of view alone, governors and legislators who refuse to fully participate in Medicaid Expansion must face up to the moral implications of blocking mental health coverage for their most vulnerable constituents. This policy choice is not only unconscionable; it harms everyone in those states, whether insured or not. 

Governors and state legislators who fight the healthcare law by failing to use available federal funds to expand Medicaid enrollment also compromise the economic competitiveness and fiscal outlook of their states, according to data developed by healthcare advocates, hospital associations, think tanks, universities, and researchers. 

But let’s remember why the Medicaid Expansion program matters: We are talking about uninsured adults with a mental illness with no children who can’t get Medicaid now in most states, no matter how poor they are. Those eligible adults with a mental illness are of all races, with the majority white, but minorities are disproportionately represented. Under the ACA Medicaid expansion, everyone with an income below 139 percent of the FPL—regardless of their age, sex, or parental status—would be able to qualify for new Medicaid coverage. 

Medicaid coverage means better mental health for millions who, with no regular source of health-care and no way to pay for medical services, cur-rently don’t get preventive care, and are likely to put off seeing a mental health practitioner when they’re sick or think something is wrong. 

When these individuals get so sick they have to seek care, they come to our emergency departments with serious mental health conditions that could have been addressed or even avoided if treated earlier. With Medicaid coverage, they will be able to see a mental health provider in a timely manner and avoid inefficient use of overall medical resources.

Medicaid Expansion offers states a historic opportunity to improve the mental health of their residents and extend their lives and productivity while infusing billions of federal dollars into state economies.

In 2009, ideologues opposed to health reform spread phony stories about “death panels” to scare Americans into thinking the law would block their medical care when they needed it most. These falsehoods about the ACA were thoroughly debunked. Now in 2014, it turns out that the only real death panels consist of governors and lawmakers standing in the doorway of New Medicaid Expansion, blocking access to services for nearly 4 million uninsured Americans with a mental illness, and many more who will need mental health services in their lives.

State policymakers—namely governors—need to say yes to the New Medicaid Expansion Program. Otherwise their enduring legacy will be that they denied health insurance—paid for by the federal government at almost 100 percent—to their most impoverished, vulnerable citizens. 

Make no mistake: Improvements in care for people with mental illness begins with better access to health insurance coverage. The health and lives of these individuals are on the line, and in the hands of 25 states.

AMHCA asks its members in the 25 states to engage the media, policymakers, and other decision-makers on the need for your state to say yes to the Medicaid expansion. AMHCA’s new report, “Dashed Hopes,” and state–related press releases and fact sheets are on our home page at Please send them to your governor, your local elected officials, and your provider associations.

It is critically important for your voice to be heard. Your practice may depend on it.