Mental health, Medicaid, and the hole that non-expansion creates

At the beginning of 2014, almost 1.1 million uninsured people did not have adequate access to mental health care because they lived in one of the 24 states that did not expand Medicaid under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). According to a study conducted by the American Mental Health Counselors Association (AMHCA), over 568,000 adults diagnosed with mental illness would have sought care but were denied access to affordable, needed mental health care because they lived in a non-expansion state. Additionally, the study revealed that 458,000 fewer adults in the U.S. would have experienced major depression if non-Medicaid expansion states would have expanded their Medicaid programs in 2014. Notably, 100 percent of the unmet treatment needs would have been paid for by the federal government, if the states had elected to expand.

The effects of expansion

Amidst a national discussion regarding mental health parity in the context of Medicaid Managed Care Organizations, the AMHCA study examined an even more fundamental relationship between Medicaid and mental illness. The study evaluated the impact of states’ decisions to reject Medicaid expansion “based on ideological intransigence—not health or fiscal interests.” On the flipside of Medicaid expansion, in the states that did expand their low income health care programs under the ACA, 700,000 people received affordable and needed treatments or did not experience major depression. Specifically, over 350,000 people received needed treatment under Medicaid expansion and another 348,000 fewer individuals experienced major depression under ACA expanded programs.

The affected

According to the study, the population of individuals who would have received needed mental health treatments under Medicaid expansion is primarily composed of white adults. More specifically, “over 90 percent of the states (44 states) show that over 60 percent of the uninsured adults with mental health conditions who were eligible for Medicaid expansion coverage and who would have sought needed care—were white Americans and between the ages of 18 and 34.” Additionally, 200,000 veterans living in the non-expansion states would have been eligible for needed mental health coverage if their state had expanded Medicaid.

The need for change

Expansion is key for individuals with mental illness because, the study projects, “the continued lack of access to covered services will result in more people with a mental illness developing severe and serious conditions with many needing expensive, acute care crisis services.” The ACA’s reliance on preventive services and Medicaid expansion serve to reduce the burden of mental illness by screening patients, identifying issues, and providing treatments before conditions escalate. The study concludes that expansion of state Medicaid programs is the most reasonable first step in obtaining health care coverage for the millions of Americans living with mental illness who, presently, have no access to mental health care at all.