Joel E. Miller Executive Director and Chief Executive Officer American Mental Health Counselors Association (AMHCA) Ap

1. DC Mental Health Counselors AssociationSpring ConferencePresentation on:Updates on the Affordable Care Act and Implications for Mental Health Counselors Joel E. Miller Executive Director and Chief Executive Officer American Mental Health Counselors Association (AMHCA) April 26, 2014

2. Affordable Care Act (ACA) Implementation --Status Report on Health Insurance Coverage • Who would have thunk it? • Just a little over 6 months ago most elements of our society said it was all over but the shouting. Obamacare was DOA! And declared it dead one week into its formal launch. • The government – specifically HHS and the White House – was attacked for being incompetent as consumers could not gain access to Healthcare.gov – the national website where Americans can shop for health insurance coverage under the Patient Protection and Affordable Care Act (ACA).

3. Pouring Gasoline on the Fire • Then there were claims that people had to give up their health insurance plans and substitute those arrangements for mandated ones under the ACA. • To pour gasoline over the raging “coverage plan” fire, many complained that health insurance premiums were sky high under the new plans and consumers could not afford the increased costs. • Then the policy wonks weighed in and said that not enough young people were enrolling to help spreadout the costs of those who had pre-existing conditions who were going to enroll in droves. • Actually what many experts found is that many older adults who were enrolling were pretty healthy as well, but could not purchase coverage prior to the ACA because they were declined coverage due to an episodic illness or a mental illness.

4. Funny Thing Happened on the Way to the (Predicted Disastrous Coverage) Forum …. • … Obamacare Worked and is Working! • This list of potential problems could go on and on like people cannot see their own doctors (which by the way changes just about every year through your employment-based system plan anyway). • Oh sure – there are still problems to be sure. Was there ever a major enterprise “start up” whether in the public and private sector that did not have endure a bunch of hiccups at the beginning. • Remember only a few years ago that the Medicare D Program got off to a horrendous start, but now it is a footnote in health policy history and seniors love the new RX benefits. • Has anyone asked lately that the slowdown in health care costs may be attributed to people over the age of 65 having access to affordable meds, which has offset the costs of expensive treatments including hospitalizations, as one’s medical condition can deteriorate due to access issues?

5. The Numbers Speak for Themselves • Trying to get millions of Americans insured over a 10-year period is an incredible challenge and there were plenty of problems with the launch of Healthcare.gov. But just look at the stats. • Over 8.5 million people have enrolled in either the state health insurance exchanges or in the federal health insurance marketplace – Healthcare.gov. • Another 1 million – and possibly more – bought coverage directly through heath insurance companies and managed care plans. • About 3 million Americans have been determined newly eligible for Medicaid as a result of the program’s expansion in 25 states and DC. • The numbers will grow on all three levels as the final tallies are not in – like one of those tight election nights where neither candidate won’t concede. • The Congressional Budget Office (CBO), the official Congressional scorekeeper when it comes to how much it will cost to implement a new piece of legislation and the potential impact – estimated two years ago that about 7 million people would gain coverage through the health insurance marketplace.

6. RAND Corporation Estimates • Estimated a net gain of 9.3 million in the number of American adults with health insurance coverage from September 2013 to mid-March 2014. • The significant uptick in insurance coverage was due to new enrollment in employer coverage and Medicaid. Enrollment in ESI increased by 8.2 million. • Put another way, the RAND survey estimates that the share of uninsured American adults has dropped over the measured period from 20.5 percent to 15.8 percent. • Although a total of 3.9 million people enrolled in marketplace plans, only 1.4 million of these individuals were previously uninsured. But RAND’s marketplace enrollment numbers are lower than those reported by the federal government at least in part because their data did not fully capture the surge in enrollment that occurred in late March.

7. Urban Institute Report • The number of uninsured adults age 18 to 64 fell by an estimated 5.4 million between September 2013 and early March 2014. • Most of the gain in coverage was among lower- and middle-income adults targeted by the ACA's Medicaid and Health Insurance Marketplace coverage provisions. • States that implemented the ACA's Medicaid expansion saw the largest declines in uninsurance, driven by gains in coverage among the lower-income adults targeted by that expansion.

8. Urban Institute – Stats on Medicaid Expansion • States that implemented the ACA's Medicaid expansion saw a large decline in uninsurance. • The uninsurance rate for adults in those states dropped 4.0 percentage points since September, compared with a drop of 1.5 percentage points for the non-expansion states. • The average uninsurance rate for adults in the 26 non-expansion states was 18.1 percent in March 2014, well above the 12.4 percent average in the expansion states. • The gap in the uninsurance rate between expansion and non-expansion states widened between September 2013 and early March 2014, from 3.2 to 5.7 percentage points.9

9. Just Imagine; Just Say Yes • Imagine the numbers if all states supported the implementation of Obamacare. Well we have an idea based on our AMHCA Dashed Hopes report that millions more with mental health conditions alone are eligible under the new Medicaid Expansion and the state exchanges. • Let’s hope the states get on board both in terms of increasing their outreach activities to assist people in enrolling in the coverage options under the ACA – rather than erecting barriers such as preventing “enrollment and coverage expert navigators” from doing their jobs. • And those 24 states that are not participating in the new Medicaid Expansion program just need to say yes. • Just say yes to enrolling over 6 million people who are eligible – 3.7 million with a mental health condition. • Just say yes to billions of dollars that will help shore up state budgets that go toward treating uninsured people with chronic or serious conditions such as people with major depression and bipolar disorders.

10. The ACA Ushers in a Golden Age for Coverage of Behavioral Health Services • The passage of the ACA was a major milestone in long-standing efforts to ensure access for all Americans to appropriate, high-quality and affordable behavioral health (BH) care and prevention and treatment services. • Many of the most prominent features of the ACA were instrumental in establishing the CENTRALITY of behavioral health services within the overall health care delivery system – such as the designation of mental health and addiction services as one of the ten categories of essential health benefits (EHB). • Expanded ACA Medicaid eligibility and the new health insurance marketplaces (exchanges) create 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. What better way to dramatically reduce stigma, discrimination and outright rejection that keep people from seeking help, than opening up the “Coverage Door” to those with mental illness. Treated like any other illness.

12. AMHCA’s “Dashed Hopes” Report on Medicaid Expansion Implementation • AMHCA’snew, groundbreaking study shows that 3.7million people with mental illnesses who are uninsured reside in the 25 states that have refused to participate in the Medicaid Expansion program under the Affordable Care Act (ACA). • Many of these individuals have severe mental health conditions and currently have no health insurance coverage through any public or private plan, but will be denied the opportunity to obtain coverage for treatment since those states have refused to participate. • States declining Medicaid Expansion represent 55 percent of all uninsured people with major mental health disorders who are eligible for coverage in the new health insurance access initiative.

13. Dashed Hopes Report • Shows that 6.7 million uninsured people with a mental illness are currently eligible for coverage under the Medicaid Expansion that went into effect on Jan. 1, 2014. • But the majority of these individuals with mental health conditions will be left out in the coverage cold due to their state’s antagonism toward the Medicaid Expansion health insurance initiative. • Nearly 75 percent (2.7 million adults) of all uninsured persons with a mental health condition or substance use disorder who are eligible for coverage in the non-expansion states (3.7 million), reside in these 11 Southern states that have rejected the Medicaid Expansion: Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas and Virginia.

14. Dashed Hopes Report • More than 1.1 million uninsured people who have serious mental health and substance abuse conditions live in just two states — Texas (625,000) and Florida (535,000). • These more than 1.1 million individuals are eligible for coverage under the new Medicaid Expansion program, but won’t receive it. • Leaving their most vulnerable citizens without health insurance, even though the federal government will pay for it (at 100 percent for the first three years of the program and slowly tapering off to 90 percent in 2020 and thereafter). • The funds for this are already included in the federal budget.

15. Dashed Hopes Report • States expanding Medicaid will have enhanced capacity to meet the needs of millions of previously uninsured people with mental illness. • Intensify the treatment disparity gap between states. • The 24 non-expansion states will be further left behind as those states that do expand Medicaid will see an influx of new federal monies to shore up their mental health systems, which have witnessed ruinous cuts since 2000.

16. Dashed Hopes Report • Health care coverage in the United States shouldn’t be a lottery based on a lucky location. But that’s the current dismaying situation • Uninsured Americans with a mental illness who live in these non-expansion states will be left out in the coverage cold. That’s not fair, and it’s not good policy because the cost of untreated mental health problems is high, in both human and economic terms. • Lack of access to covered services will result in more people with a mental illness developing a crisis condition. Medicaid Expansion can help because it includes mental illness prevention benefits such as early identification and screening services. • There is no practical or financial argument for governors and legislators in the 24 states that have rejected the Medicaid expansion to continue on their dangerous path that denies their citizens needed health care services.

17. Percentage of Uninsured Adults with Mental Health Conditions Eligible for Coverage in the 24 Non-Medicaid Expansion States (Out of the Entire Medicaid Expansion Eligible Population in the State)* • Indiana.................62% • Idaho....................58% • Alabama...............51% • South Carolina......51% • Nebraska..............50% • Virginia.................48% • Utah......................47% • South Dakota........45% • Maine....................45% • Tennessee.............44% • Louisiana..............43% • Montana...............42% • Wyoming..............41% • Wisconsin.............41% • Pennsylvania........40% • Oklahoma.............39% • Mississippi............39% • Missouri................38% • Alaska...................38% • Florida...................34% • Kansas..................33% • Texas....................28% • North Carolina......28% • Georgia ................27%

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

20. State Health Insurance Marketplaces Figure 7 Note: CI = Confidence Interval 20

21. Number of Uninsured Adults in Washington, DC with a Serious Mental Illness (SMI) Eligible for Health Insurance under the New Medicaid Expansion Program and New Health Insurance Exchange in the ACA, and Eligible for Coverage under the Current Medicaid Program • Nearly 1,000 individuals (1,393) who are uninsured in Washington, DC (not covered by a public or private health insurance program) with a serious mental illness (e.g., schizophrenia, bipolar disorder, major depression) are eligible for health insurance coverage under the New Medicaid Expansion Program in the ACA. • Nearly 1,000 (1,038) individuals who are uninsured in Washington, DC with a serious mental illness are eligible for health insurance coverage under the New Health Insurance Exchange (online marketplace) in ACA. • Nearly 3,000 (2,914) individuals who are uninsured in Washington, DC with a serious mental illness are eligible for health coverage under the Current Medicaid Program already operating in DC and in place prior to the passage of the ACA.

22. Number of Uninsured Adults in Washington DC with Serious Psychological Distress (SPD) Conditions Eligible for Health Insurance under the New Medicaid Expansion Program and New Health Insurance Exchange in the ACA, and Eligible for Coverage under the Current Medicaid Program • Nearly 2,800 adults (2,728) who are uninsured in Washington DC (not covered by a public or private health insurance program) who are in serious psychological distress (e.g., severe panic, anxiety, or mood disorders) are eligible for health insurance coverage under the New Medicaid Expansion Program in the ACA. • Nearly 1,600 (1,572) adults who are uninsured in Washington DC who are in serious psychological distress are eligible for health insurance coverage under the New Health Insurance Exchange (online marketplace) in the ACA. • Nearly 9,000 (8,993) adults who are uninsured in Washington DC who are in serious psychological distress are eligible for health insurance coverage under the Current State Medicaid Program already operating in DC and in place prior to the passage of the ACA.

23. Number of Uninsured Adults in Washington DC with a Substance Use Disorder (SUD) Eligible for Health Insurance under the New Medicaid Expansion Program and New Health Insurance Exchange in the ACA, and Eligible for Coverage under the Current Medicaid Program • Nearly 6,100 adults (6,073) who are uninsured in Washington DC (not covered by a public or private health insurance program) with a substance use disorder (e.g., dependence or abuse can involve alcohol, cocaine, heroin, and many individuals have a co-occurring mental health condition such as schizophrenia or an anxiety disorder) are eligible for health insurance coverage under the New Medicaid Expansion Program in the ACA. • Nearly 3,000 (2,923) adults who are uninsured in Washington DC with a substance use disorder are eligible for health insurance coverage under the New Health Insurance Exchange (online marketplace) in the ACA. • Nearly 14,000 (13,905) adults who are uninsured in Washington DC with a substance use disorder are eligible for health insurance coverage under the Current Medicaid Program already operating in DC and in place prior to the passage of the ACA.

24. When You Add It all Up • The nearly 19,000 uninsured adults with a mental health condition (persons with either a serious mental illness or in serious psychological distress) in Washington DC, represent (16 percent) of the 118,021 uninsured adults eligible for coverage under the three health insurance programs (Current Medicaid, New Medicaid, New Exchanges). • The nearly 42,000 uninsured adults with a behavioral health condition (people with a serious mental illness, in serious psychological distress, or with a substance use disorder) in Washington DC, represent 35 percent of the 118,021 uninsured adults eligible for coverage under the three health insurance programs.

25. Reforming the Health Insurance Market: ACA Has Already Increased Security for All Americans • Pre-Existing Conditions Are No Longer a Barrier to Coverage • One of the most important provisions in the law for children and adults with mental health needs is the ban on exclusion for a pre-existing condition(s). This provision went into effect in 2010. Insurers often denied coverage because an individual has a health condition or has been sick in the recent past, and many children and adults with mental illnesses have failed to qualify on these grounds. Insurers cannot deny coverage due to pre-existing conditions for all Americans. • Insurers cannot charge people with poor health more than others. • No health plan can have a lifetime or annual limit on certain benefits or rescind coverage if an individual gets sick. • Young Adults Can Remain Covered • Young adults (up to age 26) must be allowed to remain on their parents’ health plan, if their parents so desire.

26. Increasing Mental Health Benefits • ACA requires the inclusion of essential health benefits (EHBs) that qualified health plans must offer to participate in state health insurance exchange & essentially provided through the 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 treatments • Preventive and wellness services and chronic disease management • Ambulatory patient services • Emergency services • Hospitalization • Prescription services • Maternity and newborn care • Rehabilitative and habilitative services and devices • Laboratory services • Pediatric services, including oral and vision care.

27. Preventive Services Coverage • Preventive services must be covered without copayment or coinsurance, when delivered by a network provider. • Current list (U.S. Preventive Services Task Force) includes: For Adults: • Alcohol misuse screening • Depression screening • Obesity screening and counseling for all adults • Sexually transmitted infection prevention counseling for adults at higher risk • Tobacco use cessation interventions for tobacco users For Children: • Alcohol & drug use assessments • Behavioral assessments • Depression screening

28. Assuring Mental Health Benefits at Parity with Medical Services • The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 prohibits financial requirements &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 &substance use treatment services in the list of the 10 essential benefits. But always remember this: People can’t have comprehensive essential health benefits and at parity, unless they have health insurance coverage.

29. Benefits of the Essential Health Benefits Package for Those with Individual Coverage • Americans who currently buy coverage in the individual health insurance market (about 18 million) in 2014 will gain access to essential health benefits. • Coverage of benefits in the individual market will expand parity on many levels. • Expected EHB Expansion also means expanded BH parity: • Nearly 5 million Americans will gain substance abuse coverage parity* • Nearly 2.5 million Americans will gain mental health coverage parity * • Over 1.3 million Americans will gain prescription drug coverage *7.1 million Americans alone who have coverage in the individual market will gain BH parity through insurance reforms and the EHP.

30. Deploying and Positioning the Mental Health Workforce • Workforce experts say a major area of concern is having enough providers to ensure access to mental health services. • Policymakers and BH experts believe there is insufficient capacity and coordination in the current system to adequately serve the newly-eligible population with mental health needs under the ACA. So strategic deployment is critical. • 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 appropriately deploying -- and building on – current capacity in the current BH system. • ACA programs are helping to transform the process, by promoting integrated care for BH and PCP services – major momentum in this area. But more needs to be done.

31. Environmental Factors and the Workforce Workforce shortages will likely be impacted by additional demands that result from: • (1) a large number of returning veterans in need of services; • (2) new state re-entry initiatives to reduce prison populations, a large majority of whom have mental health or substance use disorders, and • (3) the increasing number of baby boomers and the need to train more geriatric mental health providers in the near term.

32. Key Next Steps for Clinical Mental Health Counselors (CMHCs): With the next open enrollment period under the ACA approaching this Fall, CMHCs should: • Gain professional competence on health care reform topics and on ACA eligibility and enrollment processes, which is critically important in assisting individuals with securing the best possible health insurance coverage and mental health benefits available through the health insurance exchanges and the new Medicaid Expansion program.   • When it comes to health insurance issues, individuals are often informed by their care providers about available insurance resources. • Inform policymakers and decision-makers that if the ACA is implemented properly, over 13 million uninsured people with MH services are now eligible for coverage under the state health insurance exchanges and the new Medicaid expansion programs. And these consumers will have a robust package of benefits including MH/SA services, and at parity with medical and surgical benefits. • Participate in special task forces and work groups that have been formed and organized in your locale and state that are conducting outreach and enrollment initiatives to reach people who are eligible to enroll in the ACA coverage expansions.

33. NEXT STEPS FOR CMHCs: Roles Under the ACA Participating in Outreach, Eligibility and Enrollment Initiatives • Work with other counselors to ensure that health coverage is easily accessible for those eligible to receive it through insurance expansions, and that the new “Navigator” programs are sufficiently funded and staffed to facilitate the enrollment process for those individuals for whom the process may be more burdensome (as well those transferring between Medicaid enrollment and the insurance marketplaces (exchanges) and other pools). • Work closely with other stakeholders to ensure that states conduct strong outreach and education activities, targeted to the public, eligible employers, behavioral health consumers and service providers to ensure sufficient access to coverage and benefits. • Ensure that 
governing boards and other
advisory bodies tasked with
developing and administering the
coverage expansions (Medicaid and State Exchanges/Marketplaces) include individuals with expertise regarding the unique needs of individuals with MH disorders.

34. NEXT STEPS FOR CMHCs: Roles Under the ACA Participating in Outreach, Eligibility and Enrollment Initiatives, cont. • Advocatefor the enrollment needs of individuals moving from institutions and varying transitions of care, such as IMDs or prisons to community-based settings in order to prevent discontinuity of care. • Engage with the state insurance marketplaces and Medicaid programs to determine how best to address enrollment for individuals whose income levels fluctuate between Medicaid and insurance marketplace eligibility to ensure these individuals have consistent access to MH services. • As states design and construct their health information exchanges and their enrollment Web-sites, CMHCs could encourage their colleagues and all stakeholders to think of these pieces as an integrated eligibility and enrollment system that includes Medicaid and CHIP, as well as the insurance exchanges.

35. NEXT STEPS FOR CMHCs: Roles Under the ACA Making the Essential Health Benefits’ Robust • Make recommendations to expand benefit requirements if the essential benefit package is not sufficient to meet the behavioral health needs of state residents. • Promote an overall benefit to include a universal definition of medical necessity that includes rehabilitation, habilitation, prevention, recovery programs and long term care services in order to ensure an appropriate continuum of services in the benchmark plans offered by health plans in the health insurance exchanges. • Highlight that the definition of medical necessity must balance the need for consistency with the need to apply the medical necessity definition to each individual, given the totality (behavioral and medical) of that person’s health condition.

36. NEXT STEPS FOR CMHCs: Roles Under the ACA Making the Essential Health Benefits’ Robust, cont. • Encourage their state to coordinate planning of the insurance exchange and Medicaid expansion behavioral health benefit to be consistent with one another and with traditional Medicaid. Consistency in benefits offered, means a more dependable benefit for persons in treatment. • Ensure that decision-makers remain cognizant of behavioral health concerns throughout the entire process, both during insurance exchange establishment and Medicaid. • Identify gaps by first mapping out which populations will be covered by various health insurance coverage options available under the changing health care landscape. The availability of new evidence-based approaches and funding will require large purchasers to rethink what services they purchase as well as how those services are purchased. • Although access to Medicaid and provide insurance will increase over the next few years, gaps in coverage will remain for specific populations and services. Purchasers and payers will need to determine what specific behavioral health services they should cover in addition, or over and above, to what is being covered by health insurers and other payers.

37. NEXT STEPS FOR CMHCs: Roles Under the ACA Ensuring Mental Health Parity • Work closely with state insurance divisions. Promote education of, and compliance with, parity requirements: monitor results; facilitate handling of consumer complaints; enhance transparency and accountability; and expand needed consumer protections. • Use on-going discussions with health plans and health care purchasers, to develop user-friendly MHPAEA information to inform stakeholders on the key provisions in MHPAEA and their linkage to 2014 coverage expansions. • Develop special websites to allow consumers to offer information about the implementation of the mental health parity; encouraging individuals and families to share their personal experiences with parity implementation - both positive and negative. • Inform stakeholders on MHPAEA provisions and their linkage to 2014 coverage expansions.

38. Mental Health Counselors Primed & Ready to Address ACA Coverage Expansions & Workforce Issues Competenciescritically important for improving quality and outcomes: • The skill and training of practitioners • Understanding of the “Primary Prevention Model” • Understanding emotional influences on disease-critical in PC setting and achieving integration • The use of evidence-based treatments • Trained in trauma-specific or trauma-informed approaches • Improve communication • Cultural competence Clinical mental health counselors are uniquely qualified to meet the challenges of providing high quality care and in a cost-effective manner. CMHCs can address key workforce challenges!

39. Distinctiveness and MH Benefits Provided Under ACA -- Counselors’ Key Theoretical Foundation and Belief System • Best perspective for assisting individuals to resolve personal and emotional issues underthe wellness modelof mental health. • Most of the issues individuals face are developmental in nature. • Prevention and early interventionare superior in dealing with personal and emotional problems. • The goal of counseling is to empower clients and client systems.

40. New Opportunities in Integrating Mental Health and Primary Care Services for Counselors Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. • Many enrollees have chronic conditions or are at high-risk, e.g. diabetics. • Methodology: Reduce service fragmentation and realign payment incentives. • Realigned payment incentives: Primarily FFS payments with retrospective bonus payments for demonstrable improvement in the health care and costs of enrollees. • Penalties for exceptionally high rates of hospital readmission. • Success depends upon improved care coordination and delivery of the right service at the right time. • ACOs – overall – force integration of care and providers.

41. New Opportunities in Integrating Mental Health and Primary Care Services for Counselors • Patient Centered Medical (or Health) Home is a health care setting that facilitates partnerships between individual patients, their personal physicians, mental health professionals, and when appropriate, the patient’s family. • Care is facilitated by registries, information technology, health information exchange (HIE) and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. • Provide medical assistance through Medicaid to eligible individuals with chronic conditions who select provider/support team for purposes of providing health home services. (Involves select chronic conditions: e.g., mental health, substance use disorder, asthma, diabetes, and heart disease

42. Quality: Greater Accountability of Mental Health Professionals • As delivery changes, practitioners will come under greater scrutiny for quality: - More attention on care following discharge from inpatient care. • Integration with general health: - There are a series of demonstration projects being planned. - Delivery of care through co-location of primary and specialty care in community- based mental health and behavioral health settings.

43. New Opportunities for Clinical Mental Health Counselors • Mental health counselors must be at the table with other behavioral health groups and professionals and describe the “benefits” they can provide and deliver, or risk being left out of the ACA implementation process. • If the ACA is implemented properly, over 13.5 million uninsured people currently with behavioral health services are eligible for coverage under the state health insurance exchanges and the new Medicaid expansion programs, who will have a robust package of benefits including mental health and substance use services, and at parity with medical and surgical benefits. Several million more are eligible under the Current Medicaid Program. • In addition, there are new funds for training and demonstration projects to implement new delivery models where mental health counselors can participate

44. THANK YOU FOR THE OPPORTUNITY Be At The Table! Engage! For follow up questions, and for any additional information on the ACA and health care reform, please contact Joel Miller at: jmiller@amhca.org, or at 703-548-6002