The provisions of the Patient Protection and Affordable Care Act (ACA) of 2010 that took effect in 2014 were expected to result in a substantial expansion of health insurance coverage in the United States and increased access to behavioral health services. The increase in coverage was achieved through a combination of expanded eligibility for public programs, such as Medicaid, and increased access to private insurance coverage. Private insurance was expanded through an employer mandate, subsidies for the purchase of individual coverage, and the creation of health insurance exchanges (also known as marketplaces) through which individuals and small employers could purchase coverage. The ACA was expected to expand insurance coverage to a projected 37 million previously uninsured Americans and approximately 29% of them have a behavioral health disorder.1,2 People who were uninsured prior to the ACA had a higher prevalence rate of behavioral health conditions than the overall population.3
The ACA expands Medicaid coverage to adults below 138 percent of the Federal Poverty Level (FPL) (i.e., $15,856 for an individual or $26,951 for a family of three in 2013). However, a June 2012 Supreme Court decision allowed states to opt out of Medicaid expansion.4 As of April 2015, 29 states, including the District of Columbia, were participating in Medicaid expansion, 6 states were undecided, and 16 states were not participating.5,6 In states that do not expand Medicaid or are undecided, many individuals may remain uninsured. This report compares estimates of Medicaid-eligible uninsured individuals with a behavioral health disorder living in Medicaid expansion, non-Medicaid expansion, and undecided states.
This report used data drawn from the 2009 to 2013 National Surveys on Drug Use and Health (NSDUHs), a nationally representative survey of the noninstitutionalized population in the United States conducted annually by the Substance Abuse and Mental Health Services Administration (SAMHSA). NSDUH collects detailed information on the use of alcohol and illicit drugs, mental and substance use disorders, and insurance coverage. The analytic sample includes uninsured nonelderly individuals aged 18 to 64 with a behavioral health disorder (unadjusted pooled N = 215,200). All estimates are weighted to account for NSDUH’s complex survey design and to make the estimates nationally representative.
Family income indicators were used to categorize the sample into two groups based on percentage of the FPL threshold to be consistent with the key eligibility criteria in the ACA: (1) income less than 138 percent of the FPL (i.e., Medicaid expansion eligible); and (2) income equal to or greater than 138 percent of the FPL (i.e., health insurance exchange eligible). Any mental illness (AMI) among adults aged 18 or older was defined as having had a diagnosable mental, behavioral, or emotional disorder (excluding developmental and substance use disorders) of sufficient duration to meet diagnostic criteria specified within the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) during the year prior to the survey interview.7 NSDUH also asks respondents questions to assess symptoms of substance use disorders (substance dependence or abuse) during the past year using the criteria in DSM-IV.7 It includes such symptoms as withdrawal, tolerance, use in dangerous situations, trouble with the law, and interference in major obligations at work, school, or home during the past year. The indicator for substance use disorder (SUD) refers to whether the respondent has alcohol use or any illicit drug use disorder. A behavioral health disorder in this report refers to whether the individual has either AMI or SUD. It is possible for an individual to have both AMI and SUD, so the indicators of AMI and SUD are not mutually exclusive.
Approximately 10.9 million uninsured adults aged 18 to 64 had a behavioral health disorder (Table 1); of these, 5.3 million (or 48.3 percent) were individuals with incomes below 138 percent of the FPL who were eligible for Medicaid expansion. The remaining 51.7 percent of the individuals were those eligible to participate in the marketplaces. Among the 5.3 million eligible for Medicaid expansion, 50.8 percent (or 2.7 million) lived in a Medicaid expansion state, 33.9 percent (or 1.8 million) lived in a non-Medicaid expansion state, and 15.3 percent (or 808,000) lived in an undecided state. Thus, almost half of all uninsured Medicaid expansion–eligible individuals with a behavioral health disorder may not have had access to health insurance because of their state’s decision not to expand Medicaid.
Table 1. Uninsured adults aged 18 to 64 who had any behavioral health disorder (any mental illness or substance use disorder) in the past year, by state expansion status (estimated population in thousands): 2009 to 2013
An estimated 7.9 million uninsured adults aged 18 to 64 had AMI (Table 2). Of these, 48.9 percent (or 3.8 million) were eligible for Medicaid expansion, and 51.1 percent (or 4.0 million) were eligible for health insurance exchanges. Of the 3.8 million Medicaid expansion-eligible adults, 50.3 percent (or 1.9 million) lived in an expansion state, 33.5 percent (or 1.3 million) lived in a non-Medicaid expansion state, and 16.2 percent (or 624,000) lived in an undecided state. A significant portion of uninsured adults with any mental illness may not have access to health insurance coverage.
Table 2. Uninsured adults aged 18 to 64 who had any mental illness in the past year, by state expansion status (estimated population in thousands): 2009 to 2013
An estimated 5.1 million uninsured individuals aged 18 to 64 had a substance use disorder (Table 3). Out of the 5.1 million individuals, 46.9 percent (or 2.4 million) were eligible for insurance as a result of Medicaid expansion, and 53.1 percent (or 2.7 million) were eligible for the health insurance exchanges. Among the 2.4 million Medicaid expansion eligible adults, 52.3 percent (or 1.2 million) lived in an expansion state, 34.1 percent (or 814,000) lived in a non-Medicaid expansion state, and 13.6 percent (or 324,000) lived in an undecided state. As with individuals with AMI, a significant portion of uninsured adults with a substance use disorder may not have access to health insurance coverage.
Table 3. Uninsured adults aged 18 to 64 who had a substance use disorder in the past year, by state expansion status (estimated population in thousands): 2009 to 2013
The Medicaid expansion provision of the ACA was designed to increase health insurance coverage among individuals with low incomes and limited access to employer-sponsored health insurance. Given the high prevalence of behavioral health conditions among the uninsured, the decision by some states not to participate in the Medicaid expansion suggests that a significant portion of individuals with a behavioral health disorder will remain uninsured. Mental health and substance use treatment were designated by the ACA as being among the 10 essential health benefits.
Estimates presented in this report showed that 49.2 percent of all uninsured Medicaid expansion–eligible individuals with a behavioral health disorder are unlikely to have access to health insurance because of their state’s decision not to expand Medicaid. One of the primary objectives of the ACA is to protect individuals from large and unexpected out-of-pocket health care expenses.8 Absent health insurance coverage, these expenses may constitute an important financial barrier to individuals receiving treatment and recovery services.
Ali, Mir M., Mutter, Ryan, & Teich, Judith L. (2015). The CBHSQ Report: State Participation in the Medicaid Expansion Provision of the Affordable Care Act: Implications for Uninsured Individuals with a Behavioral Health Condition. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality.