Rhetoric, Reform, and Responsibility: Our collective need to address mental health and substance use in health policy

Benjamin F. Miller
Benjamin F. Miller

Benjamin F. Miller, PsyD
Chief Policy Officer, Well Being Trust
Senior Advisor, Farley Health Policy Center, University of Colorado School of Medicine

In the United States, politics and political ideology has tended to drive dialogue on policy rather than actual evidence. While the challenges for evidence-based policymaking are not new, it is difficult to assess strategies around health policy and health care redesign in this context. No matter what direction the U.S. heads in terms of health reform, the issues facing our nation around mental health and substance use remain in need of addressing, especially in the context of health policy. The dominant national dialogue remains focused on health insurance and coverage; and make no mistake – people need coverage through health insurance, but coverage independent of care delivery and payment reform is insufficient to bring about transformative change in health care. Said differently, we can have people covered, but still have a dysfunctional and fragmented system that only leads to poorer outcomes, higher cost, and frustrated people and clinicians.

Psychology needs to have its voice heard. We have spoken before, but now it is time to speak out again.

One of the undoubted achievements of the Patient Protection and Affordable Care Act (ACA) was the codification of mental health parity. While there is no evidence-based reason why mental health should be separated from physical health, this has been the dominant narrative in the United States for decades. Even the dichotomy between the two is incoherent; mental health is physical health and vice-versa. The ACA, while not a perfect piece of legislation, at least recognized this basic fact by requiring individual and small employer health insurance plans (including plans offered through the marketplace) cover mental health conditions and benefits at the same level as medical benefits. The ACA’s prohibition on pre-existing condition exclusions had a dramatic impact in improving access to care for many people living with mental health needs.

While Congress continues to debate the future of the ACA and health care in general, people with mental health and substance use needs continue to go unaddressed. What impact will the American Health Care Act (AHCA) have on people with mental health needs? This argument has been covered, in detail but remains a major concern. We need change and transformation; we need integration. We need to shift the dialogue in this country away from incremental approaches to change and begin to think of systemic solutions.

But most importantly we need our discipline to proactively tackle health policy in service to radical integration.

I argue, based on the evidence that at both a federal and state level there is much more we can do to address the population health needs for individuals with mental health and substance use needs. There are three basic tenets to achieve this:

  1. Division divide: Mental health and substance use benefits must be seen as a part of the larger health benefits package and not as a separate benefit;
  2. A single point of entry for mental health and substance use limits access to people in a timely manner. Mental health and substance use services should be more distributed throughout the community as one mechanism to increase timely access. For example, having mental health services integrated into schools, primary care, and other major points of entry could help shift the mean on downstream demand; and,
  3. Payment reform must better incorporate mental health and substance use – comprehensive payment must include mental health. If we continue to pay for mental health and substance use services separately we will continue to have battles over who is responsible, who gets paid, and who is accountable for mental health needs.

Why should our field pay more attention and prepare for these issues? The answer is that in the current political climate, changes to certain public programs are likely on the horizon. For example, Medicaid, the largest payer of mental health services in the United States, is likely to be at the center of many legislative and regulatory debates.

One mechanism that has been proposed for managing these changes in Medicaid is through what is called a block grant. Block grants can be thought of as a fixed federal grant given to states based on the previous year’s state and federal Medicaid spending in that state. Think of it as a large pot of money given to a state that would force a state to make decisions on who is covered, what is covered, and how much a state pays for services. If block grants become the way in which Medicaid is supported, states may have to make difficult decisions on what services they keep. States could use such a dramatic shift to consider how they might more efficiently address delivery and payment reforms around mental health and substance use.

Of note, the block grants must be financially sufficient to permit states to continue their Medicaid programs (and in some cases increase coverage). Too substantial a cut to Medicaid through block grants will likely impede states’ ability to improve overall mental health and compress existing mental health inequalities. Considering that many states already have a separate budget line item for mental health (read carved out mental health benefit), this does not bode well for advancing mental health care, but screams for more innovative and integrated solutions.

Even for those clinicians who are not working within Medicaid, these changes will most likely impact the broader community, too (including the commercial market).

As outlined above, both federal and state government should consider how they can better integrate mental health and substance use as a part of their larger strategy of health reform. Carving mental health out as a separate issue or policy only works against the promise and benefit of addressing whole person population health, which would be a severe detriment to our communities.

While there are roadmaps and frameworks for such work, leaders should be thoughtful and considerate of how mental health truly fits into larger policy efforts. Regardless of political ideologies we must continue to make sure that our leaders get this one right. Health is health, and we would be mindful to consider how our policies may inadvertently keep us stuck, fragmented, and without any meaningful change.

Let us use the evidence to our advantage. Let our drive for integrated solutions for mental health and wellness push us to a place where we are outspoken in our desire for change. Let our voices be heard that there are policies that will help people if we just choose to pursue them. No matter what the federal government or our states choose to do with health care, let us use this moment to highlight the profound need this country has right now around mental health. Let us move to action and advocate for health policy that helps people everywhere.