The Waterfall Effect: Transformative Impacts of Medicaid Expansion on Uninsured People with Mental Illness

1. The Waterfall Effect: Transformative Impacts of the New Medicaid Expansion Program on Uninsured People with Mental Illness Joel E. Miller Senior Director of Policy and Healthcare Reform, NASMHPD Mental Health America Webinar April 10, 2013

2. Outline of Presentation “The Waterfall Effect: Transformative Impacts of Medicaid Expansion for Uninsured People with Mental Illness • Introduction on Current Medicaid Program – Financing and Impact • Impact of New Medicaid Expansion Program in Addressing the Needs of Uninsured Individuals with Mental Illness • Expanding Health Insurance Coverage & Increasing Access to Services • Redesigning the System • Facilitating Integration • Improving Quality and Health Information Technology • Action Steps for Advocacy Organizations on Medicaid Expansion • Action Steps on Maximizing Enrollment

3. Current Medicaid Program vs. New Medicaid Expansion Initiative Financing • Current Medicaid – Each state receives federal matching $$ (50%-76%) and varies considerably by state. • Medicaid Expansion – Federal match at 100% from 2014 to 2016 and levels off to 90 percent in 2020. Eligibility • Current Medicaid – Federal law requires states to cover certain “categories” like children and women who are pregnant. • Medicaid Expansion – State residents with incomes below 138% of the FPL are eligible for coverage. Benefits • Current Medicaid – Federal law requires states to provide a minimum benefit package for adults and children and can provide optional services such as mental health services and dental care. • Medicaid Expansion – State must provide an “essential health benefits” package that includes “mental health and substance abuse services, including behavioral health treatment.” Benefits must be at parity based on MHPAEA.

4. Transformative Impacts of Medicaid Expansion on Addressing the Needs of Uninsured People with Mental Illness 4

5. Remember the Maine, Alamo… and Oh, BTW -- the Uninsured • Purely monetary estimates of the new Medicaid expansion ignore the potential benefits to improved access to affordable health care for millions of people with a mental illness who are without health insurance. • ACA was enacted to address the magnitude of the uninsured problem in the U.S -- about 50 million people are uninsured in the U.S. • In the absence of the new Medicaid expansion in their state, millions of lower- & moderate-income adults will be left without an affordable coverage option and continue to face the health and financial consequences of going uninsured. • There are several cascading events or transitions in which improved health status and quality care can be achieved for currently uninsured persons with mental illness who are eligible under the expansion initiative. A failure to take advantage of the Medicaid expansion option will represent lost opportunities in 10 key areas.

6. Medicaid Expansion and Historical Concerns of Governors • States hit hard by the recent economic recession – fresh in the minds of governors and state legislatures. • State policy-makers concerned about new state implementation costs under the Medicaid expansion, and overall costs to federal government. • Fear of “risk and bait” under the new Medicaid expansion program. Fear underscored by recent debate on dealing with the “fiscal cliff.” • Concerns of increased enrollment under the current Medicaid program known as “Woodwork” or the “Welcome Mat” effect. • Those opposed to expansion see it as unnecessary government action. • Most consequential state Medicaid decision since 1966.

8. The Medicaid Expansion “Waterfall Effect” Will Have a Multi-Level Cascading Impact on Uninsured People with Mental Illness by: • 1. Expanding health insurance coverage to millions of uninsured people with mental health (MH) conditions – or at risk of developing such illnesses. • 2. Increasing health insurance mental health and medical benefits through the implementation of an “essential health benefits” package, which includes “mental health, substance abuse and behavioral services” that Americans will receive through the Medicaid expansion and state health insurance marketplaces. • 3. Providing mental health benefits at “parity” which means that mental health coverage and benefits must have similar provisions as medical services. • 4. Growing the country’s mental health workforce by encouraging new medical and related personnel to enter the mental health field through new incentive programs. • 5. Reinventing and redesigning state mental health systems by enabling states and federal agencies to test and evaluate improved financial and organizational tools, in order to address the fragmentation of mental health services that lead to poor quality and high cost.

9. The Medicaid Expansion “Waterfall Effect” Will Have a Multi-Level Cascading Impact on Uninsured People with Mental Illness by (Part 2): • 6. Promoting early screening & intervention of mental illness for children & young adults – and adults – and referring individuals to the right providers; to effectively reduce the burden of disease on children, their families & communities. • 7. Integrating mental health care into primary and health care services, as we have an opportunity to address this long-standing problem because many people with these conditions will now have health insurance coverage. • 8. Integrating mental health and substance abuse services which has been a persistent deterrent to appropriate care, but the Medicaid expansion provides numerous opportunities to better address this issue. • 9. Implementing evidence-based treatments and support services, that contribute to high levels of social functioning and recovery but are often not used in the care of people suffering from mental health conditions. • 10. Insuring that services and programs are person-centered and support health, recovery and resilience and healing for individuals and their families who experience mental health disorders.

10. 1. Expanding Health Insurance Coverage • NASMHPD has estimated that nearly 14 million currently uninsured Americans who have a mental illness – from serious to moderate conditions – will be eligible for health insurance coverage through the new Medicaid expansion and state health insurance exchanges between 2014 and 2019. • Between 2014 and 2019, a full Medicaid expansion effortwill provide health insurance coverage to 17 million people with incomes less than 138 percent of the federal poverty level (FPL) who were previously uninsured. • About 40 percent of this group – or 6.6 million individuals – with serious or moderate mental illnesses who are currently uninsured will obtain health insurance through the new Medicaid expansion program between 2014 and 2019. • As a result of the Medicaid health insurance expansion, researchers estimated significantly reduced mortality for people who were previously uninsured and improved health status for people with mental illness, as well as overall enhanced productivity.

11. New Medicaid Expansion Figure 6 Note: CI = Confidence Interval

12. 1A. Expanding Health Insurance Coverage • In addition to the coverage impact of the new Medicaid expansion, 6.8 million uninsured people with a mental illness will also gain health insurance coverage though the implementation of state health insurance exchanges under the ACA, out of nearly 22 million projected newly-insured people between 2014 and 2019. • We believe the combined effect of the Medicaid expansion and the health insurance exchanges will begin to reverse what has been a withering in public investment in mental health in the 21st century. • Expanded Medicaid eligibility creates a way for lower-income and other uninsured individuals to obtain health insurance – but also makes a number of changes to how the mental health and health care systems can better operate through delivery reforms.

13. State Health Insurance Marketplaces Figure 7 Note: CI = Confidence Interval 13

14. 2. Increasing Mental Health Benefits • ACA requires the inclusion of medical benefits and mental health and substance use treatment services in the list of the 10 essential health benefits (EHBs) that qualified health plans must offer to participate in state health insurance exchanges, and essentially provided through the new Medicaid expansion effort. • EHBs must include items and services within at least the following 10 categories: mental health and substance use disorder services, including behavioral health treatment, ambulatory patient services; emergency services; hospitalization; maternity and newborn care; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. • The law also allows states to extend Medicaid coverage, including all benefits and Early and Periodic Screening, Diagnosis and Treatment (EPSDT) requirements, to foster children who have aged out of the foster care system, up to the age of 26 beginning in 2014.

15. 3. Assuring Mental Health Benefits at Parity with Medical Services • The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 prohibits financial requirements and treatment limitations for mental health and substance abuse benefits in group health plans from being more restrictive than those placed on medical and surgical benefits. • The parity provisions also will apply to the new expanded Medicaid programs, as well as to Medicaid managed care programs, and under the state health insurance exchanges. • Most importantly, the ACA requires the inclusion of mental health and substance use treatment services in the list of the 10 essential benefits that insurance exchanges must offer, and as a consequence provided through the Medicaid expansion.

16. 4. Growing the Mental Health Workforce • We recognize that at this time, there is insufficient capacity and coordination in the current system to adequately serve the newly-eligible population with mental health needs under Medicaid expansion and the ACA. • A major area of concern is having enough providers to ensure access to mental health services. • Effectively serving newly-eligible children and adults who may be experiencing the first signs of a mental health condition and have immediate needs, calls for building capacity in the current mental health system. • The Medicaid expansion will force the issue as integrated care for MH and PC services is gaining momentum. • And when it comes to children, it makes perfect sense –critical shortage of MH providers and nearly all children visit the PC setting.

17. 5. Redesigning Mental Health Systems There are several reasons why the Medicaid Expansion has made reinventing and improving mental health more likely now if states pursue the expansion initiative. Following are some examples of opportunities that the states build on: • First, the Medicaid expansion provisions will enable states and federal agencies to test and evaluate improved financial and organizational tools in order to address the fragmentation of mental health services that lead to poor quality and high cost. • Second, many provisions, such as health homes, are directed toward chronic disease comorbidities. These provisions make it possible for care providers to be more responsive to clients who not only have serious mental illnesses, but also have other serious chronic diseases or disease risks. • Third, provisions in the new law allow providers to better coordinate Medicaid mental health services with social service and housing programs that seek to prevent and manage homelessness among people with serious mental illnesses. • Fourth, by extending the concepts of treatment and related supportive care to such entities as health homes, Medicaid provisions provide new pathways for incorporating evidence-based treatments, such as supported employment, that are commonly neglected.

18. 6. Promoting Early Screening & Intervention of Mental Illness and Other Illnesses • It’s all about prevention! Medicaid expansion promotes the prevention and early identification of both health care and mental health problems, thereby allowing for early intervention, which can effectively reduce the burden of disease on children, their families and communities. • The Medicaid expansion, the current Medicaid program and other ACA coverage expansions, will facilitate identification of mental illness at a young age due to increased access to key screening services. • Moreover, children could begin therapy, even without a specific diagnosis that can be difficult to determine for many adolescents. The critically important goal is to reduce the chances that a serious diagnosis will develop later. • The Medicaid expansion could begin to allow comprehensive pediatric practices and children’s mental health programs to bill for parent training and support for behavioral management, as well as reimburse pediatric and child mental health programs for care coordination with schools and other agencies. Care coordination could be more effective than layering on additional treatments.

19. There is a Strong Science Base for Preventing Behavioral Health Disorders and Promoting Emotional Well-Being • Several reports of the Institute of Medicine (IOM) over the last decade have documented the strength of the science base related to preventing mental health disorders and promoting emotional well-being. • Children and adults with serious mental illnesses are at great risk for many preventable co-occurring diseases, such as childhood obesity and diabetes. Increased access to services that can prevent these illnesses greatly improve the lives of children and families. • Some states have already announced they are going to participate in the new Medicaid expansion effort and are beginning to undertake programs to better identify the early signs of mental illness in young people, and refer children to effective treatment programs.

20. 7. Integrating Mental Health Care into Primary Care Services • A major challenge for the next decade is to integrate basic MH care into primary care. Most Americans with mental health conditions get no treatment for these problems. We also know that more people are treated for mental illnesses by their family physician or other primary care practitioner than by MH specialists. The problem is that we have many unmet needs while many specialty MH programs are at capacity. • We have an opportunity in the new expansion effort to address this problem because many people with these conditions will now have coverage that includes MH care and because practical ways to deliver basic MH care in PC settings are now well established. • There is considerably less stigma in visits to primary care. People with a chronic illness like diabetes that also have depression, have health care costs at least 50% percent higher. Improving basic MH care in the PC setting is a huge need & opportunity. • This all will not occur automatically. MH care within PC today is often inadequate. It can be done well – improving health and reducing costs – but barriers must be addressed. Payments and supports for basic MH care in PC are often lacking, so less than 15% of the people with depression in PC get adequate care.

21. 8. Integrating Mental Health and Substance Abuse Services • Lack of integration between MH & SA treatment has been a persistent deterrent to appropriate care, but expansion provides opportunities to address this issue. • The new expansion effort encourages the use of preventive services and substance abuse education, evaluation, and treatment, and it allows providers treating people with mental illnesses to pay more attention and receive payments to SA problems. • Expansion enables a transformation in the management of SA, whether occurring along with mental illness or as a condition in its own right. • Expansion does this through a “whole person” perspective focusing on the integration of services, as well as by encouraging coordination through health homes, &collaborative teams &services. • Medicaid expansion provides a major opportunity for greater collaboration and shared responsibility by requiring MH and SAservices be incorporated into current/emerging clinical models funded by the ACA.

22. 9. Implementing Evidence-Based Treatments and Support Services • Evidence-based treatments that contribute to high levels of social functioning and recovery often are not used in the care of people suffering from mental health conditions. Individuals must be involved in meaningful daily activities for them to avoid restlessness, isolation, boredom, and lack of self-regard. • CMS established a Medicare-Medicaid Coordination Office in an effort to ensure “full access to seamless, high quality care and to make the system as cost-effective as possible” for the dual-eligible population. The goal is to create new approaches to care coordination. • Addressing the risk of homelessness and victimization & providing stable housing are critical to effective & efficient long-term management of serious mental illness.   • Lifelong disability for people with mental illness is usually unnecessary. While many of the worst outcomes of serious mental illness (e.g. homelessness, comorbid medical illness, incarceration) are receiving increased attention, we are still failing systematically to help people escape poverty and disability.

23. 10. Insuring Services & Programs are Person-Centered and Support Health • A modern mental health system should include a structure in which all holistic outcomes, measures and indicators of health are collected, stored and shared with the individual who has a mental illness, and all of the providers who are associated with care of the individual. • The development of interoperable, integrated electronic health records will be necessary, as will community-wide indicators of MH and SA disordersin order to improve coordination and quality of care. • Medicaid expansion has the potential to afford uninsured people with a mental illness greatly expanded access to MH and SA treatment in an integrated and community-based setting, with a person-centered treatment focus.

24. Next Steps on Encouraging States to Participate in the New ACA Medicaid Expansion Program

25. Medicaid Expansion Should Have Extremely Positive Effects for Uninsured People with a Mental Illness • The best way to reduce mental illness and stigma is through better access to health coverage and timely, effective services. Eliminating access barriers involves fully implementing the new expansion initiative. • Advocates need to provide guidance to state decision makers on the incentives built into the expansion to improve health and well-being of individuals with mental illness. • Medicaid expansion can help accelerate the creation of a strong infrastructure of community-based services. • Simply put: The new expansion effort will save lives, improve the quality of life, and improve the health status for millions of uninsured people with mental illness.

26. Key Issues to Highlight with State Officials on Medicaid Expansion – Children’s Issues • In light of the Newtown, CT and Aurora, CO incidents, state officials should constantly hear messages around the need for: • Early screening, identification and intervention; and • Access to a full array of effective services and supports. • When both of these care delivery issues are adequately addressed, it improves outcomes, and reduces the need to serve children and young adults in high-end, high-utilization, and more costly, settings. • M.E.: Key policy vehicle to address children’s MH service delivery issues. • How will you improve access to effective MH services for children and young adults living with mental illness? Half of all mental illness occurs by age 14 and three-quarters by age 24, yet many of our youth don’t have access to the most effective MH services.

28. Table 1 – Urban Institute Worst- and Best-Case Scenarios for State Budget Effects of Key Provisions of the Affordable Care Act: 2014-2019 (in Billions) Table 2 – NASMHPD-NRI FY2009 to FY2012 Total $4.6 Billion in Cuts* *Note: Results based on 41 State Mental Health Authorities Reporting Winter 2011-2012. NASMHPD-NRI 28

29. Talking Points with State Officials: Protect & Strengthen Mental Health Services & Restore Cuts • The Medicaid expansion will replace billions of state and local dollars that are funded on mental health services, with new federal Medicaid monies. • Advocates should promote through several communications that a significant portion of the new federal dollars for MH services be used to re-strengthen state systems & begin to restore harmful cutbacks as an initial priority. • Due to severe state cutbacks over the last four years, individuals with a mental illness who areuninsured often only receive basic, state-funded public MH care services and of limited duration, and often these services are crisis-oriented. • With the new expansion, states can redirect funds from jails, prisons, and crisis-driven services, such as traditional homeless shelters and hospital emergency departments into supportive, permanent housing and evidence-based treatment. • We should invest in upstream community-based initiatives that will result in budget and quality of care gains over the long run.

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31. Medicaid Expansion Talking Points • The impact of the Medicaid expansion on state budgets is substantial. Overall, states will see over $300 billion in budget gains between 2014 and 2023 that will add to their surpluses or significantly reduce budget deficits. • It is estimated that the federal government could spend nearly $900 billion in states through the Medicaid expansion effort from 2014 to 2019. • The new Medicaid expansion and the ACA is a good deal for states, businesses and their citizens – and promotes entrepreneurship. • Several studies show that the new Medicaid expansion program will increase jobs and the state’s tax base. • States that choose not to opt in to the expansion will see their tax dollars go to other states that expand coverage.

32. Next Steps on Maximizing the Health Insurance Coverage Options:Outreach and Enrollment Strategies for Engaging People with Mental Illness

33. Where the Rubber Meets the Road: Implementing the ACA through State Outreach & Enrollment Strategies • Extent to which the promise of the ACA/Medicaid expansion is fulfilled depends in large part on how many people actually avail themselves of the new coverage options. Rate of Medicaid enrollment among currently eligible adults averages only 62% across the states. • In recognition of specific types of problems and challenges, legislation and regulations envision a streamlined process for enrolling Americans into either Medicaid or private plans through the exchanges. Aseries of enrollmentregshave been finalized by CMS. • ACA lays out a number of interrelated strategies for streamlining enrollment process, coordinating across programs &helping people learn about options. • Efforts at streamlining enrollment are vital not only for individuals and families in need of coverage and care, but also for the U.S. health care mental health safety-net system. • Now is the time to find out what your state is planning and to urge state officials to take maximum advantage of the opportunity to modernize systems.

34. A NEW WAY TO ENROLL IN COVERAGE 34

35. New Application Process and No Wrong DoorApproach • States will be required to use a single, streamlined application form. And collect the data needed for enrollment in Medicaid & exchanges, & to coordinate enrollment across various options. • The goal is to ensure that there is, as many experts describe it, "no wrong door" for an applicant. • Regardless of the system individuals use or the program they start off applying for, they will be screened for eligibility under all available options & enrolled in the correct one.

36. Promote Data-Driven, Integrated Eligibility Systems • Data-driven eligibility. One of the most important things that a new IT system must support is a true data-driven eligibility system. The system needs to establish real-time connections with a range of federal, state, and private databases that contain information relevant to eligibility for exchange coverage, Basic Health, Medicaid, and CHIP. • Coordination between health coverage programs. It is also critically important that the exchange, Medicaid, and other health programs coordinate their eligibility processes. • A centralized “my account” feature. Enrollees should have access to their coverage enrollment information online & by phone. This will allow them to easily see which coverage each member of the household is enrolled in and what assistance they are eligible to receive. • Coordination with other human services programs. An additional consideration when designing the data-driven, integrated eligibility system will be whether and how to integrate eligibility for other human services programs, like SNAP and TANF.

37. Help Wanted: Preparing Navigators and Other Assisters to Meet MH Consumer Needs Navigator programs are a required component of exchange consumer assistance. At a minimum, each entity that is selected to be a navigator must do the following: • 1. Maintain expertise in and conduct outreach and public education on the health coverage options and financial assistance that are provided through the exchange. • 2. Distribute accurate & impartial information about the full range of coverage options that are available through the exchangeand public programs. • 3. Facilitate enrollment in qualified health plans through the exchange. • 4. Make referrals to health insurance consumer assistance or ombudsman programs and to state agencies for help with grievances, complaints, appeals. • 5. Provide information and services in a manner that is culturally and linguistically appropriate and accessible to people with disabilities. Selecting Navigators • Entities that exchanges select to become navigators must include at least 1 community-based and consumer-focused nonprofit &at least 1other type of public or private entity.

38. Key Recommendations that MH Advocates Can Make for Implementing Robust Navigator Program • Secure adequate & sustainable funding for navigator programs. • Establish a central source to provide tech support for navigators. • Provide formal mechanisms for communication and data sharing among navigators, the exchange, and state agencies. • Create seamless referral system among entities providing consumer assistance. • Work with navigator entities to develop data collection requirements that enable the exchange to evaluate navigator performance. Ensure that outreach & public education strategies that are used by the exchange and navigator programs are consistent & coordinated. • Provide contact information for the navigator program in all outreach and public education materials.

39. Develop an Effective Outreach Plan Convene—or strengthen—state and local coalitions. • An effort of this magnitude will require a partnership among many different stakeholders. Many diverse voices should be at the table, including you, hospitals; community health centers and safety-net providers; doctorsother providers; consumer groups; groups representing communities of color; health insurance plans; business community; etc. • Groups can work together to establish an outreach strategy that leverages the strengths and connections each partner brings. Encourage the state to invest in outreach. • There is no federal funding explicitly earmarked for outreach, but states can include funding for outreach in their Exchange Establishment Grant requests. • Stakeholders should urge their states to develop a plan for outreach this year and to include significant resources in their grant requests to accomplish this task. Identify segments of the uninsured to target. • The uninsured MH population may require different messages and different outreach strategies. • In order to develop the most effective outreach campaign, it will be important to know who the uninsured with mental illness are in your state & pick segments of that population to target in an outreach campaign.

40. Eligibility & Enrollment Systems – Advocates Need to Be at the Table to Ask Questions • Issue #1 – Will the online application and consumer web-based services be easy to use? • Issue 2 – How will the website facilitate access to personalized help from the call center, navigators, or other assisters? • Issue 3 – How will the IT system use electronic data sources to verify eligibility in real-time? • Issue 4 – How will the IT infrastructure coordinate coverage seamlessly between an exchange, Medicaid, and CHIP? • Issue 5 – Will the web-based services help consumers compare, make an informed selection and enroll in a health plan of their choice? • Issue 6 – How will the system help people maintain and renew coverage? • Issue 7 – How will the system protect the privacy and confidentiality of personal information? • Issue 8 – Does the system provide clear information about grievance and appeal procedures and incorporate due process protections?

42. NASMHPD Medicaid Expansion Resource Management Portfolio* • NASMHPD Report on “The Waterfall Effect: Transformative Impacts of Medicaid Expansion on States” • Fact Sheet • Talking Points • FAQs • Recommendations and Actions to Begin Restoring State MHFunding • Workforce Issues • Guidance on Outreach and Enrollment, IT Systems, Navigators *All materials can be accessed on our website at www.nasmhpd.org

43. THANK YOU FOR THE OPPORTUNITY! Follow up questions, and for any additional information on Medicaid expansion and health care reform, please contact Joel Miller at: joel.miller@nasmhpd.org, or at 703-739-9333