Money, mental health care, Medicaid and what works for NC

There is no money in mental health. That’s something we hear all the time. But in the world of health care, it’s clear there’s lots of money. All you have to do is look at Duke Medicine and UNC Healthcare. New medical practices are springing up everywhere. There’s clearly a buck to be made.

But not in mental health. We have vastly different systems for physical health and mental health. All the talk about the mental health system in The N&O and newspapers across the nation focuses primarily on the public mental health system.

But mental illness and addiction are equal opportunity maladies. They strike rich and poor, young and old, famous and anonymous. Any comprehensive approach to treating mental illness must address huge gaps in both private and public insurance coverage that put optimal treatment out of reach for far too many Americans.

Ten years ago, along with my colleagues Diana Perkins and David Penn, I helped create a program for persons with emerging psychotic disorders that put into practice what researchers had been learning about optimal care. In the planning stages, we were told we needed a business plan. I puzzled over that statement: How do you make a business plan when your business is caring for people who live in poverty? That’s what I was used to in our clinic that provided care for people who lived with schizophrenia.

We got start-up capital from two N.C. foundations: the Duke Endowment and Kate B. Reynolds Charitable Trust. We almost didn’t make it. In our business plan, we had projected clinical revenue, and after our first year, we weren’t meeting our targets. But we were doing important work, and we persisted.

In its 10th year, OASIS continues to provide excellent care for young people with emerging psychotic disorders.

In 2005, we designed services at OASIS to fit in with the state’s newly reformed mental health system, and one of our key services fit well with the original form of community support. However, as the program evolved, we moved toward a private practice model because most of our referrals did not qualify for Medicaid and many had private insurance.

That’s when I learned how private insurance funded mental health. There were great differences among health plans. Some paid for family therapy; others did not. Some had huge coinsurance expectations, requiring families to pay for care out of pocket. Our clinic administrator took significant time to tease out what each plan covered. We knew our program would not survive if it had an unsustainable business model.

A major goal of our early-intervention program was to avoid the disability that often accompanies severe mental illness. However, the goal of avoiding disability creates a conundrum: If our mental health system is funded primarily by Medicaid, what happens to the people who don’t qualify for it? Medicaid has strict eligibility criteria, and most young people don’t meet them.

Why doesn’t private insurance fund optimal outpatient mental health care for illnesses like schizophrenia? We know what works, and medications alone are not nearly enough. There are numerous effective psychosocial treatments and helpful social supports, that in combination with medications, offer a meaningful chance at recovery. But are they available? The recent debate over private insurance covering behavioral services for autism highlights the problem: Private insurers don’t want to pay for psychosocial treatments. They shift costs to the public system.

The Affordable Care Act has already made some changes that support better care for mental illness. Young people can stay on their parents’ private insurance until age 26. Because most severe mental illnesses emerge in adolescence and early adulthood, this change ensures insurance coverage during a high-risk time frame.

The ACA also requires that coverage of mental illnesses be on par with that of physical illnesses.

Despite these improvements, mental health care remains like our school systems before Brown v. Board of Education – separate but not equal. If we are to fix the mental health system, we need to look beyond Medicaid. We also need to call on private insurers to modernize their coverage and to pay for person-centered, effective medical and psychosocial treatment options.

With good treatment and community support, people with mental illness can live full and productive lives. We owe it to them to identify and address the gaps in both private and public systems.

Barbara B. Smith is a clinical assistant professor in the UNC School of Social Work.