Feature Story: Legislative Analysis: Will Health Care Reform Help Those Most at Risk?
Since the passage of massive health care reform legislation earlier this year, most Americans are still trying to understand what it means. While a few of the provisions have gone into effect this fall, the majority of reforms won’t be implemented until 2014. At NAMI, we have been asking, will health care reform help some of our most vulnerable members--those who are at risk of involvement with the criminal justice system?
The reforms are not likely to have an effect on individuals currently in jail or prison; these individuals are considered exempt from the health care reform law. These individuals have a limited right to health and mental health care protected by the Constitution. However, for people who are at risk of encountering the police or those re-entering society after jail and prison, the impact could be significant.
What do we know about people living with mental illness who are involved with the justice system? We know that a high percentage live with a co-occurring substance use disorder. We know that involvement with the justice system often starts early in --with more than two-thirds of children in the juvenile justice system having at least one diagnosable mental disorder. People who are incarcerated and live with mental illness tend to experience higher rates of sexual and physical abuse and unemployment than other inmates.
We also know that people who are involved with the justice system often get trapped in cycles of crisis--alternating between jails, homelessness, shelters and emergency rooms. Once someone has been in jail, he or she often has trouble connecting or reconnecting with life-saving services like income supports, Medicaid and housing. We know that people living with mental illness who encounter the justice system are likely to not have access to treatment or to have ceased treatment.
The new health care reform bill will not address all of these concerns, but it should be a means of helping many individuals get and keep health care, which is vital to staying well and steering clear of the justice system. Under the new reforms, an estimated 94 percent of Americans will have health care. Access to health care will increase in several ways:
Medicaid. Medicaid is a joint state-federal health care program for the poor. With new federal funds, states will be required to expand eligibility criteria for Medicaid to people with incomes at 133 percent of the federal poverty level. This expansion will make Medicaid available to many individuals who were previous ineligible, but were unable to afford private insurance. Medicaid plans will be required to include basic mental health and substance abuse benefits. However, ensuring that these expanded Medicaid programs will cover needed services such as assertive community treatment (ACT), intensive case management and multi-systemic therapy for youth will be a challenge.
- Private Insurance Patient Protections. A variety of protections will go into place to improve the quality of private insurance. Several of these provisions will help ensure that people living with serious mental illness can get or keep insurance, including provisions that:
- prohibit insurers from denying coverage for individuals based on a pre-existing condition;
- prohibit insurers from dropping coverage because someone gets sick;
- require insurers to accept any individual or employer who applies for coverage;
- prohibits lifetime limits on benefits; and
- prohibits annual limits for group plans and new plans in the individual market.
Insurance Exchanges. States can create special markets for private insurance called exchanges; if the state opts not to create an exchage, state residents can participate in a federal exchange. These exchanges will certify insurance plans and provide consumers with information and assistance in comparing plans. The exchanges are designed to provide options for uninsured Americans (and others) to obtain coverage. Provisions relevant to people living with mental illness who come in contact with the justice system include:
for those under an income threshold, subsidies to purchase insurance; and
all qualified plans must offer uniform benefit packages, including mental health and substance use benefits. Federal parity requirements will apply.
Services for Youth. The health care reform bill also improves and expands coverage of services for youth under the Children’s Health Insurance Program (CHIP). Linking youth with serious mental health conditions with CHIP services will be an important strategy for reducing the numbers of these youth in juvenile justice systems.
In addition to increasing access for individuals who need menal health treatment, the health reform legislation promises to improve the quality of coverage for many people who live with mental illness. Of particular interest to people at risk of justice-involvement, the new law improves integration of substance abuse, mental health and primary care services for many Americans. This is important because there is great overlap in the need for these services, yet most people don’t receive them in an integrated manner. Some of the provisions that relate to services integration include:
Medicaid Medical Home Option. A new option available to state Medicaid programs that would allow Medicaid enrollees with at least two chronic conditions or one serious mental health condition to designate a provider as a medical home. Medical homes are providers responsible for overseeing and coordinating all health care, including substance abuse and mental health care.
Grant Program. A new federal grant program will support co-location of primary and specialty care services in community mental health settings.
While it is impossible to predict the future, the health care reform legislation should increase access to mental health care, and improve the quality of that care for many Americans living with mental illness.Still, this will not be a magic bullet for people who are at risk of involvement with the criminal justice system. Some provisions of the health care legislation will need to be shaped at the state level by individuals living with mental illness and family advocates. These include:
Medicaid Expansion. While states are required to expand Medicaid eligibility, they will not be required to provide the same package of benefits as they offer to other Medicaid beneficiaries. State advocates will need to push for a wide array of mental health services in Medicaid expansions, including rehabilitative services. In addition, federal health care reforms do not have an impact on the availability of Medicaid benefits upon release from jail or prison; advocates will need to continue to ensure that their states have a system in place for assisting people leaving correctional settings in resuming or re-applying for Medicaid.
Medicaid Option. The Medicaid option to allow recipients to designate a medical home is not automatic; state Medicaid plans must opt to utilize the option. Advocates should press their Medicaid administrators to take advantage of this opportunity.
Finally, advocates will need to continue many of the efforts that they have worked on for decades, including:
Other Supports and Services. People living with mental illness who are at risk of justice involvement need more than health care; they often need assistance with employment, education, housing, income supports and other services. Without these supports, these individuals remain vulnerable to relapse of their illness. Advocates will need to continue to push for the availability of these services, including to individuals with a criminal record, who often have greater difficulty getting housing and employment.
Restoration of Medicaid Benefits. While more people will be eligible for Medicaid, people often lose their benefits when they enter jail or prison and do not get any assistant in re-applying upon release. Advocates need to continue pushing for state and federal legislation that suspends rather than terminates benefits upon entry to jail, and that requires jails and prisons to assist people with mental illness in re-applying for benefits as part of comprehensive re-entry planning.
- Coordination between Mental Health and Criminal Justice Systems. Advocates have learned that coordination and planning between individuals living with mental illness and their families, mental health providers and criminal justice systems can mean the difference between life and death for people living with mental illness. As long as law enforcement are the first-responders, crisis intervention teams (CIT), mental health courts and other programs that actively partner with criminal justice systems will continue to have a vital role to play in keeping people out of jails and prisons.
Health care reform offers promise that people livig with mental illness and substance use disorders will have access to improved services. However, advocates face a significant challenge in learning about the key provisions in the law and ensuring that the provisions are implemented in a way that covers services needed to foster recovery and prevent incarceration. As NAMI develops more resources to assist advocates, you can find them on our website at: www.nami.org/healthcare. For a general overview of the health care reform legislation, download these fact sheets.