© 2008, johns hopkins university. all rights reserved. mental health and substance use disorder...

© 2008, Johns Hopkins University. All rights reserved.

Mental Health and Substance Use Disorder Policy in an Era of Rapid Change

Colleen L. Barry, PhD, MPPAssociate Professor & Associate Chair for Research and Practice

Department of Health Policy and Management

Johns Hopkins Bloomberg School of Public Health

Maryland Statewide Summit on Behavioral Health

Visionary Conversations: Information, Innovation, Integration

November 2013


Overview• Enormous changes in health policy environment

• Promises and perils for persons with mental illness & substance use disorders

Potential of some policy changes to broaden access, improve treatment rates, improve quality of care, promote consumer-oriented care

Some potential perils too – adverse selection, increased stigma, lower quality of care, access problems, threat to financing of services outside traditional health care services


What is going on?1. Affordable Care Act

• Increased coverage through expansion of public programs (Medicaid)

• Reform and redesign of insurance markets

• Delivery system and payment reform

2. Policies responses following Sandy Hook tragedy

3. Federal parity law

How might each of these changes affect behavioral health?


What are our Stories?

And, how can applied policy research health inform our portrayals?


Big Change #1: ACA • State and federal health exchanges for individuals and

small businesses (up to 100 employees)

• Premium and cost-sharing subsidies for those at 133% to 400% of poverty

• Medicaid Expansion to 133% FPL for states that choose

• Individual mandate to maintain coverage else tax penalties

• Employer mandate for those with >50 employees


State & Federal Health Exchanges

• Reorganizes individual and small group markets

• Participating health plans certified by exchanges

• Plans must meet essential benefits requirements – including mental health and substance abuse

• Scope of benefits must be equal to small group benchmark

• Domenici-Wellstone Mental Health Parity and Addiction Equity Act requirements must be met


What does bumpy start mean for risk pool?


ACA Private Market Reforms • Preexisting condition exclusions for adults prohibited -

January 2014

• Preexisting condition exclusions for children prohibited - September 2010

• Guaranteed issue and renewability - 2014

• Premiums can no longer be based on health status - 2014

• No lifetime caps on benefits – 2010; no annual limits on benefits 2014

• Extended private coverage of dependent children up to age 26 - September 2010


ACA Medicaid Expansion• Shift to income-based eligibility to 133% FPL

• Regardless of traditional eligibility categories (i.e., childless adults)

• Income limit: $14,404 for individuals and $29,326 for families of four

• No asset test

• Enhanced federal funding for those newly eligible: • 100 % federal in 2014, 2015, 2016

• Phases down to 90% federal by 2020


ACA Medicaid Expansion Benefit Package • Not necessarily full Medicaid benefits; benchmark coverage

instead – private insurance model• Concern about appropriateness for higher need population

with benefits modeled after private market• But certain groups exempt from benchmark package: people

with disabilities (regardless of SSI eligibility), duals, institutionalized individuals, medically needy, parents on TANF

• Benchmark coverage must comply with essential health benefit package (includes mental health and SUD benefits)

• Wellstone/Domenici Parity Law applies

• Other payment sources (SAPT Block Grant) to continue as important source of financing for excluded services, remaining uninsured

• Role of block grant changing


ACA Delivery System Reforms• Medicaid health home option (2011)

• Grants to support co-location of primary and specialty care in community behavioral health centers (2010)

• Grants for community health teams

• Changes to Medicaid home- & community-based services option (sec.1915(i))

• Medicaid Inpatient Psychiatric Care Demo - reimburse private psych hospitals for emergency psychiatric stabilization

• Payment bundling and accountable care organization demonstration programs


New Integration Care Models: Decision to Enter Treatment

Willingness to Enter Mental Health Treatment (%)

N=1,040

Willingness to Enter Drug

Treatment (%)N=231

Willingness to Enter Alcohol Treatment

(%)N=572

Usual Care Arm 32% 26% 17%

Primary Care Arm 44%* 42%* 25%*

Collaborative Care Arm 38% 37% 25%*

1 If X treatment were free to you and available in your areas with appointments open, would you enter treatment? (Free means there would be no cost to you even if you do not have insurance or if your insurance company sometimes charges copayments)

Barry and colleagues, working paper, 2013


ACA Prevention-Oriented Delivery System Reforms Affecting Behavioral Health• Medicare annual wellness visit –includes depression

screening

• Elimination of co-pays, mandatory coverage Medicare preventive services including depression screening

• Medicaid incentive for states to cover with no cost-sharing clinical preventive services including depression screening

• Grants for early childhood home visitation ($1.5 billion over five years to states)

• Grants for school-based health centers

• A bunch more……


ACA:


And, what should researchers be focused on studying?


Big Issue #2: Mental Illness & Gun Violence Four major mass shootings in the past six years

(Newtown, Aurora, Tucson, Virginia Tech) Common element = framed by news media in term

of mental illness

Policy response: Serious mental illness gun restrictions

Policy response: improved mental health care


Controversy around gun policies targeting people with mental illness

Journal of the American Medical Association (JAMA), 2011. Vol. 305, No.20

Effectiveness? Unintended consequences?Chilling effect on mental health treatment seeking? Exacerbate stigma surrounding serious mental illness?


Gun Policies Affecting those with Mental Illness

% Favor Overall(N=2402)

Non-gun owners(N=823)

Non-gun owner, gun

in household(N=742)

Gun owners(N=837)

NRA Members(N=171)

Requiring states to report a person to the background check system who is prohibited from buying a gun due either to involuntary commitment to a hospital for psychiatric treatment or to being declared mentally incompetent by a court of law?

86% 85% 87% 87% 82%

Requiring health care providers to report people who threaten to harm themselves or others to the background check system to prevent them from having a gun for six months?

75% 75% 76% 73% 65%

Requiring the military to report a person who has been rejected from service due to mental illness or drug or alcohol abuse to the background check system to prevent them from having a gun?

79% 79% 81% 76% 67%

Allowing police officers to search for and remove guns from a person, without a warrant, if they believe the person is dangerous due to a mental illness, emotional instability, or a tendency to be violent?

52% 54% 54% 44%** 33%**

Allowing people who have lost the right to have a gun due to mental illness to have that right restored if they are determined not to be dangerous?

31% 31% 29% 33% 41%

Barry et al., NEJM 2013


Gun Policies Affecting those with Mental Illness

% Favor



Effect of News Story about Mass Shooting on Perceived Dangerousness of Person with SMI

High PerceivedDangerousness

McGinty, AJP, 2013


Mixed Public Attitudes about Mental Illness

Overall(N=1530)

No Experience with Mental

Illness(N=752)

Experience with Mental

Illness(N=765)

Would you be willing or unwilling to have a person with serious mental illness as a neighbor? (% willing)

33.1 26.3 39.9‡

Do you agree or disagree that discrimination against people with mental illness is a serious problem? (% agree)

58.2 49.9 66.4‡

Do you agree or disagree that most people with serious mental illness can, with treatment, get well and return to productive lives? (% agree)

55.9 48.9 63.2‡

Do you favor or oppose increasing government spending on mental health screening and treatment as a strategy to reduce gun violence? (% favor)

60.6 54.4 66.8‡



Critical to Shift Policy Focus • Ill-thought-out policies adopted in haste can wreak havoc on the mental

health system and lead to counterproductive consequences

• Effectiveness in reducing gun violence questionable

• Given very small share of violence attributable to mental illness, policies

aimed exclusively unlikely to significantly increase public safety

• Could be counterproductive

• Those people most in need of treatment for suicidal or violent impulses may

be deterred from treatment

• Massive infringement of privacy of people in treatment

• Further strengthens association in the public mind between mental disorders and violence

• Mentally ill more often victims of violence than perpetrators

• Need to consider alternatives not focused on people with mental illness


Gun Violence:




Big Change #3: Federal ParityPrivate insurance substantially more limited for

behavioral health than for general medical care

Advocates view benefit limits as discriminatory

Economic Explanations: Moral hazard: health plan incentive to control

consumer demand for services Selection: health plan incentive to compete to avoid

‘bad risks’

Regulatory response - parity policies require equivalent coverage for behavioral health and general medical care


Wellstone-Domenici Law – Key Provisions• Equal benefits - all financial requirements & treatment limits • Annual and lifetime dollar limits • Coverage not mandated • Group coverage • Conditions covered • Protections for state parity laws • Benefit management • Out-of-network coverage • Monitoring; compliance and enforcement provisions • Cost exemption • Other populations


Interim Final Rule• Interpretation of terms predominant financial

requirements and substantially all medical/ surgical benefits

• How deductibles should be treated

• How plans can manage the benefit • non-quantitative treatment limits (NQTLs)

Major Concerns Remain:

• Lots of remaining areas of uncertainty (e.g., scope of services)

• Concerns about law circumvention

• Final rule still pending


Federal Parity:




Thank you!

comments:[email protected]

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