Let’s Enroll 7 Million Peers! Key ACA Actions We Need Today

The pace has quickened as we have accelerated from planning to implementation of the Affordable Care Act (ACA). The state Affordable Insurance Marketplaces (AIMs) are being built, states are designing different approaches to Medicaid Expansion (ME), and insurance companies already have submitted their Qualified Health Plans (QHPs).

Here, we present some important factoids regarding ACA implementation. Each factoid has a recommended key action that you and I must take to help make the ACA successful. We only have one option, and that option must be resounding success.

Numbers to be Insured

Factoid: HHS estimates that up to 18 million persons will become enrolled in health insurance through the optional state MEs and 20 million through the mandatory AIMs. Of these numbers, 11 million persons will have a prior mental health or substance use condition at the time of enrollment. About 6 % of these persons will have serious mental illness and 14% will have a substance use disorder. We can enroll 7 million of these peers by next March 31.

Key Action: This is a huge, unprecedented opportunity for behavioral healthcare. We must spread the word throughout the entire behavioral health community and beyond, and we must make enrollment very easy for those with behavioral health conditions.

Enrollment and Insurance Activation

Factoid: Enrollment will begin on October 1, 2013, and health insurance coverage through the MEs and AIMs will be activated on January 1, 2014. Between now and October 1, HHS will implement a major enrollment initiative in collaboration with Enroll America (www.enrollamerica.org) and a broad range of national, not-for-profit entities that are partnering with HHS. This initiative will be undertaken between October 1, 2013, and March 31, 2014. SAMHSA is a major participant in this initiative.

Key Action: Each of us must become directly involved in enrolling uninsured persons. Details on how we can do this will be made available in the next two months.

Mandatory AIMs

Factoid: HHS will operate Federally-Facilitated Marketplaces and will partner in the operation of state Partnership Marketplaces for those states that have elected one of these options. All remaining states will operate their own state Marketplaces. As of this month, all QHPs developed by insurance companies for 2014 have been submitted to their respective states, and for Federally-Facilitated Marketplaces and state Partnership Marketplaces, also to HHS. Those receiving insurance coverage through an AIM will receive a federal tax subsidy if their income is below 400% of the federal poverty level (FPL), as well as reduced co-pays and deductibles if their income is below 250% FPL.

Key Action: We must find out what QHPs have been submitted for our respective states and whether their mental health and substance use benefits meet parity requirements. We also must reach across the aisle and offer to partner with these QHPs to deliver needed services including peer support.

Optional Medicaid Expansion

Factoid: The number of states undertaking the optional ME has increased over the past several months due to a new strategy that combines expansion of the state Medicaid Program for a portion of the uninsured population eligible for Medicaid and enrollment in private insurance with premium supplementation for the remainder. If you live in a state that has not yet elected to undertake the optional ME, please find out the details about this new approach.

If your state will not undertake the optional ME for 2014, then health insurance coverage under the AIM will begin at 100% FPL; otherwise, AIM coverage will begin at 133% FPL.

The federal government will pay 100% of the cost for the optional ME in 2014, 2015, and 2016; subsequently, the federal contribution will decrease to 90% by 2020 and remain at that level thereafter.

Key Action: We must monitor each of these issues very closely. If your state has not elected to do the optional ME for 2014, you must become engaged and help to organize state advocacy to turn this decision around. There are at least 50 cogent reasons to undertake the optional ME. The national Coalition for Whole Health will work with you to organize this advocacy.

Essential Health Benefit (EHB)

Factoid: QHPs for a state must cover the 10 required benefits for an EHB, and both the mental health and substance use benefits must be at parity with the medical and surgical benefits. Each state EHB is based on a single benchmark plan for that state, typically the largest small group plan. Similarly, the Alternative Benchmark Plan for the optional ME also must meet these same basic requirements.

Key Action: If we believe that parity requirements are not being met by our state, then we should inform the Secretary of HHS and the national Coalition for Whole Health. Very close monitoring of this issue over the next half year will be essential.

Supplantation of State and Local Funds

Factoid: Direct federal funding of the optional MEs and federal tax subsidies for the AIMs will supplant state and local funds that previously were spent on these newly insured persons to provide needed health care services. Clearly, these supplanted funds will be needed for social wrap around services for many of the newly insured and for charity care for persons, such as immigrants, who remain uninsured.

Key Action: We must monitor the disposition of these supplanted funds in our states, particularly efforts to reprogram these funds away from health care or into state or local tax rebates.  Strong, well-organized advocacy will be essential.

Thoughts Going Forward

The present time is the most exciting and promising since President Franklin Roosevelt created the Social Security Program in 1935 and President Lyndon Johnson created the Medicaid and Medicare Programs in 1964. We from the behavioral healthcare field must make the most of this once-in-ever opportunity. It will not recur again.

As a field, we also must set a stretch goal for insurance enrollment during the initial ramp-up period. Let me suggest that we seek to enroll at least 7 million of the 11 million uninsured peers with prior mental health or substance use conditions between October 1, 2013, and March 31, 2014.

Clearly, the only way that this fundamental goal can be met is if each of us fully engages the endeavor.