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Position Statement 71: Health Care Reform
Mental Health America (MHA) believes that all individuals and families should have access to a broad scope of medically appropriate, evidence-based behavioral health services and supports, in full parity with other conditions.
The Patient Protection and Affordable Care Act ("PPACA," the "Affordable Care Act" or the "Act") (Pub. L. 111-148) is expected to expand health care coverage to an additional 32 million citizens and legal immigrants by 2019 through a combination of state-based private insurance exchanges and a Medicaid expansion. In addition, the Affordable Care Act includes a number of reforms to curb harmful insurance company practices as well as provisions to slow the growth of health care costs and improve quality of care.
The Affordable Care Act takes ground-breaking steps toward improving access to mental health and substance use disorder treatment services. Significantly, the Act includes mental health and substance use disorder services as well as rehabilitative services as components of the "Essential Benefits" package that must be offered to cover the uninsured. With the enactment of the Act, America has the ability to create a reformed health care system that provides comprehensive, culturally and linguistically appropriate behavioral health services and supports. However, the details remain to be determined.
Major Principles of a Modern Behavioral Health System
MHA represents the experiences and needs of consumers and families who too often endure chronic and intractable barriers to accessing high-quality, culturally and linguistically competent, adequately-financed, community-based services and supports. We support the effort to increase access to health care and improve the quality of health care delivery. In light of the Act's reforms, we believe that a modern behavioral health system must embody the following major principles:
- All people are entitled to comprehensive health insurance coverage that affords access to health care services that are effective, high-quality, culturally and linguistically appropriate, affordable and accessible.
- Coverage should include prevention, early-intervention, treatment, and rehabilitation services, and offer a full range of services to address the continuum of behavioral health needs for consumers experiencing mild to severe illnesses.
- All services provided should be seamlessly integrated with primary care, with the focus on the consumer as the center of the health care system. Recovery-oriented systems that operate within a shared decision-making framework should provide adequate reimbursement and flexible staffing so that consumers will have time to work with their clinicians in developing a meaningful treatment plan reflecting their goals and accommodating the acuity of their illness.
- MHA sees the health/medical home as the core element in the engagement of consumers in a recovery-oriented system. The health home will be charged with promoting the seamless integration of behavioral health and primary care and providing access to the full array of appropriate behavioral health services.
- MHA suggests that, depending on the resources of the provider and the needs of the consumer, the behavioral health provider may function better than the primary care provider as the medical home for people with serious mental illness.
- A wide range of services should be available for people based on a range of acuity, disability, and engagement levels. The degree of disability and the need for long-term vs. acute care services, as well as the consumer's goals, should dictate the services rendered. While the needs and goals of many individuals with behavioral health needs can be addressed by basic services offered within the health home, individuals with enduring disabilities or with mental illnesses that do not respond to primary care services should have available more intensive services that will likely be afforded outside (but closely coordinated with) the health home.
Appropriate implementation of the Affordable Care Act at both the state and federal levels will be critical in achieving accessible healthcare for individuals and families coping with mental health and substance use conditions. Monitoring implementation will require that Mental Health America prioritize and advocate for the following:
- Providing integrated services within the health home model should allow for better identification and access to behavioral health services and management of co-morbid illnesses.
- Recognizing the high prevalence of co-occurring mental health and general health conditions, behavioral health services and supports should be available as an essential component of any disease management program.
- Plans should cover services provided in frequented locations in order to reduce barriers, identify needs, and engage individuals in care as early as possible. School-based clinics and workplace health services should be considered reimbursable providers.
- Longer-term, more intensive care for illnesses that are proving to be more disabling should be easily accessible from the health home, and coordination with primary care/health home should be systematic and on-going. Individuals should also be able to move out of more intensive services and into support services when they are no longer in need of the longer-term services.
- A graduated set of services should be available, serving the full spectrum of needs, and responsive to the severity of behavioral health needs.
- Families should be viewed as an insured unit, so services available to the parent to support the treatment of a child with a mental health or substance use condition can be covered. For instance, parenting supports to teach parents to cope with the special needs of their child should be reimbursable, even though the parent is the recipient of the service and the child is the beneficiary of the service.
- Communication and integration between the children's health system and the adult health system should promote seamless delivery of behavioral health services and supports that are developmentally appropriate for the individual.
- To eliminate behavioral health disparities and the resulting burden, policies and practices should incorporate and be responsive to cultural pathways related to problem identification, help-seeking patterns, referrals, diagnosis and treatment preferences.
There is a significant body of research that powerfully argues for the implementation of effective interventions to prevent the onset and reduce the rate of mental health and substance use conditions, particularly among children. To ensure these strategies are a priority:
- Evidence-based interventions focused on the prevention of mental health and substance use conditions should be part of any benefit package. We have overwhelming evidence pointing to both targeted and broad interventions that can prevent mental health and substance use disorders and promote mental health and wellness.
- Many of the preventive services for children are targeted at supporting the parent in raising a healthy child. As is the case in providing treatment services to the parent for the benefit of the child, preventive interventions that are delivered to the parent with the goal of developing a healthy child should be reimbursable.
- Screening for mental health and substance use conditions should be a basic element of practice within the health home and specialty settings. Competent staff should be available to screen and further assess as indicated in order to promote early intervention and provide the most appropriate service for the needs and goals of the individual.
Mental Health America is committed to the principle that every individual with a mental health or substance use condition can recover. We believe that a modern behavioral health system should provide supports and promote services and systems that facilitate the recovery of people with mental health and substance use conditions so every person with an illness can live a meaningful live in the community. To achieve this critical goal:
- The modern mental health system should operate within a framework of shared decision-making. Adequate time should be available for an individual to work with his or her provider to select the recovery services that are most appropriate for her goals.
- Individuals should develop their own recovery plan with the goal of community integration and engagement in roles that are meaningful to each person. Services should support community integration with a full range of activities, including employment, education, and family and civic participation.
- For individuals with significant disability and longer term care needs, the definition of what is medically necessary should be expanded to ensure that the wide array of services and supports that help consumers integrate into the larger society are accessible. This may occur through assertive, accountable case management systems or within a disease management plan for persons with significant rehabilitation needs.
- Younger adults will have special and different recovery needs than older adults. A special emphasis for them is engaging in education and vocational services that will assist them in becoming self-sufficient and integrated in the community. Early, accessible recovery services for younger adults will likely mitigate large long-term direct and indirect costs for individuals who are not engaged in the workforce and have few social supports in the community.
Call to Action
Mental Health America and its affiliates should work with local, state, and federal decision makers to ensure adequate representation of behavioral health interests in the implementation of the Affordable Care Act. MHA should also be engaged with employers, insurers, and providers to ensure that the implementation of the Act provides for meaningful access to behavioral health coverage and services. As a first priority, MHA needs to scrutinize the "Essential Benefit" definition, which will determine the scope of coverage for mental health and substance use conditions, and is bound to be controversial. A coalition like that assembled for parity will need to advocate persuasively to get real parity in the "Essential Benefit."
The Mental Health America Board of Directors adopted this policy on March 5, 2011. It is reviewed as required by the Mental Health America Public Policy Committee
Expiration: December 31, 2016
- Bernal, G. & Saez-Santiago, E., "Culturally Centered Psychosocial Interventions," Journal of Community Psychology, 34(2), 121-132 (2006).
- See MHA Position Statement 48, Prevention.