The ACA and behavioral health: A look ahead

After all the political maneuvering, the technical glitches with Healthcare.gov, the wrangling in state legislatures over whether or not to accept Medicaid expansion, this much is clear: this year, millions (exactly how many millions isn't clear yet) of Americans will either become newly eligible for Medicaid or will buy insurance plans through state- or federally-run marketplaces. And thanks to requirements within the Affordable Care Act (ACA) and the previous 2008 Mental Health Parity and Addiction Equity Act, many of those will receive coverage for services that were previously unaffordable or inaccessible.

Mental health and chemical dependency services providers, advocacy groups, and state agencies are bracing for an influx of new consumers, many of whom have little or no experience with either Medicaid or private insurance, and who face unique challenges in accessing services.

States that established their own marketplaces (rather than rely on the Federal marketplace model) got an early look at what may be coming. Behavioral Healthcare spoke to stakeholders in three of those states (Kentucky, Washington, and Connecticut) to find out what they've encountered so far, and what may lie ahead.

Cautious optimism

Amid trepidation about the logistics of enrollment and the accessibility of adequate services, there is also excitement and enthusiasm about what the ACA will mean for low-income patients. In Washington State, more than 270,000 individuals have been enrolled in coverage, either through Medicaid expansion or via private plans available on the state’s Healthplanfinder (www.wahealthplanfinder.org).

Adults who are childless, low-income, or seriously mentally ill “are going from a situation where at best they can't access services until they are in crisis, to becoming Medicaid eligible," says Jane Beyer, assistant secretary of the state’s Behavioral Health and Service Integration Administration. "They get not only a medical benefit, but also a more comprehensive set of mental health benefits. For that population of folks, those under 138 percent of the poverty level, it's access to a whole different level of benefits than they have ever had."

Across the country in Kentucky, the impact of the Affordable Care Act has been just as dramatic. Kentucky is the only southern state that accepted Medicaid expansion and established its own health insurance marketplace. There were an estimated 640,000 Kentuckians (roughly 15 percent of the state's population) without insurance prior to the ACA; Medicaid expansion alone is expected to affect 308,000 of those. The state already had nearly 800,000 Medicaid recipients.

Kentucky suffers from an acute shortage of behavioral healthcare services providers and a limited pot of money to fund consumer care. According to Dr. Allen Brenzel, medical director of the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities, the state's 14 community mental health centers (CMHCs) serve roughly 190,000 individuals annually, and about 30 to 40 percent of those people currently don't have a payer source for their care. "We've been limited in funding those without payers and we've really struggled to meet demand," he says.

With the Medicaid expansion, one of the most difficult to serve populations (childless adults that were not previously eligible for Medicaid) will now have coverage options that didn’t' exist before.

"We have never had substance abuse treatment as a covered benefit under our state Medicaid program," Brenzel says. But all that has changed. The benefit package associated with Medicaid expansion  “included a full and robust substance abuse treatment benefit, which will apply to standard Medicaid. That is earth-shattering for us."

In Connecticut, as many as 50,000 uninsured, childless adults could receive coverage via (Medicaid) expansion by 2020. In the meantime, though, the state has reduced funding for some mental health services in anticipation of the expanded share of coverage costs that are to be paid by the federal government, which will match at least 90 percent of costs for those newly covered by the Medicaid expansion. The budget currently under consideration there would provide $5 million in funds for services for the poor (including increased funding for youth services) and some new funding for subsidized housing.

"The budget passed last year made cuts to providers in the funding for uncompensated care," says Luis Perez, president and CEO of the Mental Health Association of Connecticut. "Hospitals and community providers took a fairly large hit. While they are being made whole this year, that is not necessarily something that will carry forward in years to come. We're taking a wait-and-see approach at this point."

"There has been a four-fold increase in the number of phone calls being received, from people looking for help," says MaryAnne Lindeblad, Medicaid Director for the Washington State Health Care Authority. "Keeping up with the demand for information about those who are just entering into the program is a big challenge. We're dealing with a new population that had not been there in the past."

"There are extra challenges in working with folks who are seriously mentally ill or chemically dependent, because they have been disengaged from the entire healthcare system," adds Beyer. "We're trying to engage them enough in wanting to seek care at all, other than at the emergency room. They have to have enough trust in the relationship to even be willing to enroll in Medicaid in the first place."

There still aren't enough providers

The availability of qualified mental health and addiction services providers - particularly qualified providers who accept Medicaid reimbursement - was a problem even before the passage of the ACA. A new influx of Medicaid-covered consumers is likely to exacerbate the issue as more patients receive coverage and begin seeking services.

In Connecticut, Perez says the Husky D plan (the new Medicaid plan for adults) is paying provider rates that "are better than Medicaid," which could draw in more providers. He adds that the Connecticut Behavioral Health Partnership (CBHP) is also expected to assist with access. The CBHP includes the Department of Children and Families, the Department of Social Services, Mental Health and Addiction Services, behavioral health maintenance organization ValueOptions, and an oversight council, and was established to help provide access to more coordinated care.

"That has been a very successful partnership in terms of providing access and enhancing rates for insurers, and has worked very well on children's side," Perez says. "We are hopeful that it will evolve to be just as effective for adults."

In Kentucky, the Medicaid program is being adjusted to help increase provider availability. The state has expanded provider eligibility by opening up the network to independently licensed clinicians outside of the state’s CMHC infrastructure. "The wait list in Kentucky can be three months, or people can't get in at all," says Cathy Epperson, executive director of NAMI Kentucky. "That varies across the state, but opening up to private providers will help."

"We'll see an increase in access in Kentucky through those efforts," Brenzel says. "Looking ahead, we also have to take a look at how we use telehealth and telepsychiatry to deploy the providers we do have, as well as the role of nurse practitioners in the provision of care.” Even then, he says, “There are still going to be challenges with access, because we can't grow people on trees."

Still, provider participation will be critical. "We really need providers to step up and be agreeable to serving this population," Brenzel says. "This only works if we get rates that will entice providers to provide services, and if we can get more providers to take Medicaid as a reimbursement source."

In Washington, which transitioned its Medicaid program to a managed care model several years ago, ensuring that available provider networks have the right kind of providers may be the biggest challenge. According to Lindeblad, the state has been analyzing whether providers in its managed care plan networks will be adequate to meet mental health service demands. "What we're hearing, more than anything, is not really about having enough providers, it's about having providers with the right kind of training," she says.

"The other thing we're looking at carefully is the capacity of our chemical dependency treatment providers," Beyer says. "We're trying to expand the pool of those providers and increase our capacity to provide treatment."

Limited networks

For patients with mental health or chemical dependency issues, finding the right type of provider within the right network will be critical. But according to Sandi Ando, chair of the NAMI Washington Public Policy Committee, that may be easier said than done.

"The problem is that not every managed care organization should really be dealing with people with mental health difficulties," Ando says. "As we move people into new health plans, it’s a question whether each one has a set of providers that can provide good mental healthcare. As we move people around I think what we'll see is that there are varying levels of expertise."

Even those who qualify for subsidized private health insurance plans via the state exchange may face some difficulties. In order to make those plans more affordable, many insurance companies limited their provider networks. This could force some patients to change physicians, for example.

"If they can't see their previous doctor, they may wind up with medication changes, or go into a relapse," Epperson says. "That's a big concern. We've been told the provider networks will be open, but we're waiting to see what actually happens. We're telling people to make sure they look carefully at plans and make sure their doctor is in the network."

Rural areas will face additional challenges, since they already had a shortage of providers. Though the shortage has existed for some time, “it was hidden because few had access to coverage, and they didn't go in for care," Ando says. "Now that they're required to have insurance, they may look for care and discover that it's not that easy to find."

Reaching out

Explaining the ACA has proven to be one of the Obama administration's biggest challenges. On the ground, teaching at-risk populations about the coverage they are eligible to receive, how to sign up, how to access services, and how to use their coverage will require ongoing effort by state agencies, providers, and advocacy groups. Patients with severe mental illness or chemical dependency problems likely will face unique challenges in navigating the new Medicaid/insurance system. Many have never had coverage, so the idea of “co-pays” or “deductibles” may be unknown to them. 

In Kentucky, navigator grants have helped with outreach to eligible populations. A cross-departmental effort has helped the state to reach Medicaid-eligible consumers, while funding directed to community mental health centers also has enabled CMHCs to provide assistance to patients.

"We feel pretty confident that we will reach the bulk of people eligible for Medicaid," Brenzel says. As of December, the state had enrolled 94,000 people through the exchange, the majority of whom were Medicaid eligible.

"We've done a lot to identify the uninsured as well," Brenzel says. "At least one of our hospitals went back and looked at two years of data, found every patient without a payer, and sent a personal letter to them with information on how to apply."

In Washington, the state allocated millions for its outreach program, including partnering with organizations to help difficult-to-reach constituencies that may face language, income, or other barriers related to understanding or accessing benefits.

The most difficult to reach will likely be the homeless and those with long-standing chemical dependency issues. "I'm reserving judgment until we see how effective the efforts have been, but the state has made a real effort to make this as easy as possible," Ando says of Washington’s statewide outreach effort. "Stakeholders were involved in the training the navigators, and they touched on most of the potential problems. We want to see everybody have access to insurance and care, including those who are out on the street,” he adds.

According to Beyer, providers in the behavioral health space will also play a critical role.

"We have a limited amount of money available to help those who are not on Medicaid," she says. "Those dollars tend to be focused on crisis services for non-Medicaid eligible individuals, and that pot of money is not really enough to provide any comprehensive services. The regional support networks and community mental health centers that serve these individuals are pretty motivated to help these folks enroll when they come in contact with the system, because it helps them stretch that limited pot of state-only money."

For those eligible for subsidized private health plans through the exchanges, a final concern is sticker shock. While prices vary nationwide, consumers who have never before paid health insurance premiums may find that even subsidized rates can strain the household budget.

"We're hearing some people say that they can't afford what's there, but it really depends on the individual," Epperson says. "Many are on fixed incomes, so they don't have a lot of extra money. A $5 co-pay may not be much to most people, but for some of these folks it may be the difference between eating or buying their medicine. That's still a concern." She’s concerned that perhaps some of these people may not have actually registered for coverage and are basing their complaints on the non-subsidized cost, without regard to the premium subsidies they may well be eligible to receive.

It's still early. While enrollment numbers are creeping up, it will be months before anyone can really see how the 2014 coverage expansion is affecting those looking for services, and what unexpected problems may be arising.

"People ask me about the political challenges or technical challenges, but those pale in comparison to the challenge of what we're trying to do:  changing peoples’ ideas about what the value proposition of insurance is, how it should be used, and why it's important," says Michael Marchand, communications director for the Washington State Health Benefits Exchange. That, he says, is a challenge that won’t be done “in six months or even six years for a program of this scale. This is just the first step."

Indeed, as 2014 opens, all the stakeholders contacted for this story were still waiting –optimistically - to see how expanded access to Medicaid and insurance coverage would play out. "We're preparing to field a lot of questions, "Ando says. "And we're figuring out where we can point people to get the answers."