The Affordable Care Act will significantly expand access to healthcare coverage and improve health outcomes over the next few years, especially for those with behavioral health needs. Key provisions include expanding Medicaid eligibility and establishing health insurance exchanges. This will reduce the number of uninsured Americans, including many who are currently unable to access behavioral healthcare. The changes brought about by the ACA will disproportionately benefit rural communities, where access to insurance and services is more limited. Full implementation will occur in phases over several years to allow for development of new infrastructure and systems.

1. The Affordable Care Act, Behavioral Health and Implications For Rural Communities William J. Hudock Senior Public Health Advisor Substance Use and Mental Health Services Administration

2. Patient Protection and Affordable Care Act (ACA) The Act Does Several Things: Expands Insurance Coverage Institutes Insurance Reforms Builds Infrastructure To Provide Improved Health Outcomes Puts In Motion Structural Changes To How Healthcare Delivery Is Structured & Financed Goals of Act Are To: Increase Access Provide Comprehensive Care  Better Health Outcomes Control Costs

3. Most Provisions of ACA Are Implemented Over The Next Four Years Phased Implementation Is Needed To: Build Needed Infrastructure Plan and Implement Provisions Well Changes To Benefits and Insurance Reforms Began To Be Implemented In 2010 Some Provisions Must Be Implemented Over Several Years Major Coverage Expansion Occurs in 2014 Longer-term Benefits Result From Sum of Structural and Cultural Changes

4. Expanded Health Insurance Coverage - 2014 Insurance Coverage Expands From 83% to 94% Individual Mandate Applies Subsidies For Those Under 400% FPL Medicaid Eligibility Set At 133% FPL + 5% Income Disregard = 138% FPL Medicaid Expands from 34 to 50 Million 25 Million Get Insurance Through State Exchanges Pre-existing Condition Limitation Prohibited – 129 Million Americans Protected

5. Result of Coverage Expansion Result of Change in Coverage for non-elderly individuals (by 2019) 158 M will have coverage through employers 50 M will have coverage through Medicaid/CHIP 25 M will have coverage through exchanges 26 M will have coverage through non-group plans 26 M will remain uninsured Source: Congressional Budget Office

6. Impact on Rural Populations Rural Populations Currently More Apt To Be Uninsured 36% of Employers Don’t Offer Coverage 40% of Self-Employed Not Insured 30.6% of Rural Population Eligible for Subsidies Adults and Children More Apt To Qualify For Current and Expanded Medicaid Coverage Source: Rural Policy Research Institute

7. Impact on Coverage Expansion Prior to implementation of coverage expansion: 39% of individuals served by State Mental Health Authorities have no insurance 61% of the individuals served by State Substance Abuse Agencies have no insurance Many of these individuals will be covered in 2014 (or sooner)—most likely by the expansion in Medicaid

8. What Do We Know About the Newly Covered? Annual Insurance Coverage 47% of poor adults have insurance at some point in the year 35% are uninsured all year 18% are insured all year 60% forgo medical care due to coverage Conditions are more acute when they present Care is more costly Source: Center on Budget and Policy Priorities

9. What Do We Know About the Newly Covered? Source: Center on Budget and Policy Priorities Traits <100% FPL 100-200% >200% FPL Poor or fair physical health 25% 18% 11% Poor or fair mental health 16% 11% 6%

10. What Do We Know About Coverage? 2014 - Requirement To Have Essential Benefit Coverage In Exchanges Final Decisions Not Yet Made – Categories Mandated By Law: Mental health and substance abuse services Rehabilitation and habilitation services Pharmacy Preventive and wellness services

11. Provisions Of Interest To Rural Areas National Quality Strategy Core Principles Include All Service Locations & Goal To Eliminate Disparities in Care Workforce Provisions Address Health Professional Shortages – Loan Repayment and Scholarships through National Health Service Corps. Major Increases in Federally Qualified Health Centers Incentives to Adopt Electronic Health Records Increased Focus on Telemedicine

12. Impact of Affordable Care Act Focus on coordination between primary care and specialty care: Significant enhancements to primary care Workforce enhancements Increased funding to SAMHSA, HRSA and IHS Bi-directional MH/SUD in primary care through FQHCs Primary care in MH/SUD settings through CMHCs and other agencies Services and technical assistance Health Homes and Accountable Care Organizations

13. Changes To Medicaid Medicaid Expansion to Childless Adults under 133% FPL Increased FMAP amounts for expansion population 2014 – 2016 100% FMAP 2017 95% 2018 94% 2019 and thereafter 90% Benchmark Plans: Mental Health/Substance Use Disorder at Parity - 1/1/2014 Amendment to Rehabilitation Option under Medicaid - 1/1/2013 Expand Home and Community-Based Services FY2011 enacted State can participate for a five year period and can renew for an additional five years Continued Medicaid Coverage for Foster Children – Expires 1/1/2019 Reduction in Medicaid DSH – 10/1/2011 - Reductions based on State uninsured levels

14. Medicaid Demonstration Programs Medicaid Integrated Care Demonstration Project 1/1/2012 – 12/31/2016 No later than one year after demonstration project is finished, evaluation report due Dual Eligible Demonstration Project Five year grant period, can be extended for an additional five years Emergency Psychiatric Demonstration Projects FY2011 $75 million, funds available until 12/31/2015 Report due to Congress by 12/31/2015 Payment Bundling Pilot Pilot Project can begin anytime AFTER 1/1/2016 Medicare Accountable Care Organizations 1/1/2012 – 12/31/2016 Demonstration Project No later than 1/1/2012 establish shared saving program Special Needs Plans under Medicare Advantage (MA) 1/1/2011 Secretary to periodically evaluate and revise risk adjustment system 1/1/2012 Secretary require a MA organization offering a specialized MA plan for special needs individuals be approved by the National Committee for Quality Assurance Individuals enrolled in a Specialized MA plan for special needs individuals prior to January 1, 2010, are transitioned to a plan or program described in subparagraph A by no later than January 1, 2013

15. Elements of Expanded Coverage 1/1/2014

16. Timelines for Provisions of Interest * =authorized but not yet funded 2010

17. Grants and Programs of Interest Mental Illness with Co-Occurring Primary Care Conditions Grants FY2010 $50 million FY2011 – FY2014 sums as may be necessary Mental Health and Post Partum Women Study FY2010 – FY2019, report due no later than 5 years after enactment Medicaid State Plan Amendment for Health Homes Beginning 1/1/2011 states have option for state plan amendment, Secretary can award planning grants 1/1/2014 survey states using state plan By 1/1/2017 Secretary must complete an evaluation report to Congress Primary Care Extension Program FY2011 and FY2012 $120 million FY2013 and FY2014 such sums necessary 2 year planning grants and 6 year program grants

18. Grants and Programs of Interest Maternal, Infant and Early Childhood Home Visiting Program No later than 6 months after enactment States conduct a needs assessment Report due 3 years after the initial start of the program Final report due 12/31/2015 FY2010 $100 million FY2011 $250 million FY2012 $350 million FY2013 $400 million FY2014 $400 million School-Based Health Centers include Mental Health/Substance Use Disorders Grants FY2010 – FY2014 National Prevention Strategy 7/1/2010 – 1/1/2015 submit annual National Prevention and Health Promotion Strategy Report to Congress and President Grants to Accredited Programs and Mental Health Organizations for training Behavioral Health Professionals FY2010 – FY2013 Varied Amounts Available

19. Provisions of Health Reform Now In Place Consumer Protections Protect 194 million Americans with private insurance : Insurers can no longer deny children under 19 coverage for a preexisting condition Insurance companies can’t cancel your policy if you get sick or have not committed fraud no more lifetime caps on how much insurers will pay You have a right to appeal, including external appeal

20. Provisions of Health Reform Now In Place Additions To Coverage: Medicare prescription drug beneficiaries who hit the so-called ‘doughnut hole’ gap in catastrophic coverage will receive 50% discount on brand name drugs this year. Over 1 million seniors in ‘doughnut hole’ received $250 checks in 2010 Consumers in new health plans will be able to: Receive cost-free preventive services such as screenings, vaccinations and counseling without any out-of-pocket costs. Keep young adults on a parent’s plan until age 26 Choose a primary care doctor, ob/gyn and pediatrician Use the nearest emergency room without penalty

21. Final Thoughts ACA Will Meaningfully Help Those Who Are At Risk For or Need Behavioral Health Services Change Is Complex and Imperfect – It Takes Time New Partnerships and Ways of Doing Business Will Be Needed We Who Serve Others Will Need To Keep Up With The Changes We Need To Keep Our Compass On True North

22. True North For SAMHSA Four Simple Truths: Behavioral Health Is Essential To Health Prevention Works Treatment Is Effective People Recover