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ACA: Certainty of court's decision gives way to new uncertainties about implementation

July 5, 2012
by Alison Knopf
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Now that we know that ACA is constitutional, new uncertainties about implementation of its key provisions are coming to the fore.

Under the ACA, small businesses with fewer than 50 employees do not have to purchase insurance for their workers, so these are the workers who will buy it on the exchanges, with federal health insurance subsidies available for all workers whose household incomes fall under 400 percent of the FPL. Some lower-wage workers may even qualify for Medicaid under terms of the expansion, particularly if they have children.

About 15 million currently uninsured people will be able to take advantage of the states’ health insurance exchanges; these people are expected to sign up on the exchanges, then compare pricing and benefits before making a selection. Within each state, a state-defined “essential benefit package” will help to simplify this process by requiring that a baseline package of health care services be made available in all health insurance policies (employer, exchange, Medicaid) sold in that state.

The federal Department of Health and Human Services says each state’s essential benefit package must include services within the following categories:

·         ambulatory patient services,

·         emergency services,

·         hospitalization,

·         maternity and newborn care,

·         mental health and substance use disorder services, including behavioral health treatment,

·         prescription drugs,

·         rehabilitative and habilitative services and devices,

·         laboratory services,

·         preventive and wellness services and chronic disease management, and

·         pediatric services, including oral and vision care.

 

Parity

Whether a beneficiary receives insurance through Medicaid, the exchanges, or an employer, their policy must include coverage for addiction and mental health treatment, under the ACA and under parity law. However, states have some latitude in determining the levels of care care to be required in their essential benefits package.  

Mark Covall, president and CEO of the National Association of Psychiatric Health Systems, said in a statement that the Supreme Court decision “continues the positive national movement towards ensuring that mental health and addiction are on par with other medical conditions.” However, the chief piece of legislation to enforce parity, The Mental Health Parity and Addiction Equity Act (MHPAEA) passed in 2008, still does not have a “final” set of regulations for implementation, though interim final regulations have been available for some time.

And, while concerns about the enforcement of parity regulations have been temporarily overshadowed by the ACA decision, strong future enforcement of the MHPAEA remains essential if the behavioral health benefits enabled by the ACA are to be fully realized. Otherwise, Covall worries that these benefits could be eroded. If medical and surgical conditions are treated on an inpatient basis; behavioral health conditions must be too, on an equitable basis, under the MHPAEA. Under the ACA, the terms of the parity law are extended to small businesses and individuals, both inside and outside the health exchanges, Covall noted.

Block grants

The Substance Abuse and Mental Health Services Administration (SAMHSA) didn’t wait for the Supreme Court’s decision before making plans to reshape the Substance Abuse Prevention and Treatment (SAPT) block grant starting in 2014. Today, the SAPT block grant pays for the majority of care for low-income individuals, but in 2014, SAMHSA plans to redeploy the grant to pay for wraparound services instead of treatment. This plan has caused concern among some state offices, since there is no guarantee under the ACA that everyone who needs treatment will have either Medicaid or private insurance coverage.  

“While the Supreme Court ruling helps provide some clarity in terms of moving forward with ACA implementation, many questions remain unanswered in terms of the extent to which certain substance abuse services will be covered,” said Rob Morrison, executive director of the National Association of State Alcohol and Drug Abuse Directors (NASADAD).  “For example, what will be included in each state’s essential health benefits package?  What will each state’s Medicaid benchmark plan look like?” In the end, he says, each situation will be different depending on the state.

“As we focus on the SAPT Block Grant through the lens of the ACA, it is important to remind stakeholders that any changes to the program require Congressional discussion and approval,” adds Morrison. Any changes, including those through the SAPT block grant application, should be done in partnership with the states, he says. “And as we have said before, we need to see how implementation impacts state substance abuse systems before considering major changes to the SAPT block grant.”

A NASADAD study of care systems in Maine, Massachusetts, and Vermont showed that the SAPT block grant remains a critical funding source for substance use treatment because so many people who need treatment services will remain uninsured, even under reform. Study findings demonstrate that in three states which have already implemented health care reform, neither private insurers nor Medicaid covered certain services, forcing the states to depend on the SAPT block grant to pay for services including:

·         Residential treatment;

·         ‘Non-medical’ services such as case management, other recovery support services, housing, child care, transportation and employment counseling;

·         Improvements to infrastructure of the state treatment system;

·         Addressing new challenges;

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