For Mental Health Services, Would ACA Repeal Turn ‘Warm Handoff’ into Cold Shoulder?

One of the few points of bipartisan agreement in Congress last year was finding ways to support mental health services. The 21st Century Cures Act passed in Congress and signed by the President just last month took steps to integrate mental health into primary care services, expand the pool of providers and improve the interactions between the mentally ill and the criminal justice system. But the current debate around repeal of the Affordable Care Act (ACA) and the Medicaid expansion that came with it could have the unintended consequence of setting back these efforts.

CCF’s Adam Searing reported earlier this year on health providers who are using savings from the reduction in uncompensated care costs (achieved mainly through ACA Medicaid expansion) and new grants available to community health centers under the ACA to develop new ways of integrating treatment for mental health issues into existing primary health care settings. Now he reflects on what cuts could mean.

What do we know generally about how the ACA has affected mental health services?

Adam Searing: Safety-net providers in states that have accepted the federal funding available for Medicaid expansion under the ACA are experiencing a positive ripple effect, where increased insurance coverage rates among patients and thus greater financial security for safety-net institutions are translating into better care. In some research we did last summer we found that safety-net providers in states that expand Medicaid are delivering more services and better-coordinated care than what is available in states rejecting the expansion.

Of particular interest is the effect of Medicaid expansion on attempts to integrate behavioral health services with primary health care — long a thorny issue for safety-net providers. Recent research has shown that the ACA has increased access to behavioral health services, especially in Medicaid expansion states.

Tell us about some of the progress that’s been made.

Adam Searing: Kentucky is a great case study. Family Health Centers (FHC), a seven-site system based in Louisville, Kentucky, has hired new behavioral health staff and located them in all but the smallest, most rural center in the system. Clinical social workers and clinical psychologists are now part of the health care team in participating centers and are supported by other social workers and case managers.

How does this help?

Adam Searing: It allows them to conduct an immediate behavioral health consultation if the primary care provider requests one during a health visit. Known as a “warm handoff,” this integrated approach does not require the patient to make a second appointment and allows the team to develop a care plan on the spot. Patients who need more specialized mental health services can be referred to a psychiatric nurse practitioner on staff or to a community mental heath service center.

In addition, FHC has contracted with attorneys in a medical-legal partnership to address civil legal issues such as housing, family law, and special needs plans for children. Addressing these “outside the clinic” social factors can have a substantial benefit on a patient’s physical and mental health.

What role does this ACA play in making this happen?

Adam Searing: Two ways. FHC is using HRSA grants that are available under the ACA. But the centers also find that having more paying patients under the Medicaid expansion gives them more latitude to hire behavioral specialists.

I understand that Nevada has also made progress in this area. What are they doing there?

Adam Searing: The Community Health Alliance (CHA) in Nevada has hired new clinical psychologists, clinical social workers, and psychiatric nurse practitioners to enable behavioral health services to be delivered on site. Like the Louisville centers, CHA uses the expanded staff to support warm handoffs.

In addition, CHA has gone beyond site-specific behavioral health integration to develop a new “Center for Complex Care,” based in part on a model from Cherry Street Health Services in Grand Rapids, Michigan.

How does that model work?

Adam Searing: Qualifying patients at CHA have the option of receiving more personalized and team-based care at this new center, which has integrated teams consisting of a primary care provider, clinical social worker, care coordinator, and medical assistant. Psychiatric nurse practitioners and other clinical staff are available as needed. These providers have fewer patients to manage and are given time to work as a team to help the most complex patients with their needs.

Chuck Duarte, the CEO of CHA, says this would not have been possible without the Medicaid expansion. “We would have had to be much more cautious with so many more uninsured patients” he told me back in June.

CHA cares for newly Medicaid-eligible patients who had been served at state mental health facilities and those in the community who were not eligible for Medicaid before expansion.

Could these innovations in behavioral health integration expand to other states?

Adam Searing: Not without the sort of financial support that comes with the ACA. These approaches simply would not have taken place without the grant funds available, and the decisions by Kentucky and Nevada to accept federal funding to expand Medicaid coverage. These factors offered providers the financial security and incentive not just to extend the health services they were already providing before the Medicaid expansion but also to jump in with both feet and try interesting approaches to the difficult problem of addressing their patients’ behavioral health needs while delivering primary care.

What will happen to existing programs if Congress repeals the ACA without providing similar support?

Adam Searing: One of the under-appreciated effects of the ACA, especially in states that accepted federal funds to expand Medicaid, is this innovation happening in health care delivery. When you think about it, this effect shouldn’t be so surprising. States implementing the ACA and its Medicaid expansion since 2014 are receiving infusions of new federal health funding that average in the billions of dollars. In many states this rivals or exceeds federal spending on highways and even defense.

Increasing financial stability for safety net providers, usually operating on the edge, has translated into a willingness to try new approaches to care and collaboration with new partners. Remove this funding through repeal of the ACA, and states lose not only access to care for millions of people but providers also lose much of this new freedom to experiment and innovate. In the end, we would have more uninsured people, greater uncompensated care costs and a less effective and efficient health system. It’s hard to imagine how anybody would be better off under that scenario.