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From Health Law Daily, July 21, 2015

Behavioral health care improves in Medicaid expansion states

By Bryant Storm, J.D.

Three million adults, or over 17 percent of the low-income adult population, had a behavioral health condition between 2008 and 2013 according to report published by the Government Accountability Office (GAO). The GAO review, which analyzed the frequency of behavioral health conditions among low-income individuals, options for treatment of those conditions, and the effect of Medicaid expansion on these issues, revealed that half of low-income adults living with behavioral health conditions reside in states that have not expanded Medicaid. However, for those residing in expansion states, access and treatment options have improved (GAO Report, No. GAO-15-449, June 19, 2015).

Treatment needs. Behavioral health conditions—defined as mental health or substance use conditions—affected an estimated 48.3 million adults in 2013. Due to concerns about the availability of treatment for adults with behavioral health conditions, and particularly for low-income adults with such conditions, the GAO reviewed how Medicaid—the largest payor of behavioral health services—was meeting the treatment needs of low-income adults. The review was motivated in part by the realization that Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) is increasing Medicaid eligibility in a growing number of states. The GAO considered the treatment options available in both expansion and non-expansion states

Findings. Prior to Medicaid expansion, out of 17.8 million low-income, uninsured adults, about 3 million had a behavioral health condition. More specifically, about 1 million low-income, uninsured adults were estimated to have a serious mental illness and almost 2.3 million low-income, uninsured adults were estimated to have a substance-use condition. These figures varied among individual states, with the percentage of low-income adults with a behavioral health condition ranging from 6.9 percent in state with the lowest occurrence rate to 27.5 percent the highest. About 1.4 million people, or half of those with a behavioral health condition, live in non-expansion states.

Non-expansion. In the states that have not expanded Medicaid, treatment options are available for low-income, uninsured adults with behavioral health conditions. The available treatment includes inpatient, outpatient services, and prescription drugs. Those services are provided through community mental health centers, state institutions, and contracts with providers to deliver treatments. Funding comes from a variety of sources, including state general funds, federal block grants, and Medicaid. Despite the available options, the review discovered that those states primarily reserve treatment for those with the most serious behavioral health needs. Serious needs included pregnant women, intravenous drug abusers, and those in crisis situations. For other individuals with behavior health needs, non-expansion states use eligibility criteria and place individuals on waiting lists. Generally, treatment is not available to individuals who did not fall into particular eligibility groups based upon specific diagnosis and the severity of treatment needs.

Expansion. For states that elected to expand Medicaid under the ACA, the GAO reported management of behavioral health care as a separate benefit and noted increased availability of treatment options. However, despite the relative improvements, the GAO did identify some access concerns. On the positive side, states reported that newly covered individuals under Medicaid expansion experience shorter wait times and increased access to prescription drugs as a result of the changes under the ACA. Access concerns resulted from behavioral health professional shortages, which states are working to resolve. The shortages are most prominent among Medicaid-participating psychiatrists and psychiatric drug prescribers.

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