Mental Health and Substance Use Disorder Policy in an Era of Rapid Change

1. 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

2. 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

3. What is going on? • Affordable Care Act • Increased coverage through expansion of public programs (Medicaid) • Reform and redesign of insurance markets • Delivery system and payment reform • Policies responses following Sandy Hook tragedy • Federal parity law • How might each of these changes affect behavioral health?

4. What are our Stories? And, how can applied policy research health inform our portrayals?

5. 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

6. 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

7. What does bumpy start mean for risk pool?

8. 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

9. 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

10. 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

11. 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

12. New Integration Care Models: Decision to Enter Treatment 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)

13. 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……

14. ACA: What are our Stories? And, what should researchers be focused on studying?

15. 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

16. 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?

17. Gun Policies Affecting those with Mental Illness Barry et al., NEJM 2013

18. Gun Policies Affecting those with Mental Illness % Favor Barry et al., NEJM 2013

19. Effect of News Story about Mass Shooting on Perceived Dangerousness of Person with SMI High Perceived Dangerousness McGinty, AJP, 2013

20. Mixed Public Attitudes about Mental Illness Barry et al., NEJM 2013

21. 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

22. Gun Violence: What are our Stories? And, what should researchers be focused on studying?

23. 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

24. 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

25. 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

26. Federal Parity: What are our Stories? And, what should researchers be focused on studying?

27. Thank you!comments: cbarry@jhsph.edu