There are many challenges and obstacles to assuring people have access to quality mental health and substance use treatment. If a vote was taken as to what is the one most constant and difficult challenge that besets the mental health and substance use treatment fields, my vote would be the challenge of adequately funding services. Whether we consider the lack of parity of behavioral health services with health insurance coverage or obtaining the needed public funds to address the ever-increasing demand to treat individuals with mental illnesses and/or addictive disorders, access to quality care is continually jeopardized. In the public arena (federal, state or local governments), there are revenue crises and defending a budget is a major challenge. Gaining new dollars for funding behavioral health services is becoming even more difficult in light of all the competing causes for public dollars.
Medicaid has become a major source of financing behavioral health services (especially mental health care). States and providers have come to depend on Medicaid dollars to fund community-based care. The psych/rehab option has been utilized to fund an array of services that have been essential to people with serious mental illnesses attaining and sustaining a level of successful recovery in the community. More expensive inpatient treatment has been avoided for many individuals in lieu of more cost effective and evidence based services being rendered in the community. Institutional care, once the primary approach to addressing the needs of people with serious mental illnesses, is now viewed as the antithesis of recovery in light of the successes people are experiencing by realizing “a life in the community”. However, Medicaid as a funding source for these important and critical services is perpetually threatened. States and providers find themselves in various positions of losing federal funds and dealing with additional documentation because waivers are being reevaluated and messages come out of CMS and other agencies that rehab and case management services may not be funded in the future. Consumers and families feel vulnerable because, many times, they find themselves living “on the edge” of losing the very services they need to make a life for themselves or their loved ones.
Much of the ongoing debate around Medicaid funding a range of behavioral health services is centered on defining the appropriate “mission” of Medicaid. Some within CMS have taken the position that Medicaid should be viewed as health insurance and only those services deemed “medically necessary” should be funded. This line of thinking then leads to a conclusion that services and programs that are focused on providing psych/rehab or recovery services do not fit in a “medically necessary” model. Interventions that address acute illnesses and short-term medical conditions are much easier to justify within a medically necessary framework. In addition, CMS is under great and constant pressure (OMB, Congress, etc.) to find a way to control expenditures. Clearly and narrowly defining its mission is one approach. As long as CMS presses the issue of medical necessity as a guiding principle for its mission, the mental health and substance use treatment fields are going to be on the defensive in making the argument that rehab and recovery services fit that mission. So, how can we address this issue in a way that overcomes this impasse of “medical necessity”? Here are a couple of thoughts: