Financing Adolescent Mental Health Services

254 Brief communication FINANCING ADOLESCENT MENTAL HEALTH SERVICES To the editor: Stephen King correctly points out [Vol. 2, No. 1:122-129] that large numbers of adolescents from impoverished families suffer from untreated mental health problems. The innovative programs for adolescents and young adults described in his article offer great hope for improving access to mental health services, but financing those services remains problematic. While approximately 85 percent of adolescents age 10 through 18 years have some form of private or public health insurance coverage, the breadth and depth of that coverage is often quite limited.1 Mental health benefits under private health insurance are often subject to one or more of the following restrictions that are separate from other medical coverage: a limited allowance for inpatient mental health care; a limited number of outpatient visits; a ceiling on total dollars reimbursed; lower coinsurance rates than apply for other services,and, frequently, separate copayments or deductibles.2 One recent survey of employer-based health insurance plans found that nearly half of all surveyed employers placed limits on the number of visits that would be reimbursed .3 The same survey found that only 15 percent of employers provided plans that covered the services of psychologists and psychiatric social workers as well as psychiatrists. While states may require private insurers to offer coverage for mental health services, employers who self-insure their workers and dependents are exempt from those regulations. Until recently, state Medicaid programs provided very restricted coverage of mental health services. In addition, Medicaid eligibility was frequently restricted to adolescents from only the poorest families. Congressional mandates enacted in 1989 and 1990 fundamentally altered Medicaid eligibility criteria and access to mental health services for adolescents. Because of these changes, significant opportunities now exist for improving access to mental health services for adolescents from poor families. The first change, adopted in the Omnibus Budget Reconciliation Act (OBRA) of 1989, eliminated most state Medicaid coverage limitations on treatment of health conditions identified during the course of an Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) examination. In addition, states Journal of Health Care for the Poor and Underserved, Vol. 2, No. 2, Fall 1991 ___________________________________________________________255 are now required to offer periodic examinations to Medicaid-eligible children and adolescents at intervals that meet reasonable standards of medical practice. These provisions were designed to facilitate the diagnosis and treatment of physical and mental health conditions and to remove state-imposed limits on available services, including mental health services. To date, states have been somewhat cautious in implementing provisions of this law due to concern over budget implications. Advocates for children and adolescents can help by monitoring state Medicaid agencies and by working with state legislatures and executive branches to ensure that the new EPSDT provisions are properly implemented. Over the last decade, Congress has passed a number of bills incorporating incremental expansions of Medicaid eligibility. But with few exceptions, poor adolescents have not benefited from these reforms. This changed with enactment of the Omnibus Budget Reconciliation Act of 1990. This law requires that states extend Medicaid coverage to all children born after September 30,1983, with family incomes up to 100 percent of the federal poverty level. Under this law, states are required to phase-in coverage for children and adolescents one year at a time until the year 2002, when all children and adolescents under age 19 and living below the poverty level will be eligible for Medicaid. Together, these recently enacted laws should greatly improve access to mental health services for low-income adolescents. Legislation now being considered in Congress would speed up implementation of the expanded eligibility provisions for adolescents. This would permit up to two million poor adolescents to gain easy access to needed physical and mental health services. —Paul W. Newacheck, Dr.P.H. Associate Professor of Health Policy Institute for Health Policy Studies University of California, San Francisco 1388 Sutter Street, 11th Floor San Francisco, California 94109 REFERENCES 1. Newacheck PW, McManus MA. Health insurance status of adolescents in the United States. Pediatrics 1989 Oct;84(4):699-708. 2. U.S. Congress, Office of Technology Assessment. Adolescent health. Volume III: Crosscutting issues in the delivery of health...