As Congress correctly understands, universal insurance coverage is a foundational issue for national health reform. Without it, the implementation of other key features of reform, such as broad-based health promotion and prevention interventions, will not be successful.

To understand the potential impact of universal insurance coverage in our field, it is important to understand the uninsured and underinsured populations who have mental health and substance use conditions, and that national health reform address these insurance deficits.

Universal coverage is a principal concern in the current US healthcare debate. 

Adults. The number of uninsured adults is estimated to be about 37 million, or about 20 percent of the adult population under age 65 (persons 65 and older are covered by Medicare). Recent research indicates that one in three of these adults, or about 12 million, have mental or substance use conditions. 

This rate is considerably higher than the annual prevalence of these conditions in the adult population, which is estimated at approximately 25 percent, and almost double the national uninsurance rate among adults. Another factor to be considered here is that an estimated 7-8 million of these adults are thought to be undocumented immigrants.

Due to increased unemployment, the number of uninsured is expected to grow as unemployed people lose employer-paid insurance benefits. The luckiest among these will keep their insurance, but pay far higher costs through their 18-month COBRA extension and the higher full-premium costs later. However, despite some relief as a result of the American Recovery and Reinvestment Act of 2009 (ARRA), many of the unemployed are unlikely to be able to pay these high costs, resulting in up to 20 million more being uninsured over the next two years.

Adults: People with mental and substance use conditions are often underinsured by Medicare and Medicaid due to coverage exclusions and limitations:

• No coverage for disabled persons collecting Social Security (SSDI or SSI) if their disability resulted from a substance use condition—about 2.4 million.
• No coverage for Americans in jail or prison—about 2.4 million. Yet, mental and substance use conditions have grown dramatically among this population in the last decade.
• Insufficient coverage for interventions that promote better health and disease prevention.
• Interrupted coverage due to monthly changes in income and disability status.

Even for the 100 million adults covered by private insurance, underinsurance is to be a problem for about 6 percent, or 6 million people, who are affected by serious mental health and substance use conditions.  Once again, the problem is that private insurance generally offers insufficient benefits for health promotion and disease prevention and insufficient coverage for long-term care of serious mental health and substance use conditions.   

Co-morbidity with Physical Illnesses

Sadly, mental and substance use conditions often co-occur with long-term physical illnesses. Today, public mental health clients die 25 years prematurely due principally to untreated chronic illness. Depression is frequently correlated with diabetes and heart disease, while substance use exacerbates physical problems ranging from dental health to liver disease.

Conditions are everything from dental health to liver disease.  Of great importance for health reform, providing needed treatment for mental and substance use conditions can also reduce the overall costs associated with long-term physical illnesses.

Taking Action

Ronald W. Manderscheid, PhD, worked for more than 30 years in the federal government on behavioral health research and policy. He is the Executive Director of the National Association of County Behavioral Health and Developmental Disability Directors as well as a member of Behavioral Healthcare's Editorial Board.