Issues in Mental Health Nursing, 35:558–561, 2014 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2013.869844
CULTURAL COMPETENCE COLUMN
Mental Health Care, the Affordable Care Act, and Medicaid Expansion Jacquelyn H. Flaskerud, RN, PhD, FAAN University of California—Los Angeles, School of Nursing, Los Angeles, California, USA
Edited by Jacquelyn H. Flaskerud, RN, PhD, FAAN University of California—Los Angeles, School of Nursing, Los Angeles, California, USA With The Affordable Care Act (ACA) going into effect in the United States, mental health nursing practice will change in a number of ways. One of these changes will occur because of the additional coverage provided for mental illness and addiction care; this change will result in more patients being eligible for mental health services. However, the extent of this change will vary state by state. In states that opt out of the Medicaid expansion, many low income adults will be left without insurance coverage and remain dependent on charitable organizations and free community clinics for their care. Another change may come with the new requirements and regulations for mental health care that could affect the business model of mental health professionals, especially those in solo practice. These requirements may result in more group practices—either those specializing in mental health care or those integrated medical practices that now include a mental health professional on their staff. The Affordable Care Act expands mental health and substance use disorder coverage to over 60 million Americans (Beronio, Po, Skopec, & Glied, 2013). Beginning in 2014 under the law, all new small group and individual market plans are required to cover ten Essential Health Benefit categories, including services for mental health and substance use disorders, and are required to cover them at parity with medical and surgical benefits (Beronio et al., 2013). The Affordable Care Act builds on the Mental Health Parity and Addiction Equity Act of 2008 that requires group health plans and insurers that offer mental health and substance use disorder benefits to provide coverage that is comparable to coverage for general medical and surgiAddress correspondence to Jacquelyn H. Flaskerud, School of Nursing, University of California, 700 Tiverton Ave, Factor Building, Box 951702, Los Angeles, CA 90095-1702 USA. E-mail: [email protected]
cal care (Beronio et al., 2013). For people living with mental illness, the law results in health insurance coverage for some services and treatments that have traditionally been denied or were not included in health insurance coverage in the past. The Department of Health and Human Services estimated that in total, through the Affordable Care Act, 32.1 million Americans will gain access to coverage that includes mental health and substance use disorder benefits that comply with federal parity requirements, and an additional 30.4 million Americans who currently have some mental health and substance abuse benefits will benefit from the federal parity protections (Beronio et al., 2013). The implications of these numbers are that there will be many more people seeking mental health care and there will be a need for more mental health professionals to provide these services. Many of the uninsured in each state are eligible for health coverage assistance programs—Medicaid, the Children’s Health Insurance Program (CHIP), and subsidized private coverage through the new health insurance marketplaces—under the ACA. The share of the uninsured that is eligible for assistance programs is heavily dependent on a state’s decision to expand Medicaid eligibility (often referred to as Medicaid expansion) or not (Buettgens, Kenney, Recht, & Lynch, 2013). The estimates quoted above included the assumption that states would expand their Medicaid coverage under the ACA, thereby including insurance protection to many more low-income Americans. The ACA extends Medicaid coverage to otherwise eligible state residents with incomes below 138% of the federal poverty level (FPL) (Center for Health Law and Policy Innovation [CHLPI], 2012); over 15 million uninsured adults would become newly eligible for Medicaid across all states. An additional 4 million uninsured adults are currently eligible under existing state Medicaid eligibility criteria (100% of poverty) but are not enrolled; many will likely do so once the requirement to have coverage becomes effective in 2014 (CHLPI, 2012). For those above the poverty line who do not have access to affordable employer coverage, the ACA allows credits toward the insurance premium they would have to pay. New health insurance marketplaces
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offer subsidized private health coverage to families with incomes up to 400% of the FPL who are not eligible for public coverage, do not have access to employer coverage deemed to be affordable under the law, and are lawful residents. In states that do not expand Medicaid, those with incomes below 100% of the FPL are not eligible for subsidized coverage (Buettgens et al., 2013). In June 2012 the Supreme Court upheld all provisions of the ACA including the individual responsibility requirement, health insurance exchanges and subsidies, and the Medicaid expansion (CHLPI, 2012). However, the Court restricted the federal government’s ability to withhold federal Medicaid funds if a state elects not to institute the expansion, effectively giving states a choice whether to expand coverage. Even though the federal government will pick up nearly all of the costs of the expansion (100% for the first three years, phasing down to 90% in 2020 and all subsequent years), some governors and state legislative leaders are opposed to expanding Medicaid for political/economic reasons (CHLPI, 2012). As of May 2014, 26 states (and the District of Columbia) are implementing the Medicaid expansion, 19 states have rejected it and 5 are still debating it. States rejecting it are home to about half of the country’s population, but about 68% of poor, uninsured African Americans and single mothers; about 60% of the country’s working poor are in those states (Tavernise & Gebeloff, 2013). According to the Urban Institute’s Health Policy Center, between six and seven million low-income adults live in states that have opted to not expand their Medicaid programs under the ACA (Buettgens, Kenney, Recht, & Lynch, 2013). Three million (about half) live in just four states: Texas (1.1 million are in Texas), Florida, Georgia, and North Carolina (Buettgens et al., 2013). The irony is that the 19 states rejecting Medicaid expansion—many of them Southern—are the very places where the concentration of poverty and lack of health insurance are the most acute. It is their populations that have the highest burden of illness and impose the highest costs on the entire health care system (Tavernese & Gebeloff, 2013). What are the consequences for mental health resulting from the decision to expand Medicaid or opt out of it? The National Alliance on Mental Illness (NAMI; 2013) reports that six out of ten Americans living with serious mental illness have no access to mental health care. They note that Medicaid is the most important source of funding for mental health services in America today, offering mental health services that would otherwise be out of reach for low-income people affected by mental illness (NAMI, 2013). Unfortunately, millions of lowincome Americans with mental illness are currently shut out of Medicaid, excluded from the care that would help them rebuild their lives. This leaves many people without access to needed mental health services and supports. For uninsured people living with mental illness, the impact of Medicaid expansion would be significant. If all states proceeded with expanding their Medicaid programs, as many as 2.7 million
559
people with mental illness who are currently uninsured could be added to the Medicaid rolls (NAMI, 2013). As noted above, 19 states, many with high concentrations of poverty, have decided against Medicaid expansion. These states also have high rates of mental illness. In a 2011 report, the states with the highest prevalence of serious psychological distress in adults aged 18 years and older were Arkansas, Georgia, Kentucky, Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas (Reeves et al., 2011). With the exceptions of Arkansas and Kentucky, these states have all opted out of Medicaid expansion. Medicaid coverage allows mental illness to be treated early, before symptoms worsen. Services available through Medicaid, and sometimes nowhere else, enable people who have been disabled by mental illness to rebuild their lives. When untreated, the human and fiscal impact of mental illness is felt not only in uncompensated care costs for emergency room visits and psychiatric hospitalization, but also in school failure, reduced productivity, increased incarceration, homelessness, and lost lives. By contrast, Medicaid coverage helps people with mental illness get services, stay healthy, and contribute to the vitality of their communities (NAMI, 2013). What about the consequences of Medicaid expansion for health in general? The Center for Health Law and Policy Innovation (2012) considered several issues when addressing this question: chronic diseases, infectious diseases, and health disparities. In the area of chronic diseases, they noted that preventive care and regular care reduce morbidity and mortality of chronic diseases. Access to preventive care inhibit the onset of diseases, and early diagnosis and treatment can reduce significantly the severity of prognosis and increase chances of leading a healthy and productive life (CHLPI, 2012). For infectious diseases, CHLPI cited the public health benefits of expanded Medicaid coverage, which impacts the safety and security of us all; access to care reduces the spread of disease by reducing the rate of infection or providing a curative treatment. Most importantly, the CHLPI (2012) addressed health disparities: the differences in health status based on social (race/ethnicity) and economic (income) differences, noting the health status advantage of Whites over minorities and wealthier persons over those with low incomes. Exemplifying the disadvantage experienced by persons with low incomes are higher rates of heart disease and diabetes and consistently shorter life expectancies than their wealthier counterparts (CHLPI, 2012). Other examples are based on race: African Americans with breast cancer, cardiovascular disease, or even pregnancy experience poorer outcomes than Whites with the same condition. Finally, there are tremendous disparities in rates of HIV/AIDS across the nation. Southern states (particularly Alabama, Florida, Georgia, Louisiana, Mississippi, North and South Carolina, Tennessee, and Texas) have the highest rates of both new infections and existing cases, as well as the worst outcomes in terms of HIV-related complications and deaths (CHLPI, 2012). One of the reasons for this tremendous disparity
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is that these states currently have highly restrictive Medicaid eligibility, leaving most low-income individuals without access to treatment and therefore more likely to transmit the virus as well as experience deteriorating health (CHLPI, 2012). The CHLPI (2012) also cited the fiscal impact of Medicaid expansion, noting that increased access to both Medicaid and private insurance will reduce the amount of uncompensated care that hospitals provide (as hospitals are required by law to stabilize any patient in need, regardless of ability to pay). Hospitals in states with limited Medicaid coverage will face severe deficits as they continue to treat a high volume of uninsured patients. Moreover, residents of states that do not expand will ultimately subsidize the cost of coverage in states that do, via federal taxation. There is strong empirical evidence that opting out of Medicaid expansion will have many negative implications by any measure, not only for individual and public health outcomes, but also for state fiscal stability (CHLPI, 2012). The data cited above point to a compelling argument for Medicaid expansion. Yet 19 states are not implementing it at this time. Earlier in this column, the increased numbers of insured people under the ACA was cited as a reason to believe there would be a need for many more mental health professionals to provide services, both to those newly insured under private policies and under Medicaid. With many states rejecting Medicaid expansion, this need seems to be related to the state in which a mental health nurse practices. However, it must be taken into account that the ACA requires mental illness and addiction care as one of its essential services. This means that all insured people, including those newly insured in 2014 will be able to gain access to mental health care. Despite the states that are leaving their poorest citizens with no access to health care, in situations in which a person is insured, there will be an increased willingness and opportunity to provide mental health services. How will these services be offered and what will it mean to mental health nursing practice and practitioners? Some mental health therapists who are in independent or solo practices will have to consider a new business model as the requirement for health insurance to cover mental illness at the same level as medical conditions goes into effect (Varney, 2013). Many of these practitioners have enjoyed the autonomy of choosing their own clients and their own hours and setting their own fees; many have been paid out of pocket when the client’s health insurance did not cover mental health care. Now clients will expect their providers to accept health insurance and to accept the amount of payment that the insurer is willing to provide (Varney, 2013). Therapists who already accept insurance typically make less per session, since fees are about half of what they charge for cash visits. Many in solo practice are finding it hard to adjust to these changes, along with the new skills and electronic equipment they must acquire for billing and keeping health records, and for complying with regulations governing practice.
A likely result of the implementation of the ACA will be for mental health professionals to form psychiatric specialty groups or to join large medical groups that offer mental health services as part of comprehensive care. The increasing complexity of running a practice has meant more therapists are practicing in group settings where the burdens of expense, billing, and regulations are shared (Varney, 2013). This is certainly the case with most psychiatric-mental health nurse practitioners and will become the practice model also for clinical specialists. An Internet search of jobs advertised for advanced practice psychiatric nurses were all located in group practices or clinics. In an era of integrated medicine, health professionals will better serve their patients and reduce costs by offering mental health service as part of comprehensive care—an important consideration for large medical groups that receive a set amount of money each month to cover all the needs of their patients. An increasing number of patients and a possible change in the business model for mental health professionals are issues that will need to be addressed in all states now that the ACA is in effect. In states that reject the Medicaid expansion, there will be a continuing lack of general health care and mental health care for lower-income people. Reducing health disparities, and eventually achieving health equity, has been a federal goal since the turn of the century, and it is part of the ACA’s design, particularly reflected in the expansion of Medicaid and the creation of widely available subsidized private insurance (CHLPI, 2012). Access to health insurance is a fundamental determinant of health outcomes and we, as nurses and mental health nurses, must continue to work for its universal implementation and acceptance. Declaration of Interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
REFERENCES Beronio, K., Po, R., Skopec, L., & Glied, S. (2013, February 20). Affordable Care Act expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans. U.S. Dept of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Retrieved from http://aspe.hhs.gov/health/reports/2013/mental/rb mental.cfm Buettgens, M., Kenney, G. M., Recht, H., & Lynch, V. (2013, October). Eligibility for assistance and projected changes in coverage under the ACA: Variation across states. Urban Institute Health Policy Center. Retrieved from http://www.rwjf.org/content/dam/farm/reports/issue briefs/2013/rwjf408158 Center for Health Law and Policy Innovation, Harvard Law School. (2012, July). Expanding Medicaid under the Affordable Care Act: Where do states stand today? Retrieved from http://www.law.harvard.edu/academics/clinical/ lsc/documents/CHLPI%20advocate%20tool%20state%20stances%20on% 20Medicaid2.pdf National Alliance on Mental Illness. (2013, May). Medicaid expansion and mental health care. Retrieved from http://www.nami.org/Template.cfm?Section= Health Care Reform&Template=/ContentManagement/ContentDisplay.cfm &ContentID=155752
CULTURAL COMPETENCE Reeves, W. C., Strine, T. W., Pratt, L. A., Thompson, W., Ahluwalia, I., Dhingra, S. S. . . . Safran, M. A. (2011, September 2). Mental illness surveillance among adults in the U.S. Morbidity and Mortality Weekly Report, 60(3), 1–32. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/ su6003a1.htm?s cid=su6003a1 w#Tab9 Tavernise, S., & Gebeloff, R. (2013, October 2). Millions of poor are left uncovered by health law. New York Times. Retrieved from http://www.nytimes.
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com/2013/10/03/health/millions-of-poor-are-left-uncovered-by-health-law. html? r=1& Varney, S. (2013, October 24). Therapists explore dropping solo practices to join groups. National Public Radio. Retrieved from http://www.npr.org/ blogs/health/2013/10/24/234737302/therapists-explore-dropping-solopractices-to-join-groups
Copyright of Issues in Mental Health Nursing is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
CULTURAL COMPETENCE COLUMN
Mental Health Care, the Affordable Care Act, and Medicaid Expansion Jacquelyn H. Flaskerud, RN, PhD, FAAN University of California—Los Angeles, School of Nursing, Los Angeles, California, USA
Edited by Jacquelyn H. Flaskerud, RN, PhD, FAAN University of California—Los Angeles, School of Nursing, Los Angeles, California, USA With The Affordable Care Act (ACA) going into effect in the United States, mental health nursing practice will change in a number of ways. One of these changes will occur because of the additional coverage provided for mental illness and addiction care; this change will result in more patients being eligible for mental health services. However, the extent of this change will vary state by state. In states that opt out of the Medicaid expansion, many low income adults will be left without insurance coverage and remain dependent on charitable organizations and free community clinics for their care. Another change may come with the new requirements and regulations for mental health care that could affect the business model of mental health professionals, especially those in solo practice. These requirements may result in more group practices—either those specializing in mental health care or those integrated medical practices that now include a mental health professional on their staff. The Affordable Care Act expands mental health and substance use disorder coverage to over 60 million Americans (Beronio, Po, Skopec, & Glied, 2013). Beginning in 2014 under the law, all new small group and individual market plans are required to cover ten Essential Health Benefit categories, including services for mental health and substance use disorders, and are required to cover them at parity with medical and surgical benefits (Beronio et al., 2013). The Affordable Care Act builds on the Mental Health Parity and Addiction Equity Act of 2008 that requires group health plans and insurers that offer mental health and substance use disorder benefits to provide coverage that is comparable to coverage for general medical and surgiAddress correspondence to Jacquelyn H. Flaskerud, School of Nursing, University of California, 700 Tiverton Ave, Factor Building, Box 951702, Los Angeles, CA 90095-1702 USA. E-mail: [email protected]
cal care (Beronio et al., 2013). For people living with mental illness, the law results in health insurance coverage for some services and treatments that have traditionally been denied or were not included in health insurance coverage in the past. The Department of Health and Human Services estimated that in total, through the Affordable Care Act, 32.1 million Americans will gain access to coverage that includes mental health and substance use disorder benefits that comply with federal parity requirements, and an additional 30.4 million Americans who currently have some mental health and substance abuse benefits will benefit from the federal parity protections (Beronio et al., 2013). The implications of these numbers are that there will be many more people seeking mental health care and there will be a need for more mental health professionals to provide these services. Many of the uninsured in each state are eligible for health coverage assistance programs—Medicaid, the Children’s Health Insurance Program (CHIP), and subsidized private coverage through the new health insurance marketplaces—under the ACA. The share of the uninsured that is eligible for assistance programs is heavily dependent on a state’s decision to expand Medicaid eligibility (often referred to as Medicaid expansion) or not (Buettgens, Kenney, Recht, & Lynch, 2013). The estimates quoted above included the assumption that states would expand their Medicaid coverage under the ACA, thereby including insurance protection to many more low-income Americans. The ACA extends Medicaid coverage to otherwise eligible state residents with incomes below 138% of the federal poverty level (FPL) (Center for Health Law and Policy Innovation [CHLPI], 2012); over 15 million uninsured adults would become newly eligible for Medicaid across all states. An additional 4 million uninsured adults are currently eligible under existing state Medicaid eligibility criteria (100% of poverty) but are not enrolled; many will likely do so once the requirement to have coverage becomes effective in 2014 (CHLPI, 2012). For those above the poverty line who do not have access to affordable employer coverage, the ACA allows credits toward the insurance premium they would have to pay. New health insurance marketplaces
558
CULTURAL COMPETENCE
offer subsidized private health coverage to families with incomes up to 400% of the FPL who are not eligible for public coverage, do not have access to employer coverage deemed to be affordable under the law, and are lawful residents. In states that do not expand Medicaid, those with incomes below 100% of the FPL are not eligible for subsidized coverage (Buettgens et al., 2013). In June 2012 the Supreme Court upheld all provisions of the ACA including the individual responsibility requirement, health insurance exchanges and subsidies, and the Medicaid expansion (CHLPI, 2012). However, the Court restricted the federal government’s ability to withhold federal Medicaid funds if a state elects not to institute the expansion, effectively giving states a choice whether to expand coverage. Even though the federal government will pick up nearly all of the costs of the expansion (100% for the first three years, phasing down to 90% in 2020 and all subsequent years), some governors and state legislative leaders are opposed to expanding Medicaid for political/economic reasons (CHLPI, 2012). As of May 2014, 26 states (and the District of Columbia) are implementing the Medicaid expansion, 19 states have rejected it and 5 are still debating it. States rejecting it are home to about half of the country’s population, but about 68% of poor, uninsured African Americans and single mothers; about 60% of the country’s working poor are in those states (Tavernise & Gebeloff, 2013). According to the Urban Institute’s Health Policy Center, between six and seven million low-income adults live in states that have opted to not expand their Medicaid programs under the ACA (Buettgens, Kenney, Recht, & Lynch, 2013). Three million (about half) live in just four states: Texas (1.1 million are in Texas), Florida, Georgia, and North Carolina (Buettgens et al., 2013). The irony is that the 19 states rejecting Medicaid expansion—many of them Southern—are the very places where the concentration of poverty and lack of health insurance are the most acute. It is their populations that have the highest burden of illness and impose the highest costs on the entire health care system (Tavernese & Gebeloff, 2013). What are the consequences for mental health resulting from the decision to expand Medicaid or opt out of it? The National Alliance on Mental Illness (NAMI; 2013) reports that six out of ten Americans living with serious mental illness have no access to mental health care. They note that Medicaid is the most important source of funding for mental health services in America today, offering mental health services that would otherwise be out of reach for low-income people affected by mental illness (NAMI, 2013). Unfortunately, millions of lowincome Americans with mental illness are currently shut out of Medicaid, excluded from the care that would help them rebuild their lives. This leaves many people without access to needed mental health services and supports. For uninsured people living with mental illness, the impact of Medicaid expansion would be significant. If all states proceeded with expanding their Medicaid programs, as many as 2.7 million
559
people with mental illness who are currently uninsured could be added to the Medicaid rolls (NAMI, 2013). As noted above, 19 states, many with high concentrations of poverty, have decided against Medicaid expansion. These states also have high rates of mental illness. In a 2011 report, the states with the highest prevalence of serious psychological distress in adults aged 18 years and older were Arkansas, Georgia, Kentucky, Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas (Reeves et al., 2011). With the exceptions of Arkansas and Kentucky, these states have all opted out of Medicaid expansion. Medicaid coverage allows mental illness to be treated early, before symptoms worsen. Services available through Medicaid, and sometimes nowhere else, enable people who have been disabled by mental illness to rebuild their lives. When untreated, the human and fiscal impact of mental illness is felt not only in uncompensated care costs for emergency room visits and psychiatric hospitalization, but also in school failure, reduced productivity, increased incarceration, homelessness, and lost lives. By contrast, Medicaid coverage helps people with mental illness get services, stay healthy, and contribute to the vitality of their communities (NAMI, 2013). What about the consequences of Medicaid expansion for health in general? The Center for Health Law and Policy Innovation (2012) considered several issues when addressing this question: chronic diseases, infectious diseases, and health disparities. In the area of chronic diseases, they noted that preventive care and regular care reduce morbidity and mortality of chronic diseases. Access to preventive care inhibit the onset of diseases, and early diagnosis and treatment can reduce significantly the severity of prognosis and increase chances of leading a healthy and productive life (CHLPI, 2012). For infectious diseases, CHLPI cited the public health benefits of expanded Medicaid coverage, which impacts the safety and security of us all; access to care reduces the spread of disease by reducing the rate of infection or providing a curative treatment. Most importantly, the CHLPI (2012) addressed health disparities: the differences in health status based on social (race/ethnicity) and economic (income) differences, noting the health status advantage of Whites over minorities and wealthier persons over those with low incomes. Exemplifying the disadvantage experienced by persons with low incomes are higher rates of heart disease and diabetes and consistently shorter life expectancies than their wealthier counterparts (CHLPI, 2012). Other examples are based on race: African Americans with breast cancer, cardiovascular disease, or even pregnancy experience poorer outcomes than Whites with the same condition. Finally, there are tremendous disparities in rates of HIV/AIDS across the nation. Southern states (particularly Alabama, Florida, Georgia, Louisiana, Mississippi, North and South Carolina, Tennessee, and Texas) have the highest rates of both new infections and existing cases, as well as the worst outcomes in terms of HIV-related complications and deaths (CHLPI, 2012). One of the reasons for this tremendous disparity
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is that these states currently have highly restrictive Medicaid eligibility, leaving most low-income individuals without access to treatment and therefore more likely to transmit the virus as well as experience deteriorating health (CHLPI, 2012). The CHLPI (2012) also cited the fiscal impact of Medicaid expansion, noting that increased access to both Medicaid and private insurance will reduce the amount of uncompensated care that hospitals provide (as hospitals are required by law to stabilize any patient in need, regardless of ability to pay). Hospitals in states with limited Medicaid coverage will face severe deficits as they continue to treat a high volume of uninsured patients. Moreover, residents of states that do not expand will ultimately subsidize the cost of coverage in states that do, via federal taxation. There is strong empirical evidence that opting out of Medicaid expansion will have many negative implications by any measure, not only for individual and public health outcomes, but also for state fiscal stability (CHLPI, 2012). The data cited above point to a compelling argument for Medicaid expansion. Yet 19 states are not implementing it at this time. Earlier in this column, the increased numbers of insured people under the ACA was cited as a reason to believe there would be a need for many more mental health professionals to provide services, both to those newly insured under private policies and under Medicaid. With many states rejecting Medicaid expansion, this need seems to be related to the state in which a mental health nurse practices. However, it must be taken into account that the ACA requires mental illness and addiction care as one of its essential services. This means that all insured people, including those newly insured in 2014 will be able to gain access to mental health care. Despite the states that are leaving their poorest citizens with no access to health care, in situations in which a person is insured, there will be an increased willingness and opportunity to provide mental health services. How will these services be offered and what will it mean to mental health nursing practice and practitioners? Some mental health therapists who are in independent or solo practices will have to consider a new business model as the requirement for health insurance to cover mental illness at the same level as medical conditions goes into effect (Varney, 2013). Many of these practitioners have enjoyed the autonomy of choosing their own clients and their own hours and setting their own fees; many have been paid out of pocket when the client’s health insurance did not cover mental health care. Now clients will expect their providers to accept health insurance and to accept the amount of payment that the insurer is willing to provide (Varney, 2013). Therapists who already accept insurance typically make less per session, since fees are about half of what they charge for cash visits. Many in solo practice are finding it hard to adjust to these changes, along with the new skills and electronic equipment they must acquire for billing and keeping health records, and for complying with regulations governing practice.
A likely result of the implementation of the ACA will be for mental health professionals to form psychiatric specialty groups or to join large medical groups that offer mental health services as part of comprehensive care. The increasing complexity of running a practice has meant more therapists are practicing in group settings where the burdens of expense, billing, and regulations are shared (Varney, 2013). This is certainly the case with most psychiatric-mental health nurse practitioners and will become the practice model also for clinical specialists. An Internet search of jobs advertised for advanced practice psychiatric nurses were all located in group practices or clinics. In an era of integrated medicine, health professionals will better serve their patients and reduce costs by offering mental health service as part of comprehensive care—an important consideration for large medical groups that receive a set amount of money each month to cover all the needs of their patients. An increasing number of patients and a possible change in the business model for mental health professionals are issues that will need to be addressed in all states now that the ACA is in effect. In states that reject the Medicaid expansion, there will be a continuing lack of general health care and mental health care for lower-income people. Reducing health disparities, and eventually achieving health equity, has been a federal goal since the turn of the century, and it is part of the ACA’s design, particularly reflected in the expansion of Medicaid and the creation of widely available subsidized private insurance (CHLPI, 2012). Access to health insurance is a fundamental determinant of health outcomes and we, as nurses and mental health nurses, must continue to work for its universal implementation and acceptance. Declaration of Interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
REFERENCES Beronio, K., Po, R., Skopec, L., & Glied, S. (2013, February 20). Affordable Care Act expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans. U.S. Dept of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Retrieved from http://aspe.hhs.gov/health/reports/2013/mental/rb mental.cfm Buettgens, M., Kenney, G. M., Recht, H., & Lynch, V. (2013, October). Eligibility for assistance and projected changes in coverage under the ACA: Variation across states. Urban Institute Health Policy Center. Retrieved from http://www.rwjf.org/content/dam/farm/reports/issue briefs/2013/rwjf408158 Center for Health Law and Policy Innovation, Harvard Law School. (2012, July). Expanding Medicaid under the Affordable Care Act: Where do states stand today? Retrieved from http://www.law.harvard.edu/academics/clinical/ lsc/documents/CHLPI%20advocate%20tool%20state%20stances%20on% 20Medicaid2.pdf National Alliance on Mental Illness. (2013, May). Medicaid expansion and mental health care. Retrieved from http://www.nami.org/Template.cfm?Section= Health Care Reform&Template=/ContentManagement/ContentDisplay.cfm &ContentID=155752
CULTURAL COMPETENCE Reeves, W. C., Strine, T. W., Pratt, L. A., Thompson, W., Ahluwalia, I., Dhingra, S. S. . . . Safran, M. A. (2011, September 2). Mental illness surveillance among adults in the U.S. Morbidity and Mortality Weekly Report, 60(3), 1–32. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/ su6003a1.htm?s cid=su6003a1 w#Tab9 Tavernise, S., & Gebeloff, R. (2013, October 2). Millions of poor are left uncovered by health law. New York Times. Retrieved from http://www.nytimes.
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com/2013/10/03/health/millions-of-poor-are-left-uncovered-by-health-law. html? r=1& Varney, S. (2013, October 24). Therapists explore dropping solo practices to join groups. National Public Radio. Retrieved from http://www.npr.org/ blogs/health/2013/10/24/234737302/therapists-explore-dropping-solopractices-to-join-groups
Copyright of Issues in Mental Health Nursing is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
