Resisting Medicaid Expansion Limits Access to Mental Health Care

SP2_ThumbnailStates’ refusal to expand Medicaid eligibility is barring an estimated 2.6 million low-income Americans from affordable, necessary mental healthcare, according to a 2015 report from the Substance Abuse and Mental Health Services Administration (SAMHSA).

Under the Affordable Care Act of 2010 (ACA), states were given the option to expand Medicare eligibility to an estimated additional 37 million previously uninsured Americans. SAMHSA reports that 10.9 million of these uninsured adults had a behavioral health disorder. Nevertheless, as of this reporting, 19 states had opted out of Medicaid expansion or were still undecided. Variability amongst states in Medicaid eligibility standards means that low-income Americans often wont for adequate coverage, SAMHSA claims. Experts and advocates also emphasize that expanding Medicaid is not enough to improve the quality of mental health services for those most in need.

One of ACA’s key provisions was expanding Medicaid eligibility to those living at or below 138 percent of the Federal poverty level. The 2015 SAMHSA report shows that the recent Medicaid expansions have insured an additional 3 million low-income individuals living with mental illnesses who previously did not have access to regular treatment. For the estimated 2.6 million Medicaid-eligible individuals with mental health disorders living in the 19 states that have rebuffed ACA, their only recourse is to access subsidized private insurance through the insurance marketplace. But the majority of these plans have limits to mental health coverage.

According to a 2015 report from the National Alliance on Mental Illness (NAMI), Medicaid was the largest source of funding for the U.S.’ public mental health system, even though two-thirds of Americans are covered by private insurance plans. A 2011 report from the Kaiser Commission on Medicaid and the Uninsured notes that although “individuals with low incomes are more likely to have a behavioral health problem than those with higher incomes… among all 59 million [Medicaid] enrollees, only about five percent qualify for Medicaid based on a mental illness.” The data also suggest that individuals with no insurance and with private insurance use fewer mental health services than those with Medicaid.

“Medicaid’s behavioral health benefits are generally more comprehensive than those offered by other payers,” the Kaiser report explains, “and in some cases, Medicaid is the only insurer that covers a service needed by those with behavioral health problems.”

Mental health services covered by Medicaid programs also vary widely across the nation.

“I tell people that if you’ve seen one Medicaid program, you’ve just seen one Medicaid program,” quipped Mark J. Heyrman, clinical professor of law at the University of Chicago’s Mandel Clinic, where he has taught mental health advocacy since 1978.

Under federal statute, states have autonomy in the administration of Medicaid programs; only certain services are deemed “mandatory” by federal law, and mental health services are not one of them. Instead, states are given the flexibility to define what services are “medically necessary” for Medicaid beneficiaries.

“[The ACA] still allows states to devise their Medicaid plans in a way that makes sense to them, so mental health coverage really differs from state-to-state,” Heyrman said.

While all states’ Medicaid programs cover mental health hospitalizations, coverage of long-term care in community-based behavioral health centers is less universal, according to the 2011 Kaiser Commission report. In order to do so, states must file certain waivers to claim Federal funding for these outpatient services in the community.

The Center for Medicaid and CHIP Services (CMCS) reports that 80% of Medicaid enrollees access health services through managed care organizations, which limit beneficiaries to a network of certified providers and incentivize generic treatments in order to lower treatment costs. However, research published in the British Medical Journal and in the Journal of Health Service Research has shown that managed behavioral healthcare is potentially ineffective and may reduce the quality of care for those with severe mental illness.

Thus, even with insurance coverage, public mental health systems are chronically underfunded, understaffed, and inadequate, claim advocates including the Kaiser Commission and Dr. Phyllis Solomon, a professor at the University of Pennsylvania and an internationally recognized researcher in mental health clinical services.

Solomon contends that the mental health services offered in hospitals or community-based centers rarely meet the needs of their patients.

“[Patients] see a psychiatrist for a fifteen-minute [medication] check,” she said. “And otherwise, they see a case manager who, if you’re lucky, is bachelor’s trained — not clinically trained — so what kind of service are you providing?”

While most private insurance does not cover a broad spectrum of mental health treatments, they do cover pharmaceuticals.

The Kaiser Commission reports that 49 percent of adults with any mental illness received only prescription medication as a treatment. Another 32 percent received some sort of outpatient treatment in addition to a prescription, though this treatment could have been as short as a fifteen-minute medication check, as Solomon suggests.

The National Association for Mental Illness (NAMI) estimates that only four out of 10 adults requiring mental health care actually received adequate treatment. Just over half of all children with mental health disorders received any treatment.

Nevertheless, expanding access to more low-income Americans is a national concern for many mental health advocates and Medicaid is seen as a key driver towards progress.

“The Affordable Care Act is the most important law for people with mental illnesses in my lifetime. It dramatically expands community mental health services,” said Heyrman of the University of Chicago. Unfortunately, this optimism is met with the realities of differentiated implementation on a state-by-state basis and the refusal of some states to expand Medicaid.

Heyrman noted that funding that could go toward patient-centered care instead gets siphoned off into other institutions housing the mentally ill: psychiatric hospitals, prisons and nursing homes.

“The mental health system in this country is broken,” he said. “There is inadequate funding, and that funding is spent unwisely.”


Joshua LinBefore arriving at the University of Pennsylvania, Joshua Lin was a college access counselor at a traditional public school in Harlem, New York. He is currently an intern at Research for Action, a Philadelphia-based educational policy research organization, where he is assisting a project that is evaluating the impact of outcomes-based funding in higher education.


This story has been published in partnership with the University of Pennsylvania’s School of Social Policy & Practice (SP2). In the run up to the 2016 Presidential Election, the school launched “SP2 Penn Top 10, a comprehensive multimedia initiative in which renowned SP2 faculty members analyze and address the most pressing social justice and policy issues.”

Part of the project, is the creation of stories produced by “SP2 Penn Top 10 Fellows,” graduate students from the School who are trained in solution-based journalism using the Journalism for Social Change curriculum.

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