Behavioral and Mental Health Care Policy and Practice

A Biopsychosocial Perspective

Cynthia Moniz, Stephen Gorin, Cynthia Moniz, Stephen Gorin

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9781317279815
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

Cynthia Moniz and Stephen Gorin's Behavioral and Mental Health Care Policy and Practice: A Biopyschosocial Perspective is a new mental health policy textbook that offers students a model for understanding policy in a framework that addresses policy practice. Edited to read like a textbook, each chapter is written by experts on an aspect of mental health policy. The book contains two parts: Part I chronicles and analyzes the evolution of mental health policy; Part II analyzes current policy and teaches students to engage in policy practice issues in different settings and with diverse populations.

Part I

Where We Are and How We Got Here

CHAPTER 1 BEGINS WITH CURRENT FEDERAL POLICY FOCUSING on the Affordable Care Act to introduce students to the current state of behavioral and mental health policy in the United States. It provides a brief overview of the social and political policy environment, including the Trump administration’s effort to “repeal and replace” the ACA, and examines the role of the ACA in improving access, quality, and cost related to behavioral health. This discussion includes parity, as well as the expansion of insurance, efforts at system redesign to include integration of primary care and behavioral health, and issues related to the workforce.

Chapter 2 then takes us back to early efforts to establish mental health policies, programs, and initiatives beginning in the 1800s with the mental hygiene movement. The chapter examines treatments that evolved in the 1940s and 1950s through the National Mental Health Act of 1946 and systemic changes that were the result of the Mental Retardation and Community Mental Health Center Construction Act of 1963. The role of Medicaid, Medicare, and other government benefits in the deinstitutionalization movement are discussed. Additional government initiatives in mental health treatment, including gaining of awareness of the role of co-occurring alcohol and substance abuse in mental health and the influence of the National Institute on Drug Abuse (NIDA), which began in 1972, are covered. The chapter concludes with a review of mental health initiatives that began with the 1977 Community Support Program and the 1980 Mental Health Systems Act.

Chapter 3 addresses the Reagan and Bush years, which were characterized by decreasing mental health funding, deinstitutionalization of mental hospitals, and shifting responsibility to the states to provide care. Managed care mechanisms, including health maintenance organizations (HMOs), became a popular means of cost containment. Community mental health was imperiled by the ongoing devolution policies of the Republican administrations in the 1980s and early 90s, and states were forced to create their own responses to decreased funding to community mental health centers.

Chapter 4 focuses on the valiant but failed effort to achieve universal health care through the Health Security Act by the Clinton administration and its impact on mental health policy and behavioral managed health care. With the failure of the act, a three-tiered mental health system structure emerged with public, private for-profit, and private not-for-profit components, putting the near-poor at greatest risk for lack of access to care. The emphasis in mental health policy shifted to cost containment, efficiency, and effectiveness, including the application of a managed care model to mental health services, accountability, wraparound services, and evidence-based practice. In 2002, under George W. Bush, the President’s New Freedom Commission on Mental Health was enacted to undertake a comprehensive review of the mental health system, but little funding was available to pursue the commission’s recommendations. By the mid-1990s, policy reform efforts shifted to mental health parity with passage of the Mental Health Parity Act (MHPA) of 1996, which unfortunately had little impact until passage of the Paul Wellstone Mental Health and Addiction Parity Act (MHPAE) of 2008.

Chapter 5 provides an overview of the complexity of behavioral healthcare provision and delivery structures in the U.S., the fragmented financial system (Medicare, Medicaid, private insurers, fee-for-service, managed care), and the impact of recent legislation on behavioral and mental health care, including the Mental Health Parity and Addictions Equality Act (MHPAEA) of 2009, Affordable Care Act (ACA) of 2010, Comprehensive Addiction and Recovery Act (CARA) of 2016, and 21st Century Cures Act (Cures) of 2016. The chapter concludes with areas not covered by existing policies and offers suggestions for future policy actions.

Chapter 1

Behavioral Health and the Affordable Care Act

John Orwat and Whitney Key

Introduction

WITH THE INCLUSION OF INDIVIDUALS RECEIVING INPATIENT CARE for mental health needs, the cost of mental health care in the United States exceeded $201 billion in 2013 (Roehrig, 2016). The Patient Protection and Affordable Care Act (ACA) is the largest piece of health care legislation since Medicare (Public Law 89–97) in 1965. It touches on every aspect of healthcare to include payers, providers, purchasers, and consumers. The ACA targets three performance concerns in health care: the need to increase access, improve quality, and manage costs. In this chapter, we examine the approach taken by the ACA regarding behavioral health, which is inclusive of mental health and substance use disorders. The environment for behavioral health encompasses a patchwork of federal, state, and local policies and funding streams. In alignment with the grand challenges of social work, outlined by the Academy of Social Work and Social Welfare, we will include the suggestions for a transdisciplinary approach to prevention while integrating systemic collaborative partnership.

For the purposes of this chapter, we focus on federal efforts, with a specific concentration on the ACA. This chapter starts with a brief overview of the policy environment with regard to behavioral health. Then, it spotlights specific aspects of the ACA as they pertain to improving access, quality, and cost related to behavioral health to include the conditions to which the ACA responds (impetus) and a review of the current state of behavioral health services. This discussion includes parity, as well as the expansion of insurance, efforts at system redesign to include integration of primary care and behavioral health, and issues related to the workforce. We conclude by describing possible next steps.

The Policy Environment

People with behavioral health problems were drastically overrepresented among the uninsured population prior to the Affordable Care Act (Frank, Beronio, & Glied, 2014). Under the ACA, behavioral health services have been drastically broadened by the expansion of access to include wider access to health insurance and the inclusion of behavioral health in the ten essential benefits required of health plans. However, definitions of behavioral health are varied, which leads to challenges in the identification of patients as well as the delivery of services. According to the Substance Abuse and Mental Health Services Association (SAMHSA) (2014), behavioral health is defined as “mental/emotional well-being and/or actions that affect wellness.” Mental health is characterized as “changes in thinking, mood, and/or behavior. These disorders can affect how we relate to others and make choices.” Serious mental illness, or SMI, is “at any time during the past year, a diagnosable mental, behavioral, or emotional disorder that causes serious functional impairment that substantially interferes with or limits one or more major life activities.” Serious emotional disturbance is

used to refer to children and youth who have had a diagnosable mental, behavioral, or emotional disorder in the past year, which resulted in functional impairment that substantially interferes with or limits the child’s role or functioning in family, school, or community activities.

Substance abuse occurs when “the recurrent use of alcohol and/or drugs causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home.” Co-occurring disorders are the coexistence of both mental health and substance abuse disorders. While all definitions are similar, they are thought of differently from a medical standpoint and are subsequently funded and treated differently by providers.

Coverage has been sporadic prior to the ACA for mental health and substance abuse disorders, and to some extent continues to be. This is the result of the view that behavioral health is different from physical health and a moral problem. Traditionally, mental health care and substance abuse treatment have been considered specialty care and not necessarily integrated into the primary care setting, in many cases funded separately, and often came with different benefit structures to include limits on mental health and substance abuse treatment, higher copayments, etc. Because of this, many practitioners failed to understand the complexities of each disease and ultimately inadequately treated the patient. These differentiations are counterintuitive in thinking, considering research that shows that there are many similarities between the different diseases, and there is value in the understanding and treatment of conditions. It was not until the 1990s when parallels were identified between behavioral health problems and other chronic physical diseases (e.g., diabetes, cardiovascular disease) (McLellan, Lewis, O’Brien, & Kleber, 2000). Despite continued popular belief that behavioral health problems are related to moral deficiencies, researchers and physicians increasingly treat such issues from a medical standpoint. Treatment for substance abuse was also applied to chronic disease management, suggesting that a lifetime of monitoring the disease was important for quality of life. However, individuals of lower socioeconomic status or having a co-occurring disorder were the most vulnerable, as coverage for such treatments were not adequately covered by private insurers or federal programs such as Medicaid or Medicare. This, combined with stigma, made access and utilization of care more difficult for patients and therefore only increased the stigma of mental health disorders.

Prior to the ACA, when behavioral health disorders were diagnosed, treatment was more likely out of pocket, as many private insurers did not cover such services, particularly on the individual market (Frank et al., 2014). Private insurers placed more limitations on mental health services to include lifetime caps and created higher copayments for mental health care. Many policies also did not include mental health coverage or offered coverage at extreme prices (Montz et al., 2016). In 1996, the Mental Health Parity Act (MHPA) required annual or lifetime dollar limits on mental health benefits to be no lower than any such dollar limits for medical and surgical benefits offered by a group health plan or health insurance issuer offering coverage in connection with a group health plan. Prior to MHPA and similar legislation, insurers were not required to cover mental health care and so access to treatment was limited, underscoring the importance of the act. In 2008, the Paul Wellstone and Pete Domenici Mental Health Parity and Addictions Equity Act (MHPAEA) extended the MHPA to now include substance abuse disorders (Frank et al., 2014).

With regard to substance abuse treatment, the Treatment Research Institute in Philadelphia reports that there are approximately 12,000 addiction treatment programs nationally (Treatment Research Institute, 2017). Of these programs, 80% are outpatient based, 10% are residential, and 10% are methadone clinics. Sixty-six percent of the programs are nonprofit and often dependent on government block grants to help cover the actual costs of providing services. When grant monies are reduced, waiting lists or even closures may occur. Policies vary for individual coverage and types of substance abuse treatment. Many insurance policies will state they cover 30 days of inpatient treatment, but rarely does an individual have all 30 days covered (Treatment Research Institute, 2017). In the MHPAEA and the ACA, coverage of such disorders expanded, as the MHPAE mandates that coverage of mental and behavioral health disorders must be covered the same amount as medical care under commercial insurers. The ACA also mandates that no insurance company can deny coverage based on a preexisting condition, such as mental health and substance abuse. This coverage was a major economic relief for many families that suffered from either a mental health disorder or substance abuse, and many times both disorders.

The Patient Protection and Affordable Care Act

The ACA employs a variety of interventions to increase access, improve quality, and manage costs. Certainly, a full description of the legislation is beyond the scope of this chapter. Here, we focus on four interventions of particular salience to behavioral health: expansion of health insurance, making behavioral health an essential benefit for health insurance plans, system redesign to include parity, and workforce issues.

Health Insurance

Health insurance is the strongest predictor of access and outcomes to health care. Payers design the behavioral health care delivery system through their network development and benefit design activities. Those with health insurance have greater access and better process and outcomes (Han, Gfoerer, & Colliver, 2010). However, obtaining health insurance has been difficult for the non-group market (e.g., those without group [employer]-based health insurance). Obtaining health insurance on the individual market was problematic, because it is difficult to spread risk, a key to any insurance, among an individual or unknown group. To manage this possibility, health insurers did not enter the non-group or individual market. If they did, the plans excluded those with preexisting conditions and had limited benefits, narrow networks of providers, and lifetime limits. This led to health plans that were very expensive and did not provide many benefits, if they were available at all.

This is particularly true of behavioral health. Prior to the ACA, only one-third of health plans on the individual market offered any type of substance use disorder benefit, and those that did had strict controls with regard to cost sharing, lifetime limits, provider networks, etc. (Montz et al., 2016). However, these coverages did not include mental and behavioral health packages, therefore treatment and subsequent coverage was not active during this time. Medicaid was no exception. Although Medicaid programs differ, most plans covered little more than detoxification from alcohol or the illicit drug and follow-up, and continuous treatment was limited at best. Mental health and substance abuse were treated as two separate diseases, whereas today we know that the two are intrinsically related.

Authorized in 1965 by the Social Security Amendments (Pub.L. 89–97, 79 Stat. 286), Medicaid is the largest payer for behavioral health services, eligibility for which was expanded through the ACA. Medicaid is a public health insurance program for people who are low-income U.S. citizens or legal permanent residents, and may include low-income adults, their children, and people with certain disabilities (Kaiser Family Foundation, 2017a). The program is jointly funded by the state and federal governments and is administered by the states within specific federal parameters. Although states are not required to participate in Medicaid, every state does. Under the Affordable Care Act, Medicaid was expanded to include those with incomes below 138% of the federal poverty level, thus removing any categorical constraints and increasing income eligibility. Medicaid expansion is also optional for states, and 32 states (including the District of Columbia) have adopted the expansion (Kaiser Family Foundation, 2017a). Expansion, however, puts a heavier burden onto the states because the federal government only reimburses a percentage of those on Medicaid. Individuals diagnosed with behavioral health issues cost Medicaid nearly four times more than individuals without behavioral health issues (MACPAC, 2015), suggesting that there is a higher need among this population for coverage and care.

A formative evaluation of the expansion of Medicaid assessed the effects of coverage, access, utilization, affordability, and health outcomes. Studies have demonstrated that the expansion of Medicaid resulted in a significant increase of coverage and a reduction in uninsured rates, specifically in low-income and vulnerable populations, such as young adults, prescription drug users, mothers, children, and early retirees (Kaiser Family Foundation, 2017a). This increase in enrollment was seen mostly with adults who did not previously qualify for the program and only in states that participated in the expansion. Similarly, rates of uninsured decreased across all racial and ethnic groups, which could suggest that the expansion has helped reduce income- and race-related disparities (Kaiser Family Foundation, 2017a). The expansion has led to a positive impact on access to care and utilization of services, specifically with behavioral health services. Research implies that there was a larger reduction in out-of-pocket medical spending for states that adopted the expansion, as well as a decline of the inability to pay major medical bills (Kaiser Family Foundation, 2017a). Although long-term health outcomes have not yet been discovered with the expansion, preliminary reports found improvements in perceived health outcomes due to individuals receiving life-saving or life-altering treatments (Kaiser Family Foundation, 2017a).

The ACA attempted to fill the non-group market gap by the expansion of coverage and access to and utilization of healthcare services. For those who do not qualify for Medicaid under the ACA expansion and did not have commercial or private insurance, government exchanges were ava...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Preface
• Part I Where We Are and How We Got Here
• Part II Policy Practice: Advancing Access to Behavioral and Mental Health Care
• About the Authors
• Glossary
• Index