Coverage for All: Inclusion of Mental Illness and Substance use Disorders in State healthcare Reform Initiatives
June 8th, 2008 ·
Frustrated by inaction at the federal level to address the growing number of uninsured Americans, states are increasingly moving forward on healthcare reform. Although state initiatives have been the subject of front page news, no one has examined the impact of their programs on people with mental illnesses and substance use disorders.
“Coverage for All: Inclusion of Mental Illness and Substance use Disorders in State healthcare Reform Initiatives,” a report from the National Alliance on Mental Illness (NAMI) and the National Council for Community Behavioral Healthcare (National Council), examines benefits for mental illness and substance use disorders for adults in state plans that cover the uninsured. The paper, which is based on research on 18 states’ initiatives and proposals, includes important findings on the following topics:
• The scope of the problem
• The history of financing for mental health and substance use treatment
• Analysis of state benefit packages
• Issues for future exploration
• Implications for the future
The Scope of the Problem
People with mental illness and substance use disorders are prevalent in the uninsured population. Data from the 2005 and 2006 National Survey on Drug Use and Health (NSDUH) that were tabulated specifically for this report indicate that more than one in four adults who are uninsured have a mental illness, substance use disorder, or co-occurring disorder. Approximately one-third of people with mental illness, substance use disorders, or both who are under the federal poverty level (FPL) are uninsured.
Not having insurance is a significant roadblock for people with mental illness and/or substance disorders. Almost 80 percent of people with these disorders who needed mental health treatment but did not receive it cited cost as the reason. Underinsurance is also a problem: 34 percent of insured people who had unmet mental health needs indicated that cost was a barrier to seeking treatment.
Data from the World Health Organization show that mental illness is the leading cause of disability in North American adults; substance use is the second leading cause. Neuropsychiatric disorders, which include mental illness and substance use disorders, are more significant contributors to disease burden worldwide than are other noncommunicable diseases, such as heart disease and cancer.
The consequences of untreated or under-treated mental illness, substance use disorders, and co-occurring disorders can be quite severe. Almost one-fourth of all stays in U.S. community hospitals—7.6 million of nearly 32 million stays— involved depression, bipolar disorder, schizophrenia, and other mental health disorders or substance use disorders.
Two-thirds of the U.S. homeless population are adults with chronic alcoholism, drug addiction, mental illness, or some combination of the three. Approximately 16 to 23 percent of jail, state, and federal prison inmates have a serious mental disorder, and adults with serious mental illnesses die 25 years sooner than those who do not have a mental illness.
Given the health and economic consequences of untreated mental illness and substance use disorders, along with the high prevalence of those conditions in people who are uninsured, states that do not include benefits for their residents will fail to address significant treatment needs of a considerable percentage of the uninsured, leaving them to suffer poor health and economic distress.
Over the past 40 years, the evolution in the scientific understanding of the biology of mental illnesses and substance use disorders and the effectiveness of treatments has been dramatic. Policy—aided by recent research showing the high cost of untreated mental illness and substance use disorders and the low to negligible cost of including equal benefits for those disorders and physical health conditions—has begun to reflect those trends. Yet, stigma and concerns about cost persist.
As the nation moves to cover more of the uninsured, the debate on the scope of benefits for mental illness and substance use disorders will continue. Policymakers will also seek better healthcare outcomes and lower costs for all conditions, including mental illness and substance use disorders. Lessons from the states indicate the need for further innovation as well as sharing of current practices to fully address mental healthcare and substance use treatment in state plans to cover uninsured populations.