The Bazelon Center just released a new guide to help advocates, providers and state leaders improve health coverage and mental health services in the states. We spent the day reading it and are impressed with the thoroughness and wisdom of the approach and dismayed at that same time at how difficult their recommendations are to follow. How long have we been saying we need to help state leaders understand the benefits of expanding Medicaid eligibility to ensure people with mental illness have access to the services they need? It is all well and good for Washington groups to lay out master plans but the huge challenge is implementing those plans. And in this current climate of fiscal uncertainty and dodge ball posturing, a pronouncement about “what to do” even from a most respected advocacy organization as the Bazelon Center is just not enough. I hear far too often from people on the front line that all the national guides, position papers and recommendations from above mean very little when state and local officials aren’t listening. For those that are – God bless you.

Consider just a few highlights from the Bazelon report:

• The optional expansion presents states with an unparalleled opportunity to secure federal funding for health care for low-income Americans. Scores of these individuals endure serious mental illnesses, other health challenges and even homelessness. However, people with low incomes and mental illnesses deserve the opportunity to lead a full life in the community like everyone else. 

  Hard to argue with that.

• Experience suggests that some health plans do not fully comply with the federal parity statute—sometimes due to confusion in how to compare mental health/substance use disorder services with medical/surgical services, and sometimes due to plans’ attempts to limit costs. Emphasizing the parity requirement in the state’s definition of the EHB is therefore important. In addition, the state will need to monitor implementation of that requirement if the state is to ensure that it is fully effective.

  No offense, but let’s be clear about parity. I would suggest (based on a strong hunch and what I hear repeatedly in state and community visits) that the majority of health plans do not fully comply with the parity statute. I challenge any one to show evidence that parity in the states is understood to be beyond traditional outpatient and inpatient care. (And I love to be proven wrong by the way.) So come on Network faithful, let us know what your experience is. How is parity working in your state? We are starved for examples of where parity is working the way it should with youth with serious emotional challenges and their families. Heck, we’ve even made a form for you to load up your great examples. Take 5 minutes to fill it out. We cannot be satisfied with a definition of parity as the provision of inpatient and outpatient care when we know that what really works is family-driven care, peer support and high-fidelity wraparound for youth with serious emotional challenges and their families.

• Uninsured individuals with mental illness receive at best only very basic, state-funded public mental health services—frequently of limited duration and often only crisis-oriented care. The ACA enables states to replace state and local dollars spent on mental health services with federal Medicaid funds while at the same time providing a more comprehensive array of services to those in need. States can recoup substantial savings under the Medicaid expansion because the federal government will pay nearly all of the costs for the newly eligible group.
  
  Thank you Bazelon for making our point but this will not happen magically folks. We need advocates at the doors of state decision-makers demanding a different approach to how Medicaid dollars are being used. State Medicaid directors become critical in this equation. However, currently many states are asking the very real question – “Where the heck is all of this money going to come from? Take your state Medicaid Director out to lunch and give him or her a copy of Jonathan Gruber’s book (see below)…

• Without the Medicaid expansion, states will likely continue to spend significant funds on public mental health services. In 2009, state spending on mental health services was over $16 billion, representing 42 percent of total costs for those services. Without the Medicaid expansion, states may also face high costs of unnecessary use of emergency rooms and hospitals as well as demands on other systems (such as criminal justice and social services agencies) due to lack of access to mental health services. In fact, estimates of the Medicaid expansion’s value to states show states saving between $19.9 billion and $39.7 billion on mental health services by 2019 depending on state-level circumstances.
  
  Read Jonathan Grubers comic book (yes, comic book) for an easy way to understand this.

• Bottom line? You need to read the Bazelon Guide Take Advantage: New Opportunities to Expand Medicaid Under the Affordable Care Act. Expanding Medicaid eligibility and making other wise policy choices now available under the Affordable Care Act will go a long way but don’t be lulled to thinking that the guide alone will do the work for you. True parity and effective use of Medicaid expansion will require beating down doors. Get busy.  Download the guide here.