Manderscheid.jpgRon Manderscheid, PhD
Executive Director, NACBHDD/Adjunct Professor, JHSPH

As the shadows of fall loom larger, concerns about the reform implications of the Affordable Care Act (ACA) still remain. At the same time, some very practical operational steps that will be necessary to accomplish the major goals of this landmark legislation are now overtaking these philosophical concerns. Here, I would like to identify some of these practical steps that will be necessary to effect the health insurance expansion mandated through Medicaid and the Health Insurance Exchanges.

First, I want to provide a quick overview. The ACA will offer new health insurance coverage to 32 million adults who are currently without insurance. It has been estimated that about half of these new enrollees will receive coverage through Medicaid and half through the Exchanges. Further, we have estimated that about one-third of these new enrollees will have pre-existing mental or substance use conditions, a total of about 10.5 million persons. Of this number, we also have estimated that about 60% will become Medicaid enrollees.

The 32 million newly insured will be subdivided into two groups. The first subgroup, the Medicaid expansion, seeks to cover all uninsured adults up to 133% of the Federal Poverty Level (FPL) who are not already currently eligible for Medicaid. The second subgroup includes those above 134% of the FPL. For this latter subgroup, those up to 400% of the FPL will be eligible for a sliding-scale subsidy to pay part of their health insurance premiums.

What are the very practical steps that will be necessary to effect these changes? They will include:

Consumer Information Exchanges:These entities will develop and make available consumer-friendly information on Medicaid and the Health Insurance Exchanges, and the new coverage being offered under the ACA. At a very concrete level, consumers will receive information to help them evaluate and select appropriate insurance plans. Most states have already set up these entities. The federal government has made funds available, and states have identified entities to perform these functions. Typically, this information will be provided through a web site that has been disseminated widely, as well as through paper documents and media reports. Across the states, a range of public and not-for-profit entities have applied to perform these functions.

Health Insurance Exchanges: Almost all states have already made the decision that they will set up Health Insurance Exchanges. The Exchanges can be either a state agency or a not-for-profit entity. For any states that ultimately do not to create an Exchange, the Exchange will be set up by the U.S. Department of Health and Human Services (HHS). Recently, HHS has offered options that increase the flexibility that states have to implement the Exchanges.

In each instance, the functions of the Exchange will be the same. This entity will set up an insurance bazaar that includes a range of plans from low to high option. Good comparative information will be made available to help people make decisions about the insurance plan that best meets their needs. The Exchanges will also develop an integrated IT mechanism to actually determine a person's (or couple's) eligibility for Medicaid, subsidized insurance, or participation in insurance programs offered through the Exchange, as described below.

Medicaid Program Expansion: This function will be executed either by the State Medicaid Program directly or through the State Health Insurance Exchange. A determination will be needed to specify whether a person was previously eligible for Medicaid, is newly eligible under the ACA, or is eligible for insurance under the Exchange. If they are determined to be newly eligible for coverage under Medicaid, they can be enrolled through the State Medicaid Program or through the Exchange.

Insurance Enrollment Mechanism: The eligibility determination mechanism will be a critical component of the entire process. Ideally, this could be done online with software that links income data with other data that checks eligibility for Medicaid under a prior program. This check will result in a determination of whether the person is newly eligible for Medicaid or for subsidized insurance through the Exchange because of current income, or is already eligible under a prior Medicaid program. In the latter case, the person must be enrolled in the prior program. Some States may already have some of the key elements for this determination process available, e.g., Minnesota, Massachusetts, and Utah; others will need to develop them.

Coordination with Social Service Programs: Although not required by the ACA, it will be exceptionally important to coordinate eligibility for needed social wrap around services at the same time insurance eligibility is determined. Clearly, many of the persons newly enrolled under Medicaid or the Exchanges will need housing, job, and other key support services. If they do not receive these needed services, we can expect that the health services they do receive to be less effective and more costly.

Next steps
First, because of the complexity of each of the major functions described, essential work must be done now to plan for and develop the organizational structures, tools, and software that will be permit smooth enrollment of the newly insured. Most of these mechanisms must be in place by the beginning of 2013.

Second, counties and municipalities must be full partners with the federal government and the states in implementing these functions. Clearly, it is axiomatic that "all health care is local". Counties and municipalities have detailed first-hand experience in working with persons who will become the newly insured; many of these persons already participate in other local social programs.

Third, broad sharing of successful and unsuccessful approaches can greatly facilitate this landmark transition. It is very important that the behavioral healthcare field have mechanisms in place to learn about and disseminate these successful approaches.

These developments are very energizing! Related tasks should be approached with the full commitment, energy, and enthusiasm they actually deserve.

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