By Dave Hodges
Just as the 1963 Community Mental Health Act ushered in a new era, the Affordable Care Act is intended to have much the same impact on the access to and delivery of medical care.
The ACA offers the largest expansions of mental health and substance abuse coverage in a generation, according to the Department of Health and Human Services. Beginning in 2014, businesses that offer health insurance and individual market plans created after Sept. 23, 2010, must include 10 essential health benefit categories, including mental health and substance use disorder services — and cover them on a par with other medical benefits.
Figures from the Substance Abuse and Mental Health Services Administration indicate that more than 11 million or 24 percent of U.S. adults affected by mental illness have no health coverage.
Uninsured adults are more than twice as likely to delay or skip the care they need, which leads to more serious health problems, difficulties at work and more use of emergency facilities and hospitalization.
Those who apply for health insurance are often rejected because their mental illness is considered a pre-existing condition. Even those with health insurance may encounter unequal or no benefits for mental health or substance abuse care, according to the National Alliance on Mental Illness, an advocacy group.
Even more critical — plans likely won’t cover case management, which is essential for persons who are severely and persistently mentally ill.
While he welcomes the changes, Richard Weinberg, clinical associate professor at the University of South Florida’s College of Behavioral and Community Sciences, says he thinks it’s too early to tell the extent of the ACA’s impact.
“On the one hand, I am delighted that more people will be insured and theoretically will have behavioral health-care services covered,” Weinberg said. Still, some less-expensive plans available have high deductible amounts and sizable co-pays, which may keep consumers from seeking care.
For those consumers buying coverage through the various health exchanges, larger co-pays will be offset in part by the subsidies available, said Dr. Leslie Beitsch, chair of Medical Humanities and Social Sciences at Florida State University.
“Over time I believe the ACA combined with other health reform changes (such as the Wellstone-Domenici Mental Health Parity Act in effect in 2010) will dramatically improve health access for people with mental illness,” Beitsch said.
Based on a successful pilot effort in 2001, Florida now uses “managing entities” as the providers of specialized services to vulnerable and hard-to-serve populations while emphasizing stronger ties to local public health and public safety agencies, according to the Department of Children and Families.
It’s a management structure that places the responsibility for publicly-financed behavioral health treatment and prevention services with private, nonprofit entities that represent their individual communities, DCF says.
For mental health, the state contracts with seven managing entities, which have responsibility for specific regions. Northwest Florida’s managing entity for substance abuse and mental health is Big Bend Community Based Care in Tallahassee. Big Bend’s contract began April 1 and totals $46,397,993 per year. It is a continuation of DCF’s strategy, started in 2010, to shift more dollars from centralized contract oversight into the delivery of actual services, hopefully getting help to more individuals in need.
“Our vision is to create local ownership of the service delivery system in our communities,” said Mike Watkins, CEO of Big Bend Community Based Care. “By doing so, we believe that the quality of life for the children and families we serve will dramatically improve and the prevalence of substance abuse and persistent mental illness will dramatically decrease.”
Part of the emphasis is on simplifying access from the consumer’s point of view. In the past, individuals would typically have to enroll with each new provider, causing duplication and having to provide the same personal information and facts with each one. Managing entities have the ability to share clinical data among themselves — with the patient’s consent — thereby speeding up the process.
To enhance access, managing entities in Florida have worked specifically to reach people in rural communities, increase outreach to the Hispanic and Haitian communities, and develop such tools as video conferencing that enables behavioral health workers in the field to connect with licensed clinicians at a central location.
In the Big Bend, the private, nonprofit provider DISC Village Inc. is one of the frontline organizations providing care directly to clients. One of the latest additions is E-therapy, where a counselor in Tallahassee can offer sessions via the Internet using a computer and web camera. It began as a pilot program in Jefferson County to provide web-based assessment services for Department of Corrections referrals.
DISC, which stands for Drug Information Services Center, the original name, also works with offenders in LIFT, which is Leveraging Interventions for Transformations and is funded by the Leon County Commission.
FACT, the Florida Assertive Community Treatment program, provides comprehensive, community-based services to adults with severe and persistent mental illness. The multidisciplinary teams serve as alternatives to inpatient services at Florida’s mental health treatment facilities. Those individuals who participate in the voluntary program tend to have better clinical and functional outcomes, and remain in the community with fewer episodes of crisis care or hospitalization, according to Apalachee Center, which operates the team in Leon County.
The drawback — each team is limited to 100 clients, and there are no teams formed for surrounding counties, though Apalachee serves an eight-county region.
Dan Hendrickson, an assistant public defender who is active in the Big Bend Mental Health Coalition and handles numerous cases involving individuals with mental illnesses, says FACT is “the best example of community intensive treatment there is,” but Florida doesn’t have enough teams.
“The problem is we need 10 FACT programs in Tallahassee and a couple in Gadsden County,” Hendrickson added.
Another need is residential treatment facilities. As patient populations declined at state hospitals in recent decades, there has been little establishment of the wide network of supported housing, group living facilities and residential treatment programs — even though deinstitutionalization meant there was a rapidly-growing population needing them.
Apalachee, for example, used to have 300 residential treatment beds, but Jay Reeve, president and CEO, said only 16 of those beds remain today. He cites two big reasons: a massive shift in costs to Medicaid, which won’t pay for room and board, and a general philosophy that residential programs were bad and don’t contribute to patient improvement.
“I can tell you that residential programs can make the difference between life and death for clients,” Reeve counters.
In 2012, Apalachee went to the Legislature with the message that there needs to be programming for people coming out of state hospitals and heading to a relative’s home or to an assisted living facility. “It’s not that they weren’t ready to leave the state hospital, they just weren’t ready to get along on their own,” Reeve said.
Apalachee proposed a 16-bed pilot program to start with, but it wound up on Gov. Rick Scott’s veto list due to it not being broad enough, Reeve said. Apalachee and two other community mental health centers will try again to move the proposal along.
Tallahassee psychiatrist Dr. John Bailey, the statewide legislative chair for the Florida Psychiatric Society, hopes the conversation about mental illness continues and spreads. “The thing is most people are afraid of mental illness and they don’t want to think about it every day,” he said.
What the community-based care structure has proven is the ongoing need for a team effort by providers and allied agencies. Society, Bailey said, “wants a single solution to fit everyone when what is needed is a spectrum of mental health services — and not what is convenient for the time we live in.”