mental health america; john o'brien, senior advisor for behavioral health financing, substance abuse and mental health services administration, u.s. department of health and human services. john, healthcare reform, why was it necessary? what benefits are we going to see out of it? well, ivette, we have about 50 million individuals in this country who don't have any insurance at any given point in a year. a number of them use emergency rooms and/or hospitals and that has a very significant cost for both people who have insurance, as well as employers who pay for insurance. we spend about $17.2 billion dollars on uncompensated care for those individuals. we also know that there is a significant number of people with substance abuse disorders who have benefits and don't access care, but there are a significant number

of individuals who can't access care because they don't have insurance benefits. and richard, what are the major ways the affordable care act will affect the behavioral health system? the affordable care act, the behavioral health aspects of the affordable care act are based on sort of three principles. one is coverage and parity, two is integration of behavioral health and health care and the third is prevention. and in part because the people with behavioral health disorders have had a much higher rate of being uninsured than the rest of the population, you can expect a disproportional impact on the behavioral health community because of the coverage expansions coupled to parity. okay, and let's talk a little bit more about that health parity and addiction equity act, the mental health parity and addiction equity act, richard. expand a little bit on, particularly the types of

links that are going to be made with the aca. the wellstone-domenici parity act, which was passed in 2008, went into effect in early 2010. and what it does is it really provides fairness and coverage along two dimensions. first, it requires that the standard benefits in an insurance plan be the same for the medical surgical side as it is for the behavioral health side. and so right away that means that copayments, deductibles, limits will be the same. it does a second thing, which is equally important, which is it says that if you are going to manage care, that is okay and you can manage it differently, but you have to

base it on the same clinical criteria, the same evidence, and the same logic that you use to make all your other management decisions. and in that sense, what it is doing is it's demanding fairness on the management side, as well as on the benefits side, which is really revolutionary. and the affordable care act adopts parity as one of its key principles that connects throughout the act. it connects in the exchanges, it connects in medicaid expansion, it connects in the essential benefits part of the affordable care act. and patrick, what does that mean for the consumer? that is the big question, really, i think. we are still discussing that throughout the country. we know that parity is something that we have worked hard for a long, long time and we assume that as it becomes more prevalent and really fully enacted, that that will be

a great benefit to people receiving health care. i mean, for years we had people receiving medicare without parity, where they paid a higher rate for mental health care than they did for their traditional healthcare rates. but as far as how the aca is going to play out in terms of improving mental health care and substance abuse, too, i think we are still trying to figure out where we are at the table. i just came from louisiana yesterday and we had a several-day discussion about how do, especially in the smaller states that are not so well organized, how do we get to the table to work out these details about how under-integrated health care, that mental health is not going to still be kind of a stepchild. and deb, for someone in the community that is working with

the individuals that need to get into recovery and that are currently in a treatment program or that are in recovery from substance use or mental disorders, what is the major point that we need to share with those individuals? well, i just have got to start by saying one in four families has somebody with a drug and alcohol problem and this is a fatal, it's a progressive, always fatal illness if it goes unchecked. so trying to begin to deal with this issue in a larger way through insurance is literally life and death important. i kind of want to sidestep a bit your question because i think there are several features of the affordable healthcare act that hold out a lot of hope. now we are worried, as you are, on how do consumers access some of these things. that pathway is not entirely clear to us at this point. but pre-existing conditions, the elimination of pre-existing

condition clauses has been an issue and a nettlesome one for our population. also the issue of you can't get thrown off your insurance if you start to use it was something we have seen in the drug and alcohol field. those two changes alone i think are extremely helpful. john, it seems like there are a lot of moving parts to this effort and what is samhsa doing to basically get the word out so that people are connected to what is going on and they really take action when they are supposed to? good question. we have been doing a number of things over the last 18 months, specifically around infomercials initially around parity before the regulations came out. and then as the regulations came out last year, we provided more detailed information, both in terms of traditional ways, webinars and presentations, as well as tip sheets around parity to try to get the information out. we have a 140 million people who are affected by parity.

that's good. what is a little challenging is how to reach a significant portion of those individuals who for most, parity is probably too technical of a term for them. and generally when we talk to employers, especially large employers, they say they have done a lot of effort to try to educate folks about parity, but the fact remains is that people really don't pay attention to these benefits until they almost have to use them, in most cases. so we are working with employers, we are working with our internal communications staff, external communications staff, to try to really figure out what is the best way to be able to get as much information to as many people around parity as possible. as we continue to really unveil all of this, the aca will increase access to behavioral health by expanding medicaid. how will that work?

as i said, in a sense, there are three large over-arching principles in the affordable care act. one is coverage expansion through medicaid, which you just mentioned, and the other one is insurance market reform, which deb referred to a little bit, but there is more to it than that. and then finally there is delivery system and payment reform, and they all work together, they all fit together. and so in fact, the medicaid expansions go to cover anybody with an income below 133 percent of poverty line. and that coverage will include mental health- which is approximately, what is that level? $10,000, $11,000 for an individual. and then $28,000, $29,000 for a family of four. yes. and so in fact for the first time, medicaid becomes a simple means tested program as opposed to something complicated where you have many different criteria that you have to meet.

so it's just for low income people now. and then picking up at that 133 percent level are subsidies to help you buy private insurance under these new organizations called health insurance exchanges, which is a way of giving individuals and small groups the same purchasing power that somebody who works, say for the federal government or ibm would get. and that is coupled with some new regulatory rules such as the ones that deb mentioned around pre-existing conditions and the like. there are lots more that we need to learn about this effort and we will be right back. [music] samhsa is playing a huge role in helping to implement the affordable care act. first of all, we are trying to make sure that behavioral health

is considered in every decision that is getting made, whether it's about the exchanges or whether it's about the rules that medicaid or medicare put out or whether it's about the information that goes out to the public about the kinds of things that are covered or whether it's about the preventive services that will get coverage without a copay, for example, or screenings or meaningful use activities. there's a whole bunch of stuff going on and we're trying to make sure behavioral health is at every one of those tables, so that is part of samhsa's role. one of the most important things to remember is that the affordable care act will offer services to a larger number of people that who were previously without such services. and it will treat behavioral health service needs on par with the general health service needs. it will foster an integration of care so that we can address both the physical health, as well as behavioral health

components, of the whole person. it will encourage the integration and comprehensive approach to dealing with a person's behavioral health issues, as well as their physical issues. recovery benefits everyone. i started my own company. i got my dad back. my friends believe in me. daddy's home. hi, dad. substance use and mental disorders can be treated. it all starts on day 1. join the voices for recovery. for information and treatment referral for you or someone you love, call 1-800-662-help. brought to you by the u.s. department of health and human services. before, addiction and depression kept me from living my life. now, every step i take in recovery benefits everyone. there are many options that make

the road to recovery more accessible. it begins with the first step. join the voices for recovery. for information and treatment referral for you or someone you love, call 1-800-662-help. brought to you by the u.s. department of health and human services. [music] like a lot of people experiencing mental illness kind of later in life, i really, my symptoms became profound in my 30s. i started having these mood swings, so i decided i should go see a doctor. and i went to my regular doctor, who examined me, but he was not really familiar with psychiatrics and he just said you need a vacation. so i minimized the whole idea in my mind and i continued to get worse and eventually really destroyed my company that

i owned at the time. my next step into mental health was that i ended up in a psychiatric hospital. and if we had had the type of care that we are working towards now where all care is integrated and you walk in one door and you can see all the different types of people you need to see, i wouldn't have to go through those extra 4 years of agony and destruction and then changes to my family and all of that. let's talk a little bit about how many people-we had mentioned it earlier, deb-but how many people are actually uninsured? and let's talk a little bit more about specifically in the behavioral health area. the data coming from the federal government points to 50 million people not having any kind of coverage. and people with untreated drug and alcohol problems or unaddressed mental illnesses have a hard time accessing benefits or thinking that through. if i am really in the throes of an active addiction,

i may not think about how to sign up for medicaid or how to sign up for the health exchanges. so there's this big group we've got to do something with. we are really concerned about it. i think the good news is the affordable healthcare act includes drug and alcohol and mental health, both. the problem is we're going to have to do a lot of work to help this particular population access the coverage. the coverage is there, no question, but we're dealing with a patient population that has a very difficult time getting through the hoops. and the intended goal of that is that there will be 32 million more americans that will actually have coverage, either through medicaid or private insurance. so that's about two-thirds of the 50 plus million that aren't insured at this particular point in time. the best guesses, and actually they are more than just guesses, is that anywhere from 20 to 30 percent of those individuals of the 32 million have a mental health or substance use disorder.

probably higher for those individuals that are under 133 percent of the federal poverty level, and we think even that may be under-reported. yes, a recent study by the office of the secretary at hhs showed that john is exactly right with about 25 percent of those people have a mental disorder. which means that about 20 percent of people with either a mental or an addictive disorder have no insurance, and so that is considerably higher than it is for the rest of the population. so that means that the coverage expansion are going to disproportionately affect in a positive way those populations. i have worked in a number of rural states in the south where the coverage typically had been that about 60 to 65 percent of people were either covered by medicaid, medicare,

or va, which left us with a substantial number of people who were not covered. and i think even as we cover these 32 million, we'll still have a very large amount of people who are not covered by any type of insurance benefit and, therefore, we're still looking either to the states to pick that up through their general revenue or i think the new plan is hopefully that the block grants will expand to pick up some of that slack, if i am correct. no, that is exactly right. i mean, we know 5 years later in massachusetts that there are a significant number of individuals, especially on the substance abuse side or looking at the mental health side as well, that are still unenrolled in their insurance program in their exchanges. and there's a variety of reasons why those folks are still unenrolled. some of is just education information about what does insurance mean, some of it is the way that people come on and off insurance.

and so i think the massachusetts experience is going to be very helpful as we begin to think about the exchanges in other states. you have mentioned exchanges and that was just going to be my next question. we have talked about the medicaid component of it. how do other people that do not meet that criteria, how are they going to access services? i will start with you, john. i think richard had mentioned earlier that those for those individuals that were greater than 133 percent and under 400 percent of the federal poverty level will have the opportunity through the exchange program in states and perhaps at the national level to be able to receive an insurance benefit through a qualified health plan. well, let's dissect that exchange program. what is that about, how is that going to function? well, it's going to have a number of functions. obviously, one of the major functions is an enrollment function, so the ability to be able to provide information

to people about how to enroll insurance, provide information to people about what are the qualified health plans, to identify, recruit, screen the qualified health plans that will be offering the benefit. and again, making sure that as the qualified health plans get up and running, that they actually do what they are supposed to do. am i going to call a phone number, am i going to go online? how am i going to access the exchanges? one of the things that often happens is the patients show up in our programs and the programs help people figure out what funding stream works or whether it's a charity case. there's a lot goes on at the front door of the program, but i think i need to alert you, we do have some issues here. i spend a lot of time reading benefit books. benefit books rarely reflect, to date, rarely reflect the parity act and this is going to be a problem. we really are going to need help in order to help the consumer access the benefit they are entitled to.

we have a whole lot we need to do in the consumer area and with enforcement of these statutes. the idea behind the exchange is to sort of give to the larger u.s. population the same benefits that people who are federal employees, state employees, or who work for a large employer get. and that means if you think about what those organizations do for you, first of all, they purchase at a very low administrative cost. second of all, they sift through the benefit books and other things and they put fairly easy-to-understand tables and charts together that will help people make choices. they will also make sure that the plans to participate are qualified, have been vetted, adhere to quality standards, and the like. sort of a good seal. exactly. and so just like harvard university, in my case, screens out a lot of the plans that aren't that desirable, so will the exchanges sort of help consumers get to the right

kind of place and offer them choice and offer them information for making good choices. and john, you were saying that your experience with massachusetts has been a positive one with the exchanges? well, i think it has been a positive one with the exchanges, but we still have a number of people who are still unenrolled. and so that is a little bit disturbing, given what we are trying to accomplish here in terms of getting as many people enrolled as possible. i will say, you had asked the question about how are people going to know about the exchanges, enroll in the exchanges-some of that is actually being developed and proposed over the next several months. but my guess is a number of the medium strategies that you talked about, whether it be a paper process, because not everyone has a computer, whether it will actually be ways to enroll via web, etc., are all strategies that are on the table. but i think for our populations, we are going to have to be a little bit more creative than perhaps a commercial population.

using providers, using consumer advocacy groups, using recovery organizations to get the word out and maybe help people understand what insurance does for them and then understand the process. we've done some studies over the country based on how to communicate with the consumer community and the digital divide with the mental health consumer community is gigantic. less than 40 percent have access to the internet, so we've got to find very creative ways to get these words out. and i think that that actually will be a very solid role for consumer organizations and we've made a lot of gains in recent years towards organizing in all of our states. so hopefully, we will be doing that. but it goes back to how do you get in touch with people that you don't know exist. and i really want to come back to all of those consumer issues

because there is yet another layer to the aca, which is the whole issue of electronic records that i would like to get into. we'll be right back. [music] for more information on national recovery month to find out how to get involved or to locate an event t near y, visit the recovery month web site at recoverymonth.gov. when you have a drug or alcohol problem, your whole world stops making sense. you can get help for yourself or a loved one and make sense of life again.

for information, treatment referral, and, most importantly, help, call 1-800-662-help. brought to you by the u.s. department of health and human services. they tell me i was there, but i don't remember. i don't know where i really was. i do not know what i had for breakfast. i do not know who won the game. i don't recognize this man. if you or someone you know is struggling with a drug or alcohol problem, there is a solution-recovery. call 1-800-662-help for information and for hope. through treatment, my life is a whole lot brighter now. brought to you by the u.s. department of health and human services. [music]

columbus house provides shelter, emergency shelter services to single men and women. and we do that year round, we are most known for that service. in terms of the soar project, we are targeting folks who are in our shelter and who are living outside, unfortunately, living outside but are engaged with our outreach and engagement team. soar stands for ssi, ssdi, outreach, access, and recovery. it's a project that started in 2005 when the federal government was holding policy academies to address homelessness across the country. and almost, probably at least half of the states that participated in those policy academies said that one of their goals was to try and increase access to

ssi or ssdi, but no one knew how to do it. when people are living outside or in the shelter, one of the key things that they need are an income in order to be able to find their own home and live in their own home. and a lot of folks that we serve don't come in with an income, but have a significant disability that would make them eligible for social security. for the clients that i work with, because of the mental health or substance abuse issues that they have, it's difficult for them to access the benefits and sometimes they don't even know that they are eligible for benefits. so making them aware of that is a key point sometimes. social security is set up that the people who want these benefits or who are going to apply for them are supposed to be able to walk in on their own or sit down at a computer on their own and do the application. this doesn't work really well for people who may have a brain disorder, who have trouble thinking or organizing their thoughts or if they have been homeless for a long period of time. they haven't had continuity of care, so they may have been seen in an emergency room in one community and in another

emergency room someplace else and in a detox in a third place. and it's all jumbled up, they don't remember where they were, they don't remember what they were treated for. they certainly don't remember the names of the doctors and so forth. so it becomes very difficult for them to actually fill out this application and do it on their own. in the last year, we've had many of our case managers trained in the soar approach and since that training, it's led to wonderful results and people who are getting benefits for the first time. once i was diagnosed with my disease, cirrhosis, and the doctor, the first thing he said, you can't work anymore, which i was working up until that point. so that is when i was really desperately homeless. the first time that bill and i sat down together to fill out his application, he was denied and after that i did the soar training. so i had all this knowledge and i knew what social security was looking for. they are looking for his ability to function. so we were just trying to prove that his disability limited

his function which, in turn, limits his ability to work. and with that knowledge, we were able to get him his benefits. initially the doctor told me that i needed to be on a strict diet. so being able to have access to money to go to the grocery store, i can buy fresh vegetables, fruit, things like that, which is very good for me. when i can make my own meals now, it helps immensely. i applied for ssi initially because i just came out of the hospital due to two amputations due to diabetes. well, let's just say it will give me a complete and total sense of independence again. when people receive an income, they are able to move out of the shelter or out of a car and into their own home. before soar, people who were doing these applications were getting approved at about 10 to 15 percent and after soar, nationally, we are achieving a 73 percent approval rate within 93 days. it's really fundamentally changed the way that people approach these benefits.

john, i want to go back to our previous panel dialogue on the difficulty to reach people. what are some positive best practices that we can implement? i know, richard, you mentioned some, but let's start with john. well, there's a few states and richard mentioned new york and maybe richard has a little bit more details on that, but there's also rhode island, who actually is thinking about using its soar program, s-o-a-r program as a way to be able to think about enrolling individuals. the soar program was very helpful in terms of getting people who qualified for medicaid but weren't enrolled in medicaid to actually enroll in medicaid. and it's a definitive program where people can call and get assistance and people will talk them through the system? yes. and actually even work with them face to face, work with them to walk through the applications,

meet them even in the places where they have to complete the applications. very good. any other best practices, richard? well, i think the philosophy is trying to meet people where they are. the idea is to recognize that people who are in that under 133 percent of the poverty line who are currently uninsured tend to be single, childless adults. they tend to be very poor. half of those people are under 50 percent of the poverty line, so they are extremely poor, very often homeless or have unstable housing, therefore, hard to kind of track down to one place and disproportionately, don't necessarily speak english as their first language. so i think what has developed is some strategies to trying to kind of touch these people where you are likely to find them. so you go to shelters, you go to latino community organizations and you don't just focus on the health and