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Promoting universal coverage

February 1, 2009
by Ronald W. Manderscheid, PhD
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Become an advocate for universal health insurance

Even though many states are considering or implementing universal health insurance initiatives, the economic environment will make them a tough sell in state capitols. Hence, it is very important to be able to make clear arguments in favor of universal coverage.

A principal motivation is the recognition that the usual form of healthcare for uninsured persons—the emergency room—is among the most expensive offered to any segment of our population. For an uninsured person with a mental illness, the ER has become the new inpatient ward. Stories of people spending five to six days in ERs are becoming common, as other alternatives simply are not available.

A second, related, factor is the realization that an uninsured person has no regular provider—primary care or mental health. No one is available to coordinate care or facilitate early interventions so that the ER is not needed, but as a last resource.

State universal coverage initiatives vary considerably. Some are truly universal, seeking to provide insurance for everyone. Others do not claim to be universal but seek to expand coverage to an additional group (e.g., persons between 200 and 300% of the federal poverty level). So although not truly universal initiatives, they do aim to make healthcare coverage more widespread. Universal coverage doesn't mean the same type of health insurance benefits for everyone.

Recently, the National Alliance on Mental Illness and the National Council for Community Behavioral Healthcare released a landmark paper, Coverage for All: Inclusion of Mental Illness and Substance Use Disorders in State Healthcare Reform Initiatives. This report has focused the mental health and substance use care fields' attention on state universal coverage initiatives and the mental health and substance use care benefits they aim to provide.

The paper highlights some startling data. Fully one-third of uninsured persons have a mental or substance use condition, and fully one-third of persons with these conditions have no health insurance. Looked at either way, these figures are double the uninsured percentage (17%) in the general population.

Because these numbers are so large, an urgent need exists for us to promote state universal coverage initiatives vigorously. And when we promote them through testimony, advocacy, or other means, we need to argue strenuously for good mental health and substance use care benefits.

Minnesota has an exceptional model to emulate. The state developed “safety net” insurance for its uninsured population. This insurance is intended to cover persons who do not qualify for other coverage (e.g., Medicaid). Typically, the benefits are more restrictive than Medicaid but are sufficient to assure that the insured person has access to primary care and some specialty care if needed. The Minnesota plan aims to make healthcare truly universal by meeting the needs of those without insurance, and it offers good mental health and substance use care benefits. As a result of this initiative, the rate of uninsurance in Minnesota is approaching zero, as has also happened in Massachusetts.

Placed in a broader perspective, state universal coverage initiatives extend other national examples of universal coverage for specific populations: Medicare for the elderly, Medicaid for the poor, and VA care for our veterans. Although we may not always think of these programs as universal coverage, they truly do cover entire subpopulations.

So when your state considers universal coverage, become an active and vocal advocate for good mental health and substance use care benefits (Parity is a very good place to start); testify about the importance of universal health insurance (Everyone should have an equal opportunity for good healthcare); and mobilize your friends and neighbors (They, too, could be uninsured). An oft-stated issue in universal coverage advocacy is that those with insurance don't care much about those without it. Clearly, we don't want this to be stated about us!

To help you in this work, you can access the NAMI-National Council paper at, and you can access additional information at scholar.cfm (State universal coverage initiatives were a primary topic at the 2008 American College of Mental Health Administration Santa Fe Summit). Our hats are off to NAMI and the National Council for undertaking this important work!

Ronald W. Manderscheid, PhD, currently Director of Mental Health and Substance Use Programs at the consulting firm SRA International, Inc., worked for more than 30 years in the federal government on behavioral health research and policy. He is a member of Behavioral Healthcare's Editorial Board.

To contact Dr. Manderscheid, e-mail

Behavioral Healthcare 2009 February;29(2):32