This article first appeared in the St. Louis Beacon: William Shortall is among 50,000 Missourians who are in a bind because they don't have sufficient insurance to cover treatment for their mental health problems.
“Approximately five years ago, I was diagnosed with a mental illness, bipolar disorder,” he said. Shortal's plight isn’t unusual, pointing to federal data showing that about one in four Americans is coping with some form of mental illness. Most don’t get timely help, he says, because they lack health insurance.
“Quite frankly, I don’t know what to do. I recently lost my job and health insurance. I’m not eligible for Medicaid, so I must make a difficult choice because I live on disability only. And a portion of that goes to support my son, who also has a disability.”
The Affordable Care Act was supposed to throw a lifeline to people like Shortal by extending Medicaid to uninsured Missourians with incomes up to 138 percent of poverty, which is roughly $26,000 for a family of three.
Right now, many uninsured or under-insured Missourians with mental illness don't get treatment or get crisis care only when they arrive in hospital emergency departments.
That would change if Medicaid were expanded. The 50,000 newly eligible Medicaid recipients for mental health services include two broad groups not now covered by Medicaid -- 34,000 residents already getting behavioral health services mainly through state funding, and 16,000 individuals who are getting no help for substance abuse problems and serious mental illnesses.
Drawing down the federal dollars to treat the 34,000 through Medicaid expansion, the Nixon administration says, would free up state dollars for other purposes. Also, it says placing the other 16,000 under Medicaid would reduce law enforcement, court, hospital and emergency room resources now used to address the consequences this group being without medical assistance.
Still, expansion has set off a lot of debate along political and philosophical lines. Everyone seems to agree that something has to be done to help the medically needy, but the approaches set forth are as different as night and day.
“I believe in making sure folks are provided for,” says Patrick Ismael, a policy analyst at the Show-Me Institute. “There really isn’t daylight between the idea that, whether you are on the left or on the right, we want to make sure everyone is provided for, with the best health care possible, efficiently and effectively.”
But Ismael doesn’t think “you can address the access question without addressing the cost question.” The best way to address the latter, he says, is to pay for services with today’s dollars. As a result of ACA, he says, “we are really taking our money from our kids and our grandkids to pay for a program that’s going to serve people today, and I would argue, is not serving them effectively. This is part of the equation when it comes to mental health, and to health care in general.”
He argues that society needs to tap into individuals and groups willing to meet some of the needs of the uninsured at no cost to the public. An example, he says, is Remote Area Medical, a charity that he says is making major strides in helping some Americans lacking health insurance.
“In a nutshell, I think the government needs to make sure that folks can help each other. But first, you need market-oriented reforms at the federal level that interfere with rising health care costs.”
At the other end of the spectrum are business groups, health service providers and mental health advocates who say this is not the time to reopen a debate about the Affordable Care Act. They say it would make no sense for Missouri to pass up millions of dollars in federal help to shore up the state's system for caring for the uninsured, including those with mental health needs.
While opposed by various political organizations and think tanks, such as the Heritage Foundation, Medicaid expansion has been strongly endorsed by numerous business organizations and three dozen health provider organizations in Missouri. Groups lobbying for the mental health part of expansion include the Missouri Coalition of Community Mental Health Centers, and the Missouri Association of County Development Disability Services. The two are part of the broader Coalition for Healthy Economic Growth, chaired by Joe Pierle, CEO of the Missouri Primary Care Association.
Beyond these endorsements, some mental health organizations say they are particularly concerned about the mental health of many young adults in every corner of the state if Missouri refuses to accept federal dollars to expand Medicaid.
Typically, people are between the ages of 18 and 30 when they begin developing the first symptoms of a mental illness, such as bipolar disorder or schizophrenia, says Mark Utterback, president and CEO of Mental Health America of Eastern Missouri.
"Some of these are young people who may not have full-time jobs or jobs that offer health insurance,” he says. “It’s really important that people get the preventive care that they need so that they don’t become really sick. In some instances, these people have to be really sick before they receive services. They end up in the hospital and finally get help. They get treatment and they get better, but their heath doesn’t improve to the level it was before they became sick. So it’s really key to reach people early on so that they don’t get really sick.”
Jacqueline Lukitsch, director advocacy for the National Alliance on Mental Illness (or NAMI) of St. Louis, says Medicaid expansion would throw a lifeline to “young people out there who are mentally ill, aren’t addressing it, and aren’t accepting it. But at some point, (a health crisis) happens.”
They will have difficulty getting treatment, save for short hospital stays. Ideally, she says, Missouri would save money through Medicaid expansion because it would reduce emergency room expenses. With Medicaid expansion, those needing mental health services would get help through a coordinated system of care at mental health centers. The focus, she and Utterback argue, would be on preventive care to keep the illness under control and keep patients out of emergency rooms.
In addition, Lukitsch says expansion would put an end to the mentally ill and others having to spend down modest assets to qualify for Medicaid because the program would be available automatically to anyone meeting the income guidelines.
Asked if she feels lawmakers really are aware of the problems confronting the mentally ill who are needy but don’t qualify for Medicaid, Lukitsch says, “I think a lot of them are, and if they are not aware of this problem, then they haven’t been listening.”
She says some “have this value system that says if you are able-bodied, then you should be able to go out there and get health insurance. But if you work as a waitress at a restaurant, you can work as hard as you can, but you don’t earn enough money to pay for insurance and your employer doesn’t pay for it.”
Lukitsch says Missouri’s approach to treating mental health problems lacks logic because “it turns away people who could be helped through early diagnosis and treatment.” She likens the approach to a person who is diagnosed with cancer and is told, “Come back when it’s stage four, then we’ll give you treatment.
"It’s really an immoral way to care for people with mental illness.”
Another part of the debate involves hospitals. The public generally assumes that the mentally ill and other uninsured can turn to hospitals and emergency rooms as a last resort when they need care. While legally forbidden to turn away anyone having a serious illness, a hospital’s ability to serve such patients will soon diminish. New health rules under ACA are based in part on the assumption that some payments to hospitals can be reduced because Medicaid expansion will mean that needy patients now treated in emergency rooms will have access to primary care in clinics. The law left it up to states to decide how to care for such patients in the event they were not added to an expanded Medicaid program.
The Missouri Hospital Association says the shift away from traditional hospital subsidies to care for the needy could result in a loss of $4.2 billion in federal money for its member hospitals over the next six years. The association says a loss of that magnitude means legislative inaction on Medicaid expansion is not a realistic option. That is in addition to the loss of as many as 24,000 new jobs, additional income, and tax revenue that expansion is projected to generate through 2020.
The only silver lining, it seems, is time. The governor and state lawmakers still have the second half of the legislative session to find a compromise.
