Tragedies like the recent school shooting in Newtown, Conn., initiate conversations about access to mental health services nearly as consistently as they do discussions of gun control. And though it is not known whether the shooter, Adam Lanza, was mentally ill, public officials jumped on the opportunity to promote better and increased access to behavioral care as one effort to address the massacre.
The Obama administration emphasized its own commitment to mental health care, highlighting the Affordable Care Act as evidence that it had taken steps to improve an ailing mental health system. " 'Obamacare,' if you will, has ensured that mental health services are a part of the services" available to the insured, White House press secretary Jay Carney said.
Certainly the health reform law attempts to address the perpetual problems with the accessibility and availability of mental health services in the United States. But it is the states' decisions about whether and how to implement the law that will ultimately determine how much services improve. Nearly every aspect of the law that could improve mental health services is optional; states will decide themselves whether to improve their mental health offerings.
"It's a big set of invitations. It's going to be taken up in different ways in different places," said David Mechanic, the director of Rutgers University's Institute for Health, Health Care Policy and Aging Research. "Some places see this as a fantastic opportunity and are moving quite aggressively, and there will be some places that really don't do much for quite a while."
The current mental health care system is hardly a system at all, according to Mechanic and other experts. Care is uncoordinated and often unavailable; where it is available, it is often poorly advertised or explained. About one in four adults suffers from a diagnosable mental illness, according to the National Institute of Mental Health, but millions of those who report needing mental health services don't receive care because of its cost or its negative stigma. States, moreover, have cut about $5 billion from public mental health spending in the past four years, at the same time that 10 percent more people have sought services, according to Joel Miller, a senior policy director at the National Association of State Mental Health Program Directors.
"If you talk to the families and caregivers about the mental health system in America, what they'll talk about is the amount of time it took them to find services. That can be years. Or the amount of time it took them to get a diagnosis--in many cases, that's many, many years," said Mike Fitzpatrick, executive director of the National Alliance on Mental Illness. The primary health care system and the mental health system are so disconnected, he said, "they're like ships passing in the night."
Carney is right that the Affordable Care Act requires basic insurance packages to include mental health services. All basic health plans--including those offered on exchanges to citizens who have heretofore remained uncovered--must offer behavioral care, according to the legislation. That alone should substantially improve access to mental health services for millions, Fitzpatrick said.
Other provisions in the law offer even more promise for individuals with mental illness. An expansion of Medicaid could provide access to care for millions of Americans with mental illnesses, many of whom do not currently qualify because they do not meet strict disability requirements. In states that choose to expand their programs, the law eliminates those requirements for those with very low incomes. Millions of children and adults stand to gain access to mental health services on par with other medical services provided.
The act also provides funding for innovative services for individuals with mental illness. It promotes prevention innovations, as well as home and community services that are often effective for people with mental illness or substance abuse, and eliminates some funding requirements that restricted their use in the past. It also allows for more coordinated care in health homes, where both medical and behavioral care will be provided in the same environment. Such coordinated services are especially useful for people with mental health issues, since they frequently suffer from more than one chronic condition.
But substantial questions about specific requirements and processes linger for those working to implement the law. First, the type and scope of mental health services included in an essential package have not been fully defined. The administration has yet to clarify exactly what mental health benefits a typical plan should require, according to Jennifer Mathis, the deputy legal director for the Bazelon Center for Mental Health Law, and current proposed rules fall short for mental health services.
"There are a lot of questions that [haven't been] answered," she said. "There's several significant issues that will determine how much is available to people in the way of mental health services, both in the Medicaid expansion and in the exchanges."
Perhaps more importantly, it also remains to be seen whether the current system can meet the demand of the millions who will be eligible for services beginning in 2014. Even now, there exists a shortage of mental health care professionals who will accept Medicaid services, according to Embry Howell, a senior fellow in the health policy center at Urban Institute. While most experts agree that supply will eventually catch up with demand, the infrastructure to support substantially more individuals seeking mental health services will take time to develop.
"A lot of psychiatrists don't participate in the Medicaid program, and there's a question of whether they will, after these new expansions happen," Howell said. "[A lot of people] are going to come onto the program in those states that expand without a good supply of providers for them, so they'll be entitled to benefits that they haven't had in the past, but there may not be people stepping forward to serve them."
Discrepancies between different states' Medicaid programs are not new, but the Supreme Court's June decision regarding the Medicaid expansion prevented the law from standardizing at least some aspects of healthcare across the country. Allowing states to make such disparate decisions with regard to care, Mathis cautioned, could create a system just as difficult to manage and coordinate as the one that exists today.
"As the federal government has now structured it, I think it's going to be 51 different packages, and that is going to be extraordinarily difficult for the federal government to monitor, evaluate, and keep track of, and to figure out now, in every state, what the gaps are."
If history is any indication, however, the current confusion will iron itself out in time. When the Children's Health Insurance Program was first rolled out, for example, only a few states adopted the full provisions at first. Over time, every state eventually expanded their program. And since the federal funding for this expansion is matched at a very favorable rate, states have significant incentive to opt in, both Miller and Mechanic said.
"It's like turning a battleship in a bathtub. Over the years, we've seen very slow progress in terms of expanding coverage, efforts to slow down the rate of increase in health care costs," Miller said. "Nobody expects this will happen overnight. But the way this has been addressed, through a comprehensive effort to increase coverage, slow down health care costs and improve care coordination and delivery of care, I think we'll begin to see significant progress even at the front door when this goes into effect in 2014."