"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."