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U of M examines consequences of the Affordable Care Act’s Medicaid expansions on people with mental disorders

Over the last few years, a number of tragic and unfortunate events have generated an increase in attention on mental health issues in the U.S.

With the implementation of the Affordable Care Act (ACA) expected to occur nationwide by 2014, health insurance coverage is expected to increase for lower-income populations, which often have a higher prevalence of mental disorders.  As a result, individuals with mental illness will therefore see significant gains in insurance coverage and access to care.

University of Minnesota researcher Ezra Golberstein, Ph.D., recently outlined issues around the ACA’s Medicaid expansion in an article appearing today in JAMA Psychiatry. Golberstein’s article – “Two Steps Forward, One Step Back? Implications of the Supreme Court Ruling for Individuals with Mental Illness” – examines the impact of the Supreme Court’s decisions on ACA and tries to measure its true effects. Susan Busch, Ph.D., Yale School of Public Health, co-authored the article.

“For an estimated 3.7 million uninsured people with mental disorders who were originally expected to gain coverage because of the ACA (2 million from Medicaid and 1.7 million from private insurance, according to recent estimates), this is a big step in the right direction,” said Golberstein, an assistant professor in the University of Minnesota School of Public Health. “However, an implication of the Supreme Court’s decision is that not all of these benefits may be realized for this population.”

The Supreme Court ruling to uphold the ACA while making the Act’s Medicaid expansion optional for states has divided political parties, and some states have decided not to participate in the Medicaid expansion that targets the poorest uninsured adults.

In the states that choose not to participate, uninsured individuals above the federal poverty line will receive subsidies to participate in the Federally-subsidized private insurance exchanges, while those below the federal poverty line will likely remain uninsured.

According to Golberstein, people with mental disorders who live in states that do not participate in the Medicaid expansion may have much to lose compared to residents of states that fully expand Medicaid. The Congressional Budget Office’s conservative estimates imply that approximately 700,000 people with severe mental disorders who would have gained insurance under the original ACA will remain uninsured in the wake of the Supreme Court’s decision.

“The precise number who will remain uninsured will depend on each state’s Medicaid expansion decision, but lacking insurance is already a major barrier to receiving health services, and it might be an even bigger barrier in the future,” said Golberstein. “The ACA will still increase the size of the insured population even in states that reject the Medicaid expansion, which means that the demand for mental health services will rise. Mental health providers are already in short supply in much of the country, and the uninsured may be even more likely to fall through the cracks because the ACA reduces funding for safety net care and because providers may spend more time serving the newly-insured population.”

It remains to be seen whether Medicaid coverage or private insurance coverage in the exchanges will be better for the population with severe mental disorders who are just above the poverty line and will now get private insurance from the exchanges rather than through Medicaid if their states opt out of the Medicaid expansion.

“Individuals with severe mental disorders are a vulnerable population with complex health care needs, who frequently face uneven access to care and a fragmented system of care,” said Golberstein. “On one hand, Medicaid traditionally covers a more comprehensive set of mental health services than private insurance, but on the other hand private insurance generally pays providers higher rates, which improves access to care.”

Stay tuned to Health Talk as ACA developments continue to unfold.

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