By John Jacobi
As the Biden administration works to improve health access and transform health delivery, behavioral health reform should be at the front of the queue.
People with severe mental illness and opioid use disorder are dying young for lack of routine health care. Much of the work that needs to be done in behavioral health is developed or developing at the state level. But the Biden administration has a powerful tool for encouraging state-level innovation in the § 1115 Medicaid waiver process.
Reform through state waivers
Section 1115 waiver authority permits the Department of Health and Human Services to approve pilots and demonstrations if they are found likely to promote the objectives of the Medicaid program. Waivers, which do not require Congressional or formal regulatory enactments, permit relatively rapid cycling of innovation, in contrast to the lumbering pace of legislative or regulatory change.
While applications for waivers originate with the states, presidents have set the agenda by signaling what categories of waivers will be looked upon favorably, offering the administration the ability to put its stamp on the development of care for low-income and disabled people.
Elections matter
The Clinton administration was the first to welcome § 1115 waivers as a means of expanding health care through state demonstrations and pilots on a large scale. The Bush administration shifted the focus to cost containment and personal responsibility measures, including cost sharing. The Obama administration shifted back toward clinical practice innovation and support for safety net providers. The Trump administration welcomed waivers with “with draconian restrictions on Medicaid recipients” including work requirements and other measures seemingly designed to restrict access to the program.
President Biden ran on a platform of expanding, not restricting, access to Medicaid. He specifically addressed the need to improve access to mental health and substance disorder care. To follow this up, the administration should encourage § 1115 waiver applications that promise health care transformation and improved access for vulnerable populations.
Waiver innovation can change — and extend — lives
Demonstrations and pilots under waiver authority have been transformational in other areas. The dramatic shift in long term care from institutions to home and community-based care was enabled by states’ use of waiver authority. States recognized that their residents strongly preferred to stay in the community and out of institutions. States therefore employed waivers to refine and expand programs for home-based services.
As with long term care, so with behavioral health care. Behavioral health care waivers implemented over the last decade have allowed states to: obtain federal match for services in “institutions of mental disease,” overcoming fifty years of resistance to such federal support; expand covered services to include peer support and services to ease transitions from institutional to community care; and expand income eligibility for some persons with behavioral health diagnoses.
More innovative care for people with mental illness or substance use conditions has been piloted in recent years and is ready for waiver support. And support is due; by almost any measure the health care delivery system has failed these patients in a way that would be shocking if experienced by almost any other diagnostic group. The years of life lost and illness suffered, not due directly to mental illness or substance use, but due to medical illness and a failure of medical health care, constitute a morally undeniable demand for change.
What might waiver applications propose?
States, health systems researchers, and clinical practices are hardly unaware of the disparity in health access and medical care experienced by people with serious mental illness and substance use disorders. Several categories of system improvement are ready for adoption, although pilots and investigational waivers could help establish their suitability for Medicaid payment.
- Integration of modalities of care. One of the great frustrations of clinicians treating people with serious mental illness or substance use disorder (who might be the same patients, due to substantial rates of comorbidities) is the difficulty of connecting their patients with primary physical care. While providing all mental health, substance disorder, and primary care under the same roof is now the clinical standard of care, legal and regulatory barriers stand in the way, and implementation has not yet become widespread. Medicaid payment pilots to jump-start this integration could dramatically improve outcomes.
- Expanded coverage of non-medical services to support recovery. Many patients with serious behavioral health conditions are stymied in their search for wellness and recovery due to social and social service barriers. Creating — and bolstering — programs such as supported housing and peer support can facilitate engagement in treatment and integration into society. Although there has been resistance to extending Medicaid to cover non-clinical services, these services often offer the clearest path to wellness; CMS has recently recognized the merits of support for such non-medical care.
- Coordinated “whole person care” for people with high clinical and social needs. In this instance, best practices of care also make the best economic sense. People with serious, long-term behavioral health needs are often the highest users of Medicaid services. The coordination of these services and associated social services could transform the person from a “high utilizer” to a person on the road to recovery and social integration. California’s nascent Whole Person Pilot, which is enabled by a § 1115 waiver, may show the way for innovative treatment.
The Biden administration can implement health reform for the neediest populations by clearly signaling a welcome for progressive waiver applications. Let’s turn the page and move Medicaid forward.
John Jacobi is Dorothea Dix Professor of Health Law & Policy at Seton Hall University School of Law.
