Will you treat ME? Funding mental health care treatment - Now and Under the Affordable Health Care Act"

Mental Health Symposium

Good Morning. It is indeed an honor to be asked to speak at today’s mental health symposium. As my introduction as mentioned, my “hats” are many. As a nurse practitioner working in a free clinic, I worked with many clients who struggled with issues related to mental health, addiction, and chronic health conditions. As a professor of nursing, I have taught many classes on the topic of health care ethics, justice and health care reform. This morning, I would like to talk about the topic of our current situation with funding mental health care treatment. *

In order to understand the way in which mental health care has been regulated and funded in the United States, it’s important to understand a bit of historical context regarding mental health treatment. While this is a fascinating topic (which I’m really interested in) full of horrific abuses (think “Bedlam” - the Royal Bethlem Hospital in London – one of the oldest and most infamous asylums), the most relevant historical context for today’s talk is the notion that historically, there has always been a separation of mental health care from all other “traditional” areas of medical treatment. *

As you can imagine, it’s not a far stretch that this “split”, this separation and idea that mental health care treatment is different from the treatment of the body, led separation in how we pay for mind treatments and body treatments. Historically, insurance companies have separated out mental health care treatments and placed separate limitations and instituted independent requirements for mental health coverage. *

These sorts of limitations have led many who advocate for mental health care to perceive grave injustice in our health care system. When I’m teaching about such things, we talk about this in great depth. The United States has one of the most expensive health care systems in the world, with health care costs accounting for about 17.6% of the gross domestic product in 2010 – holding steady from 17.7% of the GDP in 2009. *

This means that American’s typically spend $8233 on health care per capita per year. This is twice as much as what folks spend in relatively rich European countries like France, Sweden and the United Kingdom, places thought to have decent health care. The breakdown on this graph shows you where we typically spend it – you can see that this graph doesn’t show mental health care. Now there are a lot of reasons that the USA health care is so expensive. Rich countries across the board will spend more than poor countries, but even accounting for the relative “wealth” of America – health care spending is extremely high. Statistically, we know that hospital spending is higher than in similarly developed countries, spending on administration costs in America is particularly high (about 7%), some prices are higher and that in some cases the American health care system provides more (not necessarily better) health care. For example, in America there are more C-Sections, more total knee replacements, more coronary angioplasties, more tonsillectomies, and more CT and MRI scanners than in similar countries. *

What does not appear to be the case is that mental health care spending is much different from what is spent world wide on mental health care. I’m sure this doesn’t shock or surprise many of you. I doubt that any of you who have had any experience with the mental health care system believes that there is so much mental health care happening that this is single-handedly driving the American health care system to it’s knees. Many of you might be acutely aware of the fact that access to mental health care professionals is worse than for other health care providers. 89.3 million Americans live in federally designated mental health professional shortage areas. In fact, the United State’s mental health care spending is right on par for what other countries tend to budget and spend in the provision of mental health care services. *

When we look at how the mental health care dollar is typically spent in America, we can see that outpatient treatment and prescription drugs are the top expenditures. Recent studies indicate that increasing numbers of people are being treated for depression, but various studies have shown that the care is substandard. Medications seem to be the mainstay, with little follow-up. General practitioners prescribe about 3/5th of all psychiatric drugs and what is considered the “gold standard” – drugs and therapy – has become increasingly uncommon. Thus, even though many more people are being treated for mental health conditions, overall spending for mental health only grew by 31% while other medical services grew much more. Medicaid, the crucial safety net for those with the most serious of mental health illnesses only increased its expenditures for mental health 1% from 1996 – 2006, while expenditures for other conditions increased approximately 25%. *

Whenever we consider what we spend, and what we pay for as a society, we are determining what we value and what we prioritize as important and meaningful. Sometimes we don’t often think about the “big picture” this way, but that’s really what is happening. I’ll give you an example from my nurse practitioner practice several years ago. There is a medication called Zyban (bupropion). This particular medication is an antidepressant that is also very useful in helping patients with smoking cessation. With the patient population that I worked with at the time, I could get the medication covered for the patient if the patient said that they were interested in stopping smoking, but I could not get the medication paid for if the patient had depression. Now this was a free clinic, operating under a different set of rules (free samples, etc.), but you can see how these sorts of situations set up issues related to justice and fairness and equity. It’s the same medication. It’s the same patient. It is one person that I’m to care for – yet the “system” will pay for one condition – thereby in effect saying one “matters” and will not pay for the other – does the other condition not matter as well? *

These issues of equity and justice and “parity” (or on par, equal to other things) came to the forefront in the early 1990’s. In 1992, two senators – Senator Domenici and Danforth authored the nation’s first bill targeting mental health parity. Mental health advocates argued that health insurance companies should no longer be allowed to have separate and different deductibles, co-pays and levels of services for mental illnesses, but that mental illness coverage should be “on par with” physical or surgical conditions. At the time, the

Senators found that only 21% of insurance policies provided for inpatient mental health treatment, and over 60% of insurance policies explicitly excluded severe mental illnesses. These gaps in health insurance coverage left millions without adequate coverage in the event of significant and severe mental health crises. The bill garnered quite a bit of press and raised awareness of the issues related to mental health parity. Unfortunately, the bill failed. But, Senator Dominici didn’t give up and in 1996, he partnered with Paul Wellstone for the Mental Health Parity Act (MHPA), which did successfully pass albeit with gaping exceptions and lots of loopholes. Many called it a “toothless” victory, but it was, I believe, the beginning of the movement in this country that set the stage for at least some beginnings of mental health parity. The “toothless” aspect of the law is that it does not require insurance companies to provide mental health benefits. However, if the insurance company does provide mental health benefits, they have to be in line with the coverage provided for medical or surgical conditions *

One of the most interesting issues going forward will be how the recently passed (and upheld by the Supreme Court) healthcare reform legislation – the Patient Protection and Affordable Care Act (PPACA) also known in the media as “Obama care” will affect mental health care in the United Sates. Perhaps surprisingly, there is a lot in the Affordable Care Act that offers great potential for the expansion of mental health services, as well as hope for better integration within the context of the American health care system as a whole and improvement in the quality of care being offered. Historically, most people in the United States with significant mental health illnesses have not had private insurance coverage. They have either had to obtain coverage through some kind of publically funded program or they remained uninsured. Like it or not (and many do not like it), one of the main thrusts of the Patient Protection and Affordable Care Act as well as the Health Care and Education Reconciliation Act of 2010 is the expansion of health insurance coverage to about 32 million Americans. Access is going to be expanded in several different ways including the extension of coverage to dependents until the age of 26 (very important given that many significant mental health conditions are often diagnosed by this age), the abolishment of pre-existing conditions (often a significant concern for those with mental health conditions) and by the creation of health insurance “exchanges”. An exchange is going to be a place (or website) that an individuals or an employer can go to for the purpose of purchasing health insurance. Each state can choose whether to create and run their own exchange or to have the federal government create and run the exchange for them. While the exchanges are currently under development, the exchanges will have to standardize the language in the plan offerings so that the consumers (YOU!) can look at the plans offered and make good comparisons. All plans sold in the exchange must include 10 essential benefits, which will include coverage (and this is significant) of mental health services and substance disorder services. *

The Affordable Care Act will extend Medicaid eligibility if a state elects to extend coverage. For those who might not be as familiar with what Medicaid actually is, Medicaid is a state based program that provides health coverage to lower income people, families with children, the elderly and people with disabilities. One disappointing (my opinion only) portion of the Supreme Court ruling last summer was that the Supreme Court ruled that the

federal government couldn’t restrict Medicaid funds if a state decided not to expand Medicaid coverage. This means that each state can decide whether they want to expand Medicaid or not. The map before you shows what each state is leaning towards doing as of a week ago.

If your state is expanding, that means that more people will be covered under Medicaid as the Affordable Care Act extends Medicaid to those with incomes below 138% of the federal poverty guidelines. Over 15 million uninsured adults could become newly eligible for Medicaid across all states. *

This is where the news gets (I think) really good. Remember the Dominici & Wellstone Mental Health Parity Act? It still stands. It’s now paired with the Affordable Care Act. So all those mental health services need to be on par with, as good as medical conditions. The very act that many described as “toothless”, “worthless” and “useless” because at the time it didn’t mandate mental health coverage is predicted in combination with the Affordable care Act to bring truly bring mental health parity to millions of Americans. That’s because now mental health care services are mandated to be covered as the part of the 10 essential services and because of the mental health parity act, the coverage will have to be on par with all other coverage *

The Affordable Care Act also aims to improve and increase community and home based services for people with disabilities under Medicaid. Community First Choice Option provides assistance for people with significant disabilities who need assistance in their daily lives. Now with mental health parity – significant psychiatric disabilities must be included as well. Another Medicaid state option created by the Affordable Care Act that may be of great benefit to those with psychiatric disabilities is the option to fund a “health home” - programs that provide comprehensive care coordination and other supportive services for people with chronic health conditions. These are options that states can seek to expand and fund services for their Medicaid clients. *

I want to conclude today’s keynote discussion with ethics and notions about what we value and who we are as a society. There are many who still believe that mental illnesses are not medical conditions that should be accorded the same treatment that one could expect for a physiologic condition such as appendicitis or cancer. However, growing research indicates that there is a physiologic component to many mental illnesses. Mental illness actually results in more fatalities per year than HIV/AIDS. Increased costs of providing coverage would most likely be offset within several years by increased productivity and decreased usage of other medical services *

Given the Affordable Care Act’s complexity and scope, it will likely take some years as all the provisions become interpreted and implemented. In conclusion, I would argue that we are entering a new era with guarded optimism for how we envision the funding and provision of mental health services in this country. While there certainly is much to be determined in the coming years, including funding of provisions of the Affordable Health Care Act, the status of mental health care funding in this country has never looked better.

This is not to say that there is not a lot of work to be done. However, great strides are being made in the areas of expansion of coverage, mental health parity and provision of services. There is great reason to be hopeful.

I’ve included a list of references for this talk as well as some helpful websites. Please don’t hesitate to contact me should you have any questions. Thank you for your kind attention during today’s presentation!

References:

Krisberg, K. (2012). Health Law Raising U.S. Mental Health Parity to the Next Level. The Nation’s Health. Sept. 2012.

Mauldin, J. (2011). All Smoke and No Fire? Analyzing the Potential Effects of the Mental Health Parity and Addiction Equity Act of 2008. Law and Psychology Review 35; 193-207.

Mechanic, D. (2011). Behavioral Health and Health Care Reform. Journal of Health Politics, Policy & Law 36 (3): 527-531.

Siegwarth, A. & Koyanagi, C. (2011). The New Health Care Reform Act and Medicaid: New Opportunities for Psychiatric Rehabilitation. Psychiatric Rehabilitation Journal 34 (4); 277-284.

Smith, D., Lee, D. & Davidson, L. (2010). Health Care Equality and Parity for Treatment of Addictive Disease. Journal of Psychoactive Drugs 42 (2); 121-126.

Helpful websites:

• http://www.healthcare.gov/law/ • http://www.healthcare.gov/using-insurance/low-cost-care/medicaid/ • http://www.cbpp.org/cms/index.cfm?fa=view&id=3819 • http://www.oecd.org/