Mental health providers and advocates are growing concerned that Medicaid recipients won’t be able to access psychiatrists or certain specialty mental health services even with the massive expansion of Medicaid mandated under the Affordable Care Act.
Low provider payment rates under Medicaid, coupled with financial pressures on states and the federal government, threaten to limit access to mental health treatment just as an additional 16 million Americans gain coverage through the Medicaid program, experts said.
The Affordable Care Act, which was enacted in March 2010, expands the Medicaid program to anyone below 133% of the federal poverty level, which is an annual income of about $29,000 for a family of four. States are required to begin offering coverage to this group by Jan. 1, 2014. (Healthcare.gov offers a timeline.)
The benefits offered to new enrollees do not have to be the same as the ones provided currently under state Medicaid programs. For childless adults in the new coverage population, states must offer "benchmark" or "benchmark equivalent plans," meaning that the benefits for new Medicaid enrollees must be equivalent to benefit packages offered under the Federal Health Benefits Program, by the state’s employee health benefits program, or by the largest commercial HMO plan in the state.
The ACA requires that the benefits package include prescription drug coverage, mental health services, and addiction treatment services that comply with the Mental Health Parity and Addiction Equity Act. And federal regulations say that individuals with disabling mental disorders and those with mental disabilities that prevent them from performing everyday tasks cannot be required to enroll in a benchmark plan. But it’s unclear exactly how all of these requirements will be implemented from state to state when the Medicaid rolls swell in 2014.
That uncertainty has raised concerns. Dr. Anita S. Everett, chairwoman of the Council on Health Systems and Finance for the American Psychiatric Association and director of community mental health services at Johns Hopkins Bayview in Baltimore, said she worries that enrollees in the new Medicaid expansion plans will miss out on some of the supportive services that traditionally have been covered by a number of state Medicaid programs. For example, these new enrollees might not have access to programs that help people with severe mental illness enter or re-enter the workforce or find housing, she said.
While it’s good news that there will be millions more people with coverage for mental health services, Dr. Everett said, it seems unlikely that most of these newly covered people will be eligible for some of the specialty services that are offered under traditional Medicaid programs.
Budget constraints at the state and federal levels also will play a role in what mental health services are available to Medicaid beneficiaries. A report issued by the National Alliance on Mental Illness (NAMI) earlier this year found that from 2009 to 2011, states cut their non-Medicaid mental health spending by nearly $1.6 billion, making cuts to community- and hospital-based psychiatric care, housing, and prescription drug benefits. And states are facing added budgetary pressures because a temporary increase in federal funding for Medicaid from the Recovery Act ended on June 30. And at the national level, the newly formed Joint Select Committee on Deficit Reduction, known as the "super committee," will be considering Medicaid, along with other entitlement programs, for potential cuts this fall.
"The larger concern for us is what the Medicaid program will look like once the political and regulatory processes end," said Michael J. Fitzpatrick, NAMI’s executive director. "Will it be a different Medicaid program? And what services will be covered?"
There’s already wide variation in terms of what is covered from state to state, he said, and NAMI officials are concerned the combination of the flexibility given to states to set up their programs and ongoing financial constraints could result in less robust mental health coverage under Medicaid.
The other problem experts see with the coming Medicaid expansion is the availability of psychiatrists to see the influx of new patients. Low provider reimbursement rates under Medicaid are part of the problem.
"The reality is that you can pass the Affordable Care Act and you can increase the number of people covered under the Medicaid program, but if you don’t have practitioners who are willing to take the Medicaid rate, you really haven’t accomplished anything," Mr. Fitzpatrick said.
Dr. Laurence H. Miller of the University of Arkansas in Little Rock, and medical director of the Arkansas division of behavioral health services, said he knows many psychiatrists who don’t accept Medicaid at all. Not only is the reimbursement low, but Medicaid patients tend to be more complicated, and the program’s red tape can be burdensome for physicians, he said.