Mental Health and Substance Use
Disorder Policy in an Era of Rapid Change
Colleen L. Barry, PhD, MPP
Associate Professor & Associate Chair for Research and Practice
Department of Health Policy and Management
Johns Hopkins Bloomberg School of Public Health
Maryland Statewide Summit on Behavioral Health
Visionary Conversations: Information, Innovation, Integration
November 2013
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Overview
• Enormous changes in health policy environment
• Promises and perils for persons with mental illness &
substance use disorders
 Potential of some policy changes to broaden access,
improve treatment rates, improve quality of care, promote
consumer-oriented care
 Some potential perils too – adverse selection, increased
stigma, lower quality of care, access problems, threat to
financing of services outside traditional health care services
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What is going on?
1. Affordable Care Act
• Increased coverage through expansion of public programs
(Medicaid)
• Reform and redesign of insurance markets
• Delivery system and payment reform
2. Policies responses following Sandy Hook tragedy
3. Federal parity law
How might each of these changes affect behavioral health?
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What are our Stories?
And, how can applied policy research
health inform our portrayals?
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Big Change #1: ACA
• State and federal health exchanges for individuals and
small businesses (up to 100 employees)
• Premium and cost-sharing subsidies for those at 133% to
400% of poverty
• Medicaid Expansion to 133% FPL for states that choose
• Individual mandate to maintain coverage else tax penalties
• Employer mandate for those with >50 employees
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State & Federal Health Exchanges
• Reorganizes individual and small group markets
• Participating health plans certified by exchanges
• Plans must meet essential benefits requirements –
including mental health and substance abuse
• Scope of benefits must be equal to small group
benchmark
• Domenici-Wellstone Mental Health Parity and
Addiction Equity Act requirements must be met
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What does bumpy start mean for risk pool?
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ACA Private Market Reforms
• Preexisting condition exclusions for adults prohibited January 2014
• Preexisting condition exclusions for children prohibited September 2010
• Guaranteed issue and renewability - 2014
• Premiums can no longer be based on health status - 2014
• No lifetime caps on benefits – 2010; no annual limits on
benefits 2014
• Extended private coverage of dependent children up to age
26 - September 2010
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ACA Medicaid Expansion
• Shift to income-based eligibility to 133% FPL
• Regardless of traditional eligibility categories (i.e., childless
adults)
• Income limit: $14,404 for individuals and $29,326 for
families of four
• No asset test
• Enhanced federal funding for those newly eligible:
• 100 % federal in 2014, 2015, 2016
• Phases down to 90% federal by 2020
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ACA Medicaid Expansion Benefit Package
• Not necessarily full Medicaid benefits; benchmark coverage
instead – private insurance model
• Concern about appropriateness for higher need population
with benefits modeled after private market
• But certain groups exempt from benchmark package: people
with disabilities (regardless of SSI eligibility), duals,
institutionalized individuals, medically needy, parents on TANF
• Benchmark coverage must comply with essential health benefit
package (includes mental health and SUD benefits)
• Wellstone/Domenici Parity Law applies
• Other payment sources (SAPT Block Grant) to continue as
important source of financing for excluded services, remaining
uninsured
• Role of block grant changing
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ACA Delivery System Reforms
• Medicaid health home option (2011)
• Grants to support co-location of primary and specialty care
in community behavioral health centers (2010)
• Grants for community health teams
• Changes to Medicaid home- & community-based services
option (sec.1915(i))
• Medicaid Inpatient Psychiatric Care Demo - reimburse
private psych hospitals for emergency psychiatric
stabilization
• Payment bundling and accountable care organization
demonstration programs
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New Integration Care Models:
Decision to Enter Treatment
Willingness to Enter
Mental Health
Treatment (%)
N=1,040
Willingness to
Enter Drug
Treatment (%)
N=231
Willingness to Enter
Alcohol Treatment
(%)
N=572
Usual Care Arm
32%
26%
17%
Primary Care Arm
44%*
42%*
25%*
Collaborative Care Arm
38%
37%
25%*
Barry and colleagues, working paper, 2013
1
If X treatment were free to you and available in your areas with appointments open, would you enter treatment?
(Free means there would be no cost to you even if you do not have insurance or if your insurance company sometimes charges copayments)
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ACA Prevention-Oriented Delivery System
Reforms Affecting Behavioral Health
• Medicare annual wellness visit –includes depression
screening
• Elimination of co-pays, mandatory coverage Medicare
preventive services including depression screening
• Medicaid incentive for states to cover with no cost-sharing
clinical preventive services including depression screening
• Grants for early childhood home visitation ($1.5 billion over
five years to states)
• Grants for school-based health centers
• A bunch more……
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ACA:
What are our Stories?
And, what should researchers be
focused on studying?
© 2008, Johns Hopkins University. All rights reserved.
Big Issue #2: Mental Illness & Gun Violence
 Four major mass shootings in the past six years
(Newtown, Aurora, Tucson, Virginia Tech)
 Common element = framed by news media in term
of mental illness
 Policy response: Serious mental illness gun
restrictions
 Policy response: improved mental health care
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Controversy around gun policies targeting people
with mental illness
Journal of the American Medical Association (JAMA), 2011. Vol. 305, No.20
Effectiveness?
Unintended consequences?
 Chilling effect on mental health treatment seeking?
 Exacerbate stigma surrounding serious mental illness?
© 2008, Johns Hopkins University. All rights reserved.
Gun Policies Affecting those with
Mental Illness
Overall
(N=2402)
Non-gun
owners
(N=823)
Non-gun
owner, gun
in household
(N=742)
Gun
owners
(N=837)
NRA
Members
(N=171)
Requiring states to report a person to the background check system
who is prohibited from buying a gun due either to involuntary
commitment to a hospital for psychiatric treatment or to being
declared mentally incompetent by a court of law?
86%
85%
87%
87%
82%
Requiring health care providers to report people who threaten to
harm themselves or others to the background check system to
prevent them from having a gun for six months?
75%
75%
76%
73%
65%
Requiring the military to report a person who has been rejected from
service due to mental illness or drug or alcohol abuse to the
background check system to prevent them from having a gun?
79%
79%
81%
76%
67%
Allowing police officers to search for and remove guns from a person,
without a warrant, if they believe the person is dangerous due to a
mental illness, emotional instability, or a tendency to be violent?
52%
54%
54%
44%**
33%**
Allowing people who have lost the right to have a gun due to mental
illness to have that right restored if they are determined not to be
dangerous?
31%
31%
29%
33%
41%
% Favor
Barry et al., NEJM 2013
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Gun Policies Affecting those with
Mental Illness
% Favor
Barry et al., NEJM 2013
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Effect of News Story about Mass Shooting on
Perceived Dangerousness of Person with SMI
High Perceived
Dangerousness
McGinty, AJP, 2013
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Mixed Public Attitudes about Mental Illness
Would you be willing or unwilling to have a person
with serious mental illness as a neighbor? (% willing)
Do you agree or disagree that discrimination against
people with mental illness is a serious problem?
(% agree)
Do you agree or disagree that most people with
serious mental illness can, with treatment, get well
and return to productive lives? (% agree)
Do you favor or oppose increasing government spending on
mental health screening and treatment as a strategy to
reduce gun violence? (% favor)
Barry et al., NEJM 2013
Overall
(N=1530)
No Experience
with Mental
Illness
(N=752)
Experience
with Mental
Illness
(N=765)
33.1
26.3
39.9‡
58.2
49.9
66.4‡
55.9
48.9
63.2‡
60.6
54.4
66.8‡
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Critical to Shift Policy Focus
• Ill-thought-out policies adopted in haste can wreak havoc on the mental
health system and lead to counterproductive consequences
• Effectiveness in reducing gun violence questionable
• Given very small share of violence attributable to mental illness, policies
aimed exclusively unlikely to significantly increase public safety
•
Could be counterproductive
•
Those people most in need of treatment for suicidal or violent impulses
may be deterred from treatment
•
Massive infringement of privacy of people in treatment
•
Further strengthens association in the public mind between mental
disorders and violence
• Mentally ill more often victims of violence than perpetrators
• Need to consider alternatives not focused on people with mental illness
© 2008, Johns Hopkins University. All rights reserved.
Gun Violence:
What are our Stories?
And, what should researchers be focused
on studying?
© 2008, Johns Hopkins University. All rights reserved.
Big Change #3: Federal Parity
Private insurance substantially more limited for
behavioral health than for general medical care
Advocates view benefit limits as discriminatory
Economic Explanations:
 Moral hazard: health plan incentive to control
consumer demand for services
 Selection: health plan incentive to compete to avoid
‘bad risks’
Regulatory response - parity policies require equivalent
coverage for behavioral health and general medical care
© 2008, Johns Hopkins University. All rights reserved.
Wellstone-Domenici Law – Key Provisions
• Equal benefits - all financial requirements & treatment limits
• Annual and lifetime dollar limits
• Coverage not mandated
• Group coverage
• Conditions covered
• Protections for state parity laws
• Benefit management
• Out-of-network coverage
• Monitoring; compliance and enforcement provisions
• Cost exemption
• Other populations
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Interim Final Rule
• Interpretation of terms predominant financial
requirements and substantially all medical/ surgical
benefits
• How deductibles should be treated
• How plans can manage the benefit
• non-quantitative treatment limits (NQTLs)
Major Concerns Remain:
• Lots of remaining areas of uncertainty (e.g., scope of services)
• Concerns about law circumvention
• Final rule still pending
© 2008, Johns Hopkins University. All rights reserved.
Federal Parity:
What are our Stories?
And, what should researchers be
focused on studying?
© 2008, Johns Hopkins University. All rights reserved.
Thank you!
comments:
cbarry@jhsph.edu
© 2008, Johns Hopkins University. All rights reserved.