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Supreme Court Decision Boosts Field’s Support of Medicaid Expansion

Mental Health Weekly�� July 2, 2012

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In a long-awaited and historic decision the Supreme Court on June 28 upheld the Affordable Care Act (ACA) resolving two key challenges in its ruling that the federal government can require individuals to purchase health insurance and supporting Medicaid expansion, although states can opt out of the expansion.

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The decision, a key victory for the mental health field, recognizes that behavioral health is pivotal to overall health care, said advocates. The 5-4 decision will ensure that states will continue to move forward on health insurance exchanges, and integrated mental health and physical health care initiatives. The law also extends the Mental Health Parity and Addiction Equity Act and its prohibition of discriminatory limits on mental health and substance use services to those plans.

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The field had endured a number of challenges to the health reform law since its implementation, including constitutional challenges to the individual mandate and the Medicaid expansion, particularly in the last several months. Earlier this year twenty-six states filed a brief with the Supreme Court outlining their argument that the health reform law’s Medicaid expansion is “unconstitutional coercion” and “infringement” on state power (see MHW,

Jan. 17, 2012, Dec. 21, 2010)

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Although the court upheld the ACA’s massive expansion of Medicaid, states cannot be compelled to expand their own programs through the threat of removing federal funding altogether, according to the decision. Instead, states will have the choice of expanding its Medicaid program and collecting new federal money, or remaining at current coverage and federal funding levels.

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Under ACA, state programs are required to provide Medicaid coverage by 2014 to adults with incomes up to 133 percent of the federal poverty

level. Currently, states now cover adults with children only if their income is considerably lower, and do not cover childless adults at all.

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The National Council for Community Behavioral Healthcare is encouraged by the decision, but concerned about the caveat to the Medicaid expansion, said Chuck Ingoglia, vice president of public policy for the National Council. “If a state chooses not to expand Medicaid in accordance with the ACA, it will not lose the rest of the federal Medicaid” Ingoglia told MHW. Ingoglia added, “It’s a disappointment, but given the way Medicaid is financed almost exclusively by the federal government, it’s hard to believe states would turn down this opportunity,” for extra funding, he said.

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Behavioral health advocates need to work with state regulators on the Medicaid expansion and to begin planning for the expansion in 2014, said Ingoglia. Some states are already moving forward on the expansion, in particular California and Connecticut, he said. “The real work is how to

make sure consumers who are currently underinsured understand what their options are,” added Ingoglia.

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Recent analyses have shown that state governments would save a tremendous amount of money to move residents into the Medicaid program, Ingoglia said. “This is a huge opportunity for the country and for individuals to have access to care,” he said.

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The Supreme Court decision also makes a strong statement for continued support of legislation that would establish increased access to community behavioral health services for consumers with mental health and addictions disorders, said Ingoglia. The court’s ruling ensures that uninsured individuals have access to care, he said.

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“That’s why we need [national standards for] federally qualified behavioral health centers (FQBHCs),” said Ingoglia. Pending legislation, S. 2257 / H.R. 5989, would insure FQBHCs receive adequate capacity and funding for behavioral health services,” he said (see National Council story, page 5). The importance of both bills becomes even more critical with the upholding of ACA,” said Ingoglia. “People in need of care should have access to evidence-based practices in this country.”

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Overcoming ACA challenges

“The ruling by the Supreme Court today to uphold the constitutionality of the ACA is a victory for people with mental illness,” Robert Glover, Ph.D., executive director of the National Association of State Mental Health Program Directors (NASMHPD), told MHW. “In particular, [this will help] people who currently can’t get insurance on the open market because they have a mental illness that make insurers either refuse to cover them or charge

them a higher rate than healthy people. The law requires that health insurers accept all applicants.”

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The expansion of Medicaid in 2014 to cover all individuals at or below 133 percent of the federal poverty level will impact millions of Americans who do not currently qualify for Medicaid due to pending Supplemental Security Income (SSI) applications or lack of a fixed address, and individuals with part-time employment whose income may exceed current Medicaid eligibility, said Glover.

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Glover added, “Many individuals living with mental illnesses will be included among those able to purchase federally subsidized health insurance

policies in 2014 through state health insurance exchanges established by the ACA. And, these policies must cover mental health and substance abuse treatment at parity with other medical conditions.”

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Glover added, “As part of obtaining health insurance coverage through the Medicaid program, these new beneficiaries will receive an essential health benefits package that includes mental health and substance abuse services along with general inpatient, outpatient services as well as preventive treatments.”

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The law represents an enormous step forward in the field’s efforts to expand access to care for consumers with behavioral health conditions, said David Shern, Ph.D., president and CEO of Mental Health America (MHA). “The law’s guarantee of coverage for people with pre-existing conditions will address these barriers, lower costs, end discrimination, and dramatically improve health outcomes,” he said in a statement.

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Shern added, “In 2014, the law will prohibit insurance companies from denying coverage or charging more to any person based on their medical history. As a result of the law, 86 million Americans now receive coverage through their private health insurance plan for many preventive services without copays or deductibles.”

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“Overall, we’re thrilled that the Supreme Court has upheld the law, which is already working in our community,” Kara D. Ryan, senior research analyst of the health policy project at National Council of La Raza (NCLR), told MHW. “One in three uninsured Americans are Latino; they have the most to gain.” Ryan added that at least 6 million Latinos will gain new health care coverage under ACA.

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“Latinos are less likely to receive mental health treatment compared to their non-Hispanic peers,” said Ryan. “The decision will extend health care

coverage to people of color and the uninsured, provide them with more coordinated and holistic care, including mental health and behavioral

health care services.” •

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New Health Law to Ease Insurance Access for Mental Illnesses

By�� Palm Beach Post July 8, 2012

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For years Dr. Christopher��Kye, a Palm Beach psychiatrist, has warned patients about the consequences of being diagnosed with a mental illness — especially bipolar disorder. “I will warn them that it’s difficult to get insurance with a bipolar diagnosis,” Dr.��Kye��said. “I suggest that treatment be done off the books, with their own money.”

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Many patients do so, rather than risk being dropped by their insurance company or unable to get health insurance at all. For those patients,��Kye��recommends that they fill prescriptions at pharmacies they have not used before, so their insurance companies will not discover they are being treated for a mental illness.

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But the days of sneaking around may soon be over. The Affordable Care Act, upheld by the Supreme Court on June 28, will dramatically change how the mentally ill are treated by doctors and insurance companies, experts say. Historically, mental illnesses, such as depression, bipolar and schizophrenia, have been among the top��pre-existing conditions insurance companies have used to deny or limit coverage.

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By mandating behavioral health coverage and making it illegal to deny coverage for��pre-existing conditions or to set lifetime and annual limits on care, the law is expected to extend mental health care to those who previously could not afford or were afraid to seek it. Forcing insurance companies to provide the same levels of coverage for mental illnesses as they do for physical illnesses — called insurance parity — will also help to��destigmatize��mental illness, said Bob��Anis, director of behavioral health services at Columbia Hospital in West Palm Beach.

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“It would be my hope that consumers will do earlier prevention and intervention before things escalate into a crisis or emergency situation,”��Anis��said. “Maybe this is an��itty-bitty step to overcoming stigma, but it’s an��itty-bitty step towards something that has been a long-term problem.”

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Insurance companies were dealt a blow in 2008, when Congress passed the Mental Health Parity Act, which required them to cover mental illnesses at the same level as their coverage for physical illnesses. However, federal rules on how the Parity Act will be implemented, enforced and monitored have not been put in place, meaning the law has no teeth, said Steve��Daviss, chairman of the Department of Psychiatry at the Baltimore and Washington Medical Center of the University of Maryland.��Daviss, who recently��testified��before a congressional forum on parity, said the Affordable Care Act will make parity a reality.

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“Because the Affordable Care Act makes specific references to mental health parity, it sends a message to insurance companies that the days of different and less coverage for mental health care — those days are gone,”��Daviss��said.��Daviss��also believes the provision of the Affordable Care Act that allows children to be covered on their parents’ insurance plan until age 26 will also result in early detection and treatment for depression, bipolar, alcoholism and drug addictions.

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About half of all people with mental illnesses first experience it by age 14, but do not receive treatment until they are 24 years old, according to Mental Health America.

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“This covers many of the years that these illnesses start to show themselves,”��Daviss��said. “Research is very clear that early intervention in mental illness and addiction helps to reduce later disability and costs.”

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But��“it’s not time to run a victory lap yet,”��said Pam��Gionfriddo, chief executive officer of the Mental Health Association of Palm Beach County. She has concerns about how the Affordable Care Act will put in place in Florida in the wake of Gov. Rick Scott’s declaration that he will not expand Medicaid, the safety net program that aids the poor and picks up nursing-home bills for senior citizens.��It costs $21 billion a year in Florida.

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The Affordable Care Act calls for states in 2014 to expand Medicaid eligibility to those making up to 133 percent of the poverty level, or $29,326 for a family of four. The expansion could add as many as 1.95 million Floridians to the rolls of Medicaid and other state-subsidized insurance programs. The federal government will pay the costs of expanding the program until 2017.

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Scott’s vow not to expand the program will leave many low-income people who would receive coverage under the expansion — without a health care plan.

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As��Gionfriddo��sees it, people with insurance are more likely to get help sooner, avoiding costly visits to hospital emergency rooms and acute care mental health centers. The Medicaid expansion would also improve coverage and access to psychiatric medications, she said.

“It’s just better if we can get closer to having as many people insured as possible,” she said.

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