To Improve Behavioral Health, Start by Closing the Medicaid Coverage Gap
End Notes
[1] Miriam Pearsall interned at the Center on Budget and Policy Priorities from June to August 2021.
[2] The coverage gap includes people in 11 states that have not adopted the ACA Medicaid expansion: Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, and Wyoming. Wisconsin has also not adopted Medicaid expansion, but the state provides Medicaid coverage to adults with incomes up to the poverty line.
[3] Coverage gap population estimated by CBPP using 2019 American Community Survey data. Percent with a mental illness or substance use disorder estimated by the HHS ASPE using National Survey on Drug Use and Health data: https://aspe.hhs.gov/pdf-report/benefits-medicaid-expansion-behavioral-health. Applies rates for population in non-expansion states that are uninsured with incomes below 138 percent of the federal poverty line and assumes the coverage gap population is similar to other low-income, uninsured adults in non-expansion states.
[4] Farida Ahmad, Lauren Rossen, and Paul Sutton, “Provisional Drug Overdose Death Counts,” National Center for Health Statistics, August 11, 2021, https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm; Mark É. Czeisler et al., “Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24-30, 2020,” Morbidity and Mortality Weekly Report, August 14, 2020, https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm.
[5] Gideon Lukens and Breanna Sharer, “Closing Medicaid Coverage Gap Would Help Diverse Group and Narrow Racial Disparities,” Center on Budget and Policy Priorities, revised June 14, 2021, https://www.cbpp.org/research/health/closing-medicaid-coverage-gap-would-help-diverse-group-and-narrow-racial.
[6] Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, “Public Health Emergency Declarations,” 2017-2021, https://www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx.
[7] Centers for Disease Control and Prevention (CDC), “Understanding the Epidemic,” March 17, 2021, https://www.cdc.gov/opioids/basics/epidemic.html; Holly Hedegaard, Sally C. Curtin, and Margaret Warner, “Increase in Suicide Mortality in the United States, 1999-2018,” CDC, April 2020, https://www.cdc.gov/nchs/products/databriefs/db362.htm; Sabrina Tavernise, “U.S. Suicide Rate Surges to a 30-Year High,” New York Times, April 22, 2016, https://www.nytimes.com/2016/04/22/health/us-suicide-rate-surges-to-a-30-year-high.html.
[8] Dorey Scheimer and Meghna Chakrabarti, “Former Surgeon General Vivek Murthy: Loneliness is a Public Health Crisis,” WBUR, March 23, 2020, https://www.wbur.org/onpoint/2020/03/23/vivek-murthy-loneliness.
[9] Margarita Alegría et al. “Removing Obstacles To Eliminating Racial And Ethnic Disparities In Behavioral Health Care,” Health Affairs, June 2016, https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.0029.
[10] Benjamin Lê Cook et al., “Trends in Racial-Ethnic Disparities in Access to Mental Health Care, 2004–2012,” Psychiatric Services, January 1, 2017, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5895177/.
[11] Pooja Lagisetty et al., “Buprenorphine Treatment Divide by Race/Ethnicity and Payment,” JAMA Psychiatry, May 2019, https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2732871; Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality, “Results from the 2019 National Survey on Drug Use and Health: Detailed Tables,” September 11, 2020, https://www.samhsa.gov/data/report/2019-nsduh-detailed-tables.
[12] Emma E. McGinty et al., “Psychological Distress and COVID-19–Related Stressors Reported in a Longitudinal Cohort of US Adults in April and July 2020,” JAMA, November 23, 2020, https://jamanetwork.com/journals/jama/fullarticle/2773517.
[13] Nirmita Panchal et al., “The Implications of COVID-19 for Mental Health and Substance Use,” Kaiser Family Foundation, February 10, 2021, https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use.
[14] Ibid.
[15] Kareem Hamada and Xiaoduo Fan, “The impact of COVID-19 on individuals living with serious mental illness,” Schizophrenia Research, August 2020, https://doi.org/10.1016/j.schres.2020.05.054.
[16] Ahmad, Rossen, and Sutton, op. cit.
[17] Felicia Ceban et al., “Association Between Mood Disorders and Risk of COVID-19 Infection, Hospitalization, and Death: A Systematic Review and Meta-analysis,” JAMA Psychiatry, July 28, 2021, https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2782453.
[18] 42 C.F.R. §§ 438 Subpart K, 440.395, and 457.496.
[19] Health plans offered through the ACA marketplaces must cover behavioral health services that are comparable to the plan’s physical health coverage, thereby providing access to coverage for substance use disorder treatment. However, the services, medications, and cost-sharing requirements in marketplace plans vary considerably. States can enforce parity laws to improve marketplace coverage of substance use services and can use grants to fill treatment funding gaps. Rebecca Peters and Erik Wengle, “Coverage of Substance-Use Disorder Treatments in Marketplace Plans in Six Cities,” Urban Institute, June 2016, https://www.urban.org/sites/default/files/publication/81856/2000838-Coverage-of-Substance-Use-Disorder-Treatments-in-Marketplace-Plans-in-Six-Cities.pdf.
[20] Carrie E. Fry and Benjamin D. Sommers, “Effect of Medicaid Expansion on Health Insurance Coverage and Access to Care Among Adults With Depression,” Psychiatric Services, August 28, 2018, https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201800181.
[21] Benjamin W. Cowan and Zhuang Hao, “Medicaid Expansion and the Mental Health of College Students,” National Bureau of Economic Research Working Paper 27306, June 2020, https://www.nber.org/system/files/working_papers/w27306/w27306.pdf.
[22] Priscilla Novak, Andrew C. Anderson, and Jie Chen, “Changes in Health Insurance Coverage and Barriers to Health Care Access Among Individuals with Serious Psychological Distress Following the Affordable Care Act,” Administration and Policy in Mental Health, November 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6477535/.
[23] Elson Oshman Blunt et al., “Public insurance expansions and mental health care availability,” Health Services Research, 55(4), August 2020, https://onlinelibrary.wiley.com/doi/10.1111/1475-6773.13311.
[24] Government Accountability Office, “Medicaid: States’ Changes to Payment Rates for Substance Use Disorder Services,” January 30, 2020, https://www.gao.gov/products/gao-20-260.
[25] Stacey McMorrow et al., “Medicaid Expansion Increased Coverage, Improved Affordability, And Reduced Psychological Distress For Low-Income Parents,” Health Affairs, May 2017, https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.1650.
[26] Tyler N.A. Winkelman and Virginia W. Chang, “Medicaid Expansion, Mental Health, and Access to Care among Childless Adults with and without Chronic Conditions,” Journal of General Internal Medicine, March 2018, https://pubmed.ncbi.nlm.nih.gov/29181792/; Kevin N. Griffith and Jacob H. Bor, “Changes in Health Care Access, Behaviors, and Self-reported Health Among Low-Income US Adults Through the Fourth Year of the Affordable Care Act,” Medical Care, June 2020, https://journals.lww.com/lww-medicalcare/Abstract/2020/06000/Changes_in_Health_Care_Access,_Behaviors,_and.11.aspx.
[28] Mark Olfson et al., “Expansion and Low-Income Adults with Substance Use Disorders,” Journal of Behavioral Health Services & Research, November 6, 2020, https://pubmed.ncbi.nlm.nih.gov/33156464/.
[29] Matt Broaddus, Peggy Bailey, and Aviva Aron-Dine, “Medicaid Expansion Dramatically Increased Coverage for People with Opioid-Use Disorders, Latest Data Show,” Center on Budget and Policy Priorities, February 28, 2018, https://www.cbpp.org/research/health/medicaid-expansion-dramatically-increased-coverage-for-people-with-opioid-use; Minji Sohn et al., “Association between state Medicaid expansion status and naloxone prescription dispensing,” Health Services Research, February 7, 2020, https://doi.org/10.1111/1475-6773.13266.
[30] Rashunda Lewis et al., “Healthcare Access and Utilization Among Persons Who Inject Drugs in Medicaid Expansion and Nonexpansion States: 22 United States Cities, 2018,” Journal of Infectious Diseases, September 2, 2020, https://doi.org/10.1093/infdis/jiaa337.