Essential principles guide county, state ACA implementation

The Affordable Care Act (ACA) has brought both major benefits and major transformations to the behavioral health and the intellectual development/developmental disability (ID/DD) fields. The ACA is based in the principles of a primary care-centric delivery system and effective care integration. As these developments unfold, it will be very important for us to assess their impact upon county behavioral health and ID/DD service delivery programs and to identify future scenarios.

For the past three-score years, separate mental health, substance use and ID/DD programs have been developed and operated at the county and state levels. In approximate terms, 23 states, representing about 75% of the U.S. population, have developed systems in which counties are the primary service delivery units, while the remaining 27 states and the District of Columbia have developed state-operated service systems. Collectively, these systems constitute our public behavioral health and ID/DD service infrastructure.

As the ACA implements community-based integrated care through medical and health homes, our county and state systems will need to embrace these important transformational changes. However, at the same time, counties and states also will need to continue to fulfill their responsibilities for ensuring the health and safety of local populations.

Since potential apposition between transformation and responsibility fosters anxiety in some places and radical change in others, we must develop some principles to guide debates and decisions regarding our future county and state behavioral health and ID/DD service delivery systems.

With this in mind, the following principles are offered. They apply equally well to county and state systems, and equally well to mental health, substance use, and ID/DD services.

Principle 1: Assure that counties and states continue to take responsibility for the health and well-being of the public service population. This responsibility can be delegated to market entities, such as managed care entities and accountable care organizations, but it cannot be abrogated. It is a direct governmental responsibility, and it must be respected as such. The responsibility includes oversight and monitoring of services, direct service delivery, evaluation of service programs and appropriate advocacy with elected officials.

Principle 2: Assure the best quality care to the largest number of citizens at the most reasonable cost. Going forward, this means that our county and state mental health, substance use and ID/DD services will need to be adapted to integrated care. This can be done by incorporating primary care directly into these service programs by developing contractual relationships with formal partners who will deliver these necessary services, or by forming new service delivery entities.

Principle 3: Assure that county and state government behavioral health and ID/DD service delivery units are included in any planning or system redesign for reform projects. A major part of the infrastructural backbone for implementing the ACA rests with counties and states. Hence, these entities must be participants in planning and redesign efforts to assure that the best interests of county and state populations are reflected in the deliberations.

Principle 4: Assure that elected officials at the county and state levels are regularly apprised regarding the implementation of the tasks identified in Principles 1, 2 and 3. Elected officials are chosen by citizens to take responsibility fir promoting the best interests of these citizens. This responsibility can only be fulfilled effectively if elected officials have adequate information upon which to act.

Please review these principles, discuss them in your workgroups, and adapt them to your particular circumstances. They can serve as important guideposts as your county or state implements the ACA.