I’ve been working under our SAMHSA contract Bringing Recovery Supports to Scale Technical Assistance Center Strategy (BRSS TACS) to organize an annual Policy Academy to help state systems adopt a recovery orientation. Armed with a subcontract, states pull together teams of decision makers to effect a paradigm shift by bringing recovery-oriented care to their mental health and substance use services.
It has been an exciting time to work with these state systems. Health care reform has expanded the types of services that are billable under Medicaid, and more people now have insurance for these services under the Affordable Care Act (ACA). Suddenly, change seems possible, and there may be funds to support expanded care. States are now working to develop guidelines to provide these newly eligible services, such as peer support, and to expand their workforce to respond to the ballooning numbers of patients they can serve. But these changes bring up new concerns as well.
A New York Times article by Abby Goodnough, entitled, “Expansion of Mental Health Care Hits Obstacles,” nicely outlines some of these concerns. It profiles a woman who has struggled with depression and anxiety throughout her life. Now, with health insurance that covers services for mental health disorders, she is receiving therapy for the first time. Unfortunately, the system is slow to catch up. She’s had to wait long stretches for appointments and can’t always see her therapist. Providers seeking to bill for these services aren’t sure when they’ll be reimbursed, raising questions about their willingness to care for Medicaid patients.
The Mental Health Parity and Addiction Equity Act of 2008 specifies that mental health or substance use disorder benefits be no more restrictive than medical/surgical benefits – in other words, they are essential services that must be covered. Additionally, Medicaid expansion under the ACA and the affordable coverage provided through the exchanges has made health care affordable for a large number of Americans who had no access before. This means more people than ever are eligible for the behavioral health care they need.
The implications of this – longer wait times and workforce shortages – are hard to measure. A quick Google search reveals multiple news stories about long wait times and shortages for mental health care, but the research literature is scant. While research on mental health care provider shortages have been examined (see Cunningham, 2009) in the past, the impact of health care reform on this issue remains largely unstudied. The negative spillover effects of expanded coverage for primary care has been well documented (see Joynt et al. 2013; Bodenheimer & Pham, 2010), but similar research for behavioral health is limited.
Without this information, we lack an understanding about the effect of these wait times and shortages. The social services agency profiled in the New York Times article is now urging patients to attend group therapy, given the long waits for individual therapy sessions. Caseloads at their agency have doubled. While it is positive to see people in groups who previously were unable to access any kind of behavioral health, we don’t yet know the wider implications of these shifts in care as a result of workforce shortages, or the impact on patients who previously had coverage whose providers are now dealing with overwhelming caseloads.
Working with states for the past three years through the BRSS TACS Policy Academy has repeatedly reminded me that health care reform is bringing new opportunities to support recovery for people with behavioral health issues. This has been an exciting development and a refreshing change, but with some concerns. My hope is that with these policy changes we can also assess their impact – the good and the bad – so that we can provide patients, and the workforce serving them, the support they need.
Have you or someone you know experienced changes in care, good or bad, as a result of the Affordable Care Act and expanded coverage?