2008 NAMI Conference Orlando, FL

1. Coverage for AllInclusion of Mental Illness and Substance Use Disorders in State Healthcare Reform Initiatives 2008 NAMI Conference Orlando, FL

2. “Coverage for All” • Robert Wood Johnson Foundation funded study • Presentation will cover: • The scope of the problem • The history of financing for mental health and substance use treatment • Analysis of state benefit packages • Recommendations

3. New Data on Uninsured • Data from Substance Abuse and Mental Health Services Administration (SAMHSA) • 2005 and 2006 National Survey on Drug Use and Health (NSDUH) • Tabulated specifically for this report

4. Scope of the Problem • More than 1 in 4 adult Americans who lack insurance coverage have a mental illness, substance use disorder, or co-occurring disorder. • Approximately 1 in 3 of adults with mental illness &/or substance use disorders who are below the FPL are uninsured. • Adults with co-occurring disorders are even more likely to be uninsured: • 37% lack health insurance coverage.

5. Scope of the Problem • Only 37% of people under FPL who have mental illness &/or substance use disorder are Medicaid recipients. • 79% of uninsured adults with mental illness &/or substance use disorders who needed but did not receive mental health treatment indicated that they could not afford the cost. • 34% of insuredadults with unmet mental illness &/or substance use treatment needs indicated that cost was also a barrier to receiving mental health treatment.

6. Historical Trends • State funding for institutional services • Increasing role of the federal government through the creation of Medicaid and the block grant programs • Evolution of private insurance

7. Historical Trends • Reliance on limited public funding • State asylums, hospitals • Medicaid and block grants for community services • Private insurance programs developed in 1930s & 40s, when scientific understanding of mental illness and substance use was lacking.

8. Historical Trends: Parity • Limited parity at federal level (1996) • annual and lifetime limits only • specifically excluded substance use treatment • 40 states now require either • a minimum benefit set or • equal coverage (parity) • Limits of parity • Employee Retirement Income Security Act (ERISA) limits reach of state laws for self-insured companies • Does not guarantee broad array of rehabilitative services

9. Economic Costs of Mental Illness and Substance Use Disorders • Mental illness is leading cause of disability in North American adults. • Alcohol and drug use are the second leading cause of disability. • In 2003, mental illness and substance use disorders led to $171 billion in lost productivity. • By 2013, this figure expected to rise to more than $300 billion.

10. Personal Costs of Mental Illness and Substance Use Disorders • Almost 1/4 of all hospital stays involve mental health or substance use disorders. • Two-thirds of homeless population are adults with chronic alcoholism, drug addiction, &/or mental illness. • DOJ estimates 16 to 23% of jail, state & federal prison inmates have a serious mental disorder. • SAMHSA study: adults with serious mental illnesses die 25 years sooner than those who do not have a mental illness.

11. Coverage for All: The Study • 18 state study • States chosen after consultation with experts. • Must have recent, significant expansion and clear legal standard or benefit package. • Included a variety of programs. • Did not include SCHIP programs or high risk pools.

12. Questions for Investigation: • What is the scope of the benefit package for mental illness and substance use disorders? • How does that package compare with treatment for other health conditions? • Is there any relationship between the population covered and financing methods and the scope of benefits? • Do state programs address other barriers to treatment, such as cost sharing and utilization management?

13. Four Categories of Plans: • Medicaid expansions – expand access to services through the state Medicaid program. (ME, MA, MD, IL, VT). • Parity and More – equal or better benefits for mental illness and/or substance use disorders and other health conditions. (CA, CO, IL, IN, MA, ME, MN, MT, NM, VT, WA). • Limited Coverage – imposes narrower limits for mental illness and/or substance use disorders. (MD, NY, OK, PA, RI). • Minimal or No Benefits – cover few, if any, services for mental illness and/or substance use disorders. (AR, NY, PA, TN).

14. Major Findings: • Individuals with mental illnesses and substance use disorders are prevalent among the uninsured. • The scope of the benefit package for mental illness and substance use varies greatly. MN has one of the broadest packages. NY’s Healthy NY and PA’s adultBasic have no mh/sud benefits. • Approximately 60% of the states evaluated have equal coverage for serious mental illness or mental illness and other health conditions. • Approximately 28% of the states evaluated have an equal benefit for substance use disorders and other health conditions.

15. Major Findings (cont.) • Substance use disorders fare worse than serious mental illness in many state programs. • The states that are closest to achieving universal coverage provide mental health parity. • Of the programs covering all individuals, 90% require equal coverage of treatment for mental illness or serious mental illness and other health conditions. Roughly 40% provide parity for substance use disorders. • Eighty percent of the programs with more limited benefits target employers or employees with small to mid-size businesses. • Federal waivers are a component of reform in approximately 75% of the states with implemented programs, highlighting the importance of federal dollars and policy in future health care expansion efforts.

16. Major Findings (cont.) • Increased cost sharing, an overall trend in health care, is reflected in state plans to cover the uninsured. • The use of utilization management cuts across categories of benefits and is widely used regardless of the scope of the benefit. • Despite the importance of these health care policy issues, state plans for the uninsured direct little attention to workforce shortages, chronic care management, and wellness benefits for mental illness and substance use disorders. • Exceptions: MN and IN increased provider rates; IN will include mental illness and substance use disorders in its screening; VT includes chronic care management in both of its plans.

17. Recommendations • Parity is an important component of healthcare reform efforts. • Parity, by itself, does not ensure access to a broad array of services; some states have also addressed the scope of benefits, utilization management, cost sharing, and provider availability. • Several states have included MI/SUD in chronic care management and wellness initiatives.

18. Recommendations (cont.) • States would benefit from access to information about other state efforts. • To facilitate stakeholder input and informed decision-making, healthcare expansion initiatives should clearly define the scope of benefits for mental illness and substance use disorders and specify whether people with these disorders are included in all parts of the reform effort.

19. www.HealthcareforUninsured.org