This is the text of the keynote presentation given for the Virtual Ability Mental Health Symposium April 27th.

1. Will you treat ME?
Funding mental health care treatment - Now and Under the Affordable Health Care Act"
Mental Health Symposium
Good Morning. It is indeed an honor to be asked to speak at today’s mental health
symposium. As my introduction as mentioned, my “hats” are many. As a nurse practitioner
working in a free clinic, I worked with many clients who struggled with issues related to
mental health, addiction, and chronic health conditions. As a professor of nursing, I have
taught many classes on the topic of health care ethics, justice and health care reform. This
morning, I would like to talk about the topic of our current situation with funding mental
health care treatment. *
In order to understand the way in which mental health care has been regulated and funded
in the United States, it’s important to understand a bit of historical context regarding
mental health treatment. While this is a fascinating topic (which I’m really interested in)
full of horrific abuses (think “Bedlam” - the Royal Bethlem Hospital in London – one of the
oldest and most infamous asylums), the most relevant historical context for today’s talk is
the notion that historically, there has always been a separation of mental health care from
all other “traditional” areas of medical treatment. *
As you can imagine, it’s not a far stretch that this “split”, this separation and idea that
mental health care treatment is different from the treatment of the body, led separation in
how we pay for mind treatments and body treatments. Historically, insurance companies
have separated out mental health care treatments and placed separate limitations and
instituted independent requirements for mental health coverage. *
These sorts of limitations have led many who advocate for mental health care to perceive
grave injustice in our health care system. When I’m teaching about such things, we talk
about this in great depth. The United States has one of the most expensive health care
systems in the world, with health care costs accounting for about 17.6% of the gross
domestic product in 2010 – holding steady from 17.7% of the GDP in 2009. *
This means that American’s typically spend $8233 on health care per capita per year. This
is twice as much as what folks spend in relatively rich European countries like France,
Sweden and the United Kingdom, places thought to have decent health care. The
breakdown on this graph shows you where we typically spend it – you can see that this
graph doesn’t show mental health care. Now there are a lot of reasons that the USA health
care is so expensive. Rich countries across the board will spend more than poor countries,
but even accounting for the relative “wealth” of America – health care spending is
extremely high. Statistically, we know that hospital spending is higher than in similarly
developed countries, spending on administration costs in America is particularly high
(about 7%), some prices are higher and that in some cases the American health care system
provides more (not necessarily better) health care. For example, in America there are
more C-Sections, more total knee replacements, more coronary angioplasties, more
tonsillectomies, and more CT and MRI scanners than in similar countries. *

2. What does not appear to be the case is that mental health care spending is much different
from what is spent world wide on mental health care. I’m sure this doesn’t shock or
surprise many of you. I doubt that any of you who have had any experience with the
mental health care system believes that there is so much mental health care happening that
this is single-handedly driving the American health care system to it’s knees. Many of you
might be acutely aware of the fact that access to mental health care professionals is worse
than for other health care providers. 89.3 million Americans live in federally designated
mental health professional shortage areas. In fact, the United State’s mental health care
spending is right on par for what other countries tend to budget and spend in the provision
of mental health care services. *
When we look at how the mental health care dollar is typically spent in America, we can see
that outpatient treatment and prescription drugs are the top expenditures. Recent studies
indicate that increasing numbers of people are being treated for depression, but various
studies have shown that the care is substandard. Medications seem to be the mainstay,
with little follow-up. General practitioners prescribe about 3/5th of all psychiatric drugs
and what is considered the “gold standard” – drugs and therapy – has become increasingly
uncommon. Thus, even though many more people are being treated for mental health
conditions, overall spending for mental health only grew by 31% while other medical
services grew much more. Medicaid, the crucial safety net for those with the most serious
of mental health illnesses only increased its expenditures for mental health 1% from 1996
– 2006, while expenditures for other conditions increased approximately 25%. *
Whenever we consider what we spend, and what we pay for as a society, we are
determining what we value and what we prioritize as important and meaningful.
Sometimes we don’t often think about the “big picture” this way, but that’s really what is
happening. I’ll give you an example from my nurse practitioner practice several years ago.
There is a medication called Zyban (bupropion). This particular medication is an
antidepressant that is also very useful in helping patients with smoking cessation. With the
patient population that I worked with at the time, I could get the medication covered for
the patient if the patient said that they were interested in stopping smoking, but I could not
get the medication paid for if the patient had depression. Now this was a free clinic,
operating under a different set of rules (free samples, etc.), but you can see how these sorts
of situations set up issues related to justice and fairness and equity. It’s the same
medication. It’s the same patient. It is one person that I’m to care for – yet the “system”
will pay for one condition – thereby in effect saying one “matters” and will not pay for the
other – does the other condition not matter as well? *
These issues of equity and justice and “parity” (or on par, equal to other things) came to
the forefront in the early 1990’s. In 1992, two senators – Senator Domenici and Danforth
authored the nation’s first bill targeting mental health parity. Mental health advocates
argued that health insurance companies should no longer be allowed to have separate and
different deductibles, co-pays and levels of services for mental illnesses, but that mental
illness coverage should be “on par with” physical or surgical conditions. At the time, the

3. Senators found that only 21% of insurance policies provided for inpatient mental health
treatment, and over 60% of insurance policies explicitly excluded severe mental illnesses.
These gaps in health insurance coverage left millions without adequate coverage in the
event of significant and severe mental health crises. The bill garnered quite a bit of press
and raised awareness of the issues related to mental health parity. Unfortunately, the bill
failed.But, Senator Dominici didn’t give up and in 1996, he partnered with Paul Wellstone
for the Mental Health Parity Act (MHPA), which did successfully pass albeit with gaping
exceptions and lots of loopholes. Many called it a “toothless” victory, but it was, I believe,
the beginning of the movement in this country that set the stage for at least some
beginnings of mental health parity. The “toothless” aspect of the law is that it does not
require insurance companies to provide mental health benefits. However, if the insurance
company does provide mental health benefits, they have to be in line with the coverage
provided for medical or surgical conditions *
One of the most interesting issues going forward will be how the recently passed (and
upheld by the Supreme Court) healthcare reform legislation – the Patient Protection and
Affordable Care Act (PPACA) also known in the media as “Obamacare” will affect mental
health care in the United Sates. Perhaps surprisingly, there is a lot in the Affordable Care
Act that offers great potential for the expansion of mental health services, as well as hope
for better integration within the context of the American health care system as a whole and
improvement in the quality of care being offered. Historically, most people in the United
States with significant mental health illnesses have not had private insurance coverage.
They have either had to obtain coverage through some kind of publically funded program
or they remained uninsured. Like it or not (and many do not like it), one of the main
thrusts of the Patient Protection and Affordable Care Act as well as the Health Care and
Education Reconciliation Act of 2010 is the expansion of health insurance coverage to
about 32 million Americans. Access is going to be expanded in several different ways
including the extension of coverage to dependents until the age of 26 (very important given
that many significant mental health conditions are often diagnosed by this age), the
abolishment of pre-existing conditions (often a significant concern for those with mental
health conditions) and by the creation of health insurance “exchanges”. An exchange is
going to be a place (or website) that an individuals or an employer can go to for the
purpose of purchasing health insurance. Each state can choose whether to create and run
their own exchange or to have the federal government create and run the exchange for
them. While the exchanges are currently under development, the exchanges will have to
standardize the language in the plan offerings so that the consumers (YOU!) can look at the
plans offered and make good comparisons. All plans sold in the exchange must include 10
essential benefits, which will include coverage (and this is significant) of mental health
services and substance disorder services. *
The Affordable Care Act will extend Medicaid eligibility if a state elects to extend coverage.
For those who might not be as familiar with what Medicaid actually is, Medicaid is a state
based program that provides health coverage to lower income people, families with
children, the elderly and people with disabilities. One disappointing (my opinion only)
portion of the Supreme Court ruling last summer was that the Supreme Court ruled that the

4. federal government couldn’t restrict Medicaid funds if a state decided not to expand
Medicaid coverage. This means that each state can decide whether they want to expand
Medicaid or not. The map before you shows what each state is leaning towards doing as of
a week ago.
If your state is expanding, that means that more people will be covered under Medicaid as
the Affordable Care Act extends Medicaid to those with incomes below 138% of the federal
poverty guidelines. Over 15 million uninsured adults could become newly eligible for
Medicaid across all states. *
This is where the news gets (I think) really good. Remember the Dominici & Wellstone
Mental Health Parity Act? It still stands. It’s now paired with the Affordable Care Act. So
all those mental health services need to be on par with, as good as medical conditions. The
very act that many described as “toothless”, “worthless” and “useless” because at the time it
didn’t mandate mental health coverage is predicted in combination with the Affordable
care Act to bring truly bring mental health parity to millions of Americans. That’s because
now mental health care services are mandated to be covered as the part of the 10 essential
services and because of the mental health parity act, the coverage will have to be on par
with all other coverage *
The Affordable Care Act also aims to improve and increase community and home based
services for people with disabilities under Medicaid. Community First Choice Option
provides assistance for people with significant disabilities who need assistance in their
daily lives. Now with mental health parity – significant psychiatric disabilities must be
included as well. Another Medicaid state option created by the Affordable Care Act that
may be of great benefit to those with psychiatric disabilities is the option to fund a “health
home” - programs that provide comprehensive care coordination and other supportive
services for people with chronic health conditions. These are options that states can seek
to expand and fund services for their Medicaid clients. *
I want to conclude today’s keynote discussion with ethics and notions about what we value
and who we are as a society. There are many who still believe that mental illnesses are not
medical conditions that should be accorded the same treatment that one could expect for a
physiologic condition such as appendicitis or cancer. However, growing research indicates
that there is a physiologic component to many mental illnesses. Mental illness actually
results in more fatalities per year than HIV/AIDS. Increased costs of providing coverage
would most likely be offset within several years by increased productivity and decreased
usage of other medical services *
Given the Affordable Care Act’s complexity and scope, it will likely take some years as all
the provisions become interpreted and implemented. In conclusion, I would argue that we
are entering a new era with guarded optimism for how we envision the funding and
provision of mental health services in this country. While there certainly is much to be
determined in the coming years, including funding of provisions of the Affordable Health
Care Act, the status of mental health care funding in this country has never looked better.

5. This is not to say that there is not a lot of work to be done. However, great strides are being
made in the areas of expansion of coverage, mental health parity and provision of services.
There is great reason to be hopeful.
I’ve included a list of references for this talk as well as some helpful websites. Please don’t
hesitate to contact me should you have any questions. Thank you for your kind attention
during today’s presentation!
References:
Krisberg, K. (2012). Health Law Raising U.S. Mental Health Parity to the Next Level.The
Nation’s Health.Sept. 2012.
Mauldin, J. (2011). All Smoke and No Fire? Analyzing the Potential Effects of the Mental
Health Parity and Addiction Equity Act of 2008. Law and Psychology Review 35; 193-207.
Mechanic, D. (2011). Behavioral Health and Health Care Reform. Journal of Health
Politics, Policy & Law 36 (3): 527-531.
Siegwarth, A. &Koyanagi, C. (2011). The New Health Care Reform Act and Medicaid:
New Opportunities for Psychiatric Rehabilitation. Psychiatric Rehabilitation Journal 34
(4); 277-284.
Smith, D., Lee, D. & Davidson, L. (2010). Health Care Equality and Parity for Treatment
of Addictive Disease. Journal of Psychoactive Drugs 42 (2); 121-126.
Helpful websites:
• http://www.healthcare.gov/law/
• http://www.healthcare.gov/using-insurance/low-cost-care/medicaid/
• http://www.cbpp.org/cms/index.cfm?fa=view&id=3819
• http://www.oecd.org/