Advocates say Medicaid can shelter the homeless in Pennsylvania

Pennsylvania could use Medicaid to address its homelessness problem, according to advocates that believe the state’s Medicaid program should include additional supportive housing services. Those individuals assert that additional supportive housing services can be included in Medicaid as a “wrap-around support service”—a type of service that CMS endorses and described in a Center for Medicare & CHIP Services Informational Bulletin last year.

Housing services

CMS expressly does not provide Federal Financial Participation (FFP) for room and board as part of additional support services. However, states are permitted to assist individuals through coverage of certain housing-related activities and services. Some of the housing-related services and activities that Medicaid can cover include: (1) services designed to support an individual’s ability to prepare for and transition to housing; (2) services aimed at supporting an individual’s ability to sustain tenancy; and (3) services dedicated to assisting a state in identifying and securing housing options for individuals. Specific examples of each of those services are covered in the Informational Bulletin. The Open Door is an example of an organization that provides housing support services.

Pennsylvania

In Pennsylvania, advocates like The Housing as Health Campaign are asserting that, for many Medicaid enrollees with substance abuse problems, additional support is needed to keep beneficiaries in their homes. Advocates argue that without a consistent funding stream, Medicaid beneficiaries wind up homeless. The Corporation for Supportive Housing (CSH) created a blueprint, or “Crosswalk,” to serve as a map to assist the Pennsylvania Department of Health and Human Services with aligning Medicaid-eligible services with supportive housing services.

Crosswalk

The Crosswalk was designed to guide the state of Pennsylvania, managed care entities, and service providers towards resources that can improve access to substance use treatment and mental health recovery, with a focus on housing. According to the report, individuals with unmet housing needs are often particularly vulnerable due to the high occurrence of low incomes, chronic health conditions, and behavioral health challenges among the population. The report proposes several methods to improve housing and care access for at-risk individuals. CSH started its analysis by considering the services that the state already provides through several Medicaid waivers. While Pennsylvania does have mechanisms to provide some housing support services for elderly individuals, beneficiaries with traumatic brain injuries, and individuals with a physical disability, CSH noted that additional individuals could benefit from supportive housing.

Alignment

The report identified potential opportunities for alignment, where services that are already covered under the state plan could be aligned to better address housing support service needs. For example, the report suggested that, because the Pennsylvania state Medicaid plan covers Individualized Service Plans (ISPs) for the treatment of individuals with severe mental illness, an individual could, possibly, identify housing goals as part of his or her treatment plan, thereby including housing support services through an ISP. The report lists several other types of services with potential for alignment to reduce or eliminate gaps in housing service coverage.

Rethinking Medicaid

Advocates are not directly asking for a change as to the kind of services covered by the Pennsylvania Medicaid program. Instead, the CSH report and other efforts are asserting that housing problems can be best improved through a better application of existing services under the Medicaid state plan. Advocates hope that such a rethinking of Medicaid will improve health by putting a roof over the head of more individuals.

States’ failure to include substance abuse benefits goes untreated

Over two-thirds of state benchmark health plans violate requirements to cover treatment for addiction disorders put into place by the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). The National Center on Addiction and Substance Abuse (the Center) surveyed addiction treatment benefits offered among 2017 Essential Health Benefits (EHB) benchmark plans and found none offered what it considers to be “adequate” addiction treatment benefits. The main problem, the Center believes, is that although the ACA requires coverage of substance use disorder (SUD) services as an EHB and requires that the SUD benefits be provided at parity with comparable medical/surgical benefits, the ACA does not specifically define what those benefits should be. It leaves that up to the states, and that is where they fall short.

Analysis

The Center analyzed those benefits offered within each of the 50 states to determine the minimum level of benefits available to those covered in state exchange plans. Each state’s 2017 EHB-benchmark plan was then reviewed to determine whether it: (1) satisfies the ACA’s requirements regarding coverage of addiction benefits; (2) complies with parity requirements; (3) provides adequate care for addiction by covering the full range of critical benefits without imposing harmful treatment limitations; and (4) provides enough information to fully evaluate compliance and adequacy of benefits. Clouding the review, the Center noted, is the problem that plan documents for 88 percent of state plans lacked sufficient detail for it to fully evaluate parity, compliance, and the adequacy of addiction benefits.

Most commonly missing

Many plans either frequently exclude or do not explicitly cover benefits related to residential treatment and the use of methadone maintenance therapy. The Center found that 18 percent of the plans lacked compliance with parity requirements, while 31 percent of the plans contained possible parity violations. Over half of plans violate the EHB requirement for tobacco cessation coverage and nearly half violate the ACA’s requirement for coverage of prescription drugs to treat addiction. Although the ACA specifically prohibits the use of per-beneficiary annual or lifetime dollar limits for EHB, Texas and Michigan are in violation of this requirement. Further, Alaska’s plan does not even cover services and supplies relating to diagnosis and treatment of addiction.

“Addiction is a chronic disease that often goes untreated, and when patients can’t access addiction treatment it can lead to disability and premature death,” said the report. “In order to fulfill the ACA’s intent of dramatically expanding access to addiction treatment, states should revise their EHB benchmark plans to comply with the law … This will help to close the addiction treatment gap, improve the health of patients seeking addiction treatment, and decrease costs for the health plans in the long-term.”

The importance of parity and the problem of unenforcement

Federal law requires that mental health benefits are equivalent—in terms of restrictions and limitations—with medical health benefits. However, the specific provisions of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) that mandate the parity are, in many cases, going unenforced. The result is that individuals are having trouble accessing care—the very problem the parity was designed to remedy.

Why?

Although there many potential reasons why the parity rules aren’t being followed, one report suggests the failures are caused by the difficulty of implementing the ACA and the slow regulatory processes of the federal government. For example, the rules that govern parity for private insurers were not put into effect until 2014 and some rules—those pertaining to parity for Medicaid plans—have yet to take effect.

High stakes

The importance of parity is illustrated by the number of individuals with mental health and substance use disorders. According to the most recent survey by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), almost 44 million adults experienced some form of a mental illness. According to SAMHSA, fewer than half of those individuals receive mental health care. Additionally, 20.2 million adults had a substance abuse disorder in the past year. Also at issue is the nation’s heroin and painkiller epidemic, which claims 78 lives each day.

Task Force

Acknowledging that something is wrong with the state of parity enforcement, the White House issued a presidential memorandum creating an interagency Mental Health and Substance Use Disorder Parity Task Force designed to ensure better compliance with the parity rules.  Specifically, the task force was designed to:

  • identify and promote best practices for compliance and implementation;
  • identify and address gaps in guidance, particularly with regard to substance use disorder parity; and
  • implement actions during its tenure and at its conclusion to advance parity in mental health and substance use disorder treatment.

The memorandum also directs the task force to conduct outreach efforts to patients, consumer advocates, health care providers, specialists in mental health care and substance use disorder treatment, employers, insurers, state regulators, and other stakeholders.

Enforcement

Not all states have dropped the enforcement ball. For example, the California Department of Managed Health Care imposed a $4,000,000 administrative penalty on the Kaiser Foundation Health Plan, Inc. in 2013 for parity violations that resulted from mental health service wait times. However, continuing access problems and the creation of the task force suggest that enforcement is the exception rather than the rule.

Beyond parity

Part of the problem is that to meet behavioral health demands, stakeholders need to do more than obtain parity. Based upon that understanding, some lawmakers are pushing for more systemic changes with legislation like The Mental Health Reform Act of 2016, which would assist with enforcement of current requirements (including parity), ensure federal funding to help states provide mental health care services, promote best practices, and increase access. Whichever way is the next step forward, there is little doubt that some action is necessary to improve access to and the provision of behavioral health care.

HELP Committee focuses on access to mental health services

On January 20, 2016, the Senate Committee on Health, Education, Labor, and Pensions (HELP) heard testimony from four experts in the field of mental health with very different perspectives. The three who had been directly involved with patients all testified, however, that there is a dearth of resources for treatment and that serious needs go unmet.

Penny Blake, R.N., C.C.R.N., an emergency room nurse and Chair of the Advocacy Advisory council of the Emergency Nurses Association, told the committee that people with mental health or substance use conditions comprise about 10 percent of the patients that present to the emergency department at the West Palm Beach hospital where she works. The loud noises and chaotic atmosphere of a busy emergency department can be harmful to a patient who may be hallucinating. Because the hospital does not have a psychiatric ward, patients who are dangerous to themselves or others must be transferred to other hospitals. There are so few beds available that they must be “boarded” in the emergency department. Usually the wait is 12 to 24 hours, but it is not unusual for a patient to wait for four days to be transferred.

The need to isolate and observe patients who may require involuntary commitment also diverts staff from other patients who need care. The emergency room physicians lack the experience and expertise to begin treatment of the psychiatric emergency with appropriate medication. Blake attributed the difficulties in accessing treatment to the insufficiency of treatment providers available and the lack of insurance coverage for psychiatric care.

Brian Hepburn, MD, Executive Director of the National Association of State Mental Health Directors, expressed gratitude for the mental health block grant programs and funding for demonstration projects. For example, he believes that the First Episode of Psychosis program, which now receives a 10 percent set-aside from mental health block grants, will make a significant difference. He noted that treatment of serious mental illness is much more likely to be successful when begun in the early stages of the illness. He asked that Congress modify the Medicaid exclusion of services of institutions for mental disease (IMD) to allow payment for adult stays in IMDs. Hepburn also recommended increasing support for monitoring and enforcement of the laws requiring mental health and addiction parity.

Both Hepburn and William W. Eaton, PhD, Professor in the Department of Mental Health at Johns Hopkins University Bloomberg School of Public Health, told the committee that patients with mental illness or substance use disorder also are at higher risk for physical illnesses, such as heart attacks, stroke, or diabetes. Eaton also emphasized the lack of research and resources dedicated to mental illness, especially with respect to public health interventions that could prevent or alleviate mental illness.

Pending legislation

Finally, Hakeem Rahim, representing the National Alliance on Mental Illness, put a human face on the problem by describing the experience of living and coping with psychosis. Rahim told the committee that S. 1893, the Mental Health Awareness Act, which was recently passed by the Senate and is now pending in the House, was a good start. However, he urged the committee to support S. 1945, the Mental Health Reform Act, sponsored by committee members Bill Cassidy (R-La) and Christopher Murphy (D-Conn). S. 1945 would create an Assistant Secretary of Mental Health and Substance Use Disorders and expand funding for many training and treatment programs.