Access to behavioral health treatment--services and prescription drugs to address behavioral health conditions--is important because of the harmful consequences of untreated conditions, which may result in worsening health, increased medical costs, negative effects on employment and workplace performance, strain on personal and social relationships, and possible incarceration. Behavioral health treatment can help individuals reduce their symptoms and improve their ability to function. However, research suggests that a substantial number of individuals with behavioral health conditions may not receive any treatment or less than the recommended treatment, even among those with serious conditions. For example, in 2013, SAMHSA estimated that there were 3.9 million adults aged 18 or older with a serious mental illness who perceived an unmet need for mental health care within the last 12 months. This number includes an estimated 1.3 million adults with a serious mental illness who did not receive any mental health services. One potential barrier to accessing treatment is shortages of qualified behavioral health professionals, particularly in rural areas. SAMHSA noted that more than three-quarters of counties in the United States have a serious shortage of mental health professionals. Behavioral health treatment includes an array of options ranging from less to more intensive, and may include prevention services, screening and assessment, outpatient treatment, inpatient treatment, and emergency services for mental health and substance use conditions. Prescription drugs may also be included as part of treatment for either substance use or mental health conditions. See table 1 for information on select behavioral health treatments. In addition to these treatments, other supportive services exist for behavioral health conditions that are designed to help individuals manage mental health or substance use conditions and maximize their potential to live independently in the community. These supportive services are multidimensional--intended to address not only health conditions, but also employment, housing, and other issues. For example, they include recovery housing--supervised, short-term housing for individuals with substance use conditions or co-occurring mental and substance use conditions that can be used after inpatient or residential treatment. The Centers for Medicare & Medicaid Services (CMS)--a federal agency within the Department of Health and Human Services (HHS)--and states jointly administer the Medicaid program, which finances health care, including behavioral health care, for low-income individuals and families. States have flexibility within broad federal parameters for designing and implementing their Medicaid programs. States may use Medicaid waivers--which allow states to set aside certain, otherwise applicable federal Medicaid requirements--to provide health care, including behavioral health treatment, to individuals who would not otherwise be eligible for those benefits under the state's Medicaid program. For example, states may use waiver programs to target residents in a geographic region or to target individuals with particular needs, such as those with serious mental illness. States may also choose different delivery systems to provide benefits including behavioral health treatment to Medicaid enrollees, such as FFS or managed care. Some states with managed care delivery systems may elect to "carve out" behavioral health benefits, i.e., contract for them separately from physical health care benefits. For example, some states contract with limited benefit plans, which are managed care arrangements designed to provide a narrowly defined set of services. Similarly, states with FFS delivery systems may choose to contract with separate companies to administer behavioral health benefits than those administering physical health care benefits.Our previous work has noted that while using a separate plan to provide mental health services may control costs, it can also increase the risk that treatment for physical and mental health conditions will not be coordinated. A variety of sources provide funding for behavioral health treatment in public programs. Medicaid is the largest source of funding for behavioral health treatment, with spending projected to be about $60 billion in 2014. Another significant source of revenue for state BHAs is state general revenues. In contrast to Medicaid, for which payment of benefits to eligible persons is required by law, state general funding for the treatment of uninsured and underinsured residents is discretionary. The extent to which state-funded treatment is provided may depend on the availability of funding. States may also use SAMHSA mental health and substance use block grants to design and support a variety of treatments for individuals with behavioral health conditions. See figure 1 for information on sources of state BHA revenues for mental health in 2013. (Similar figures for substance use were not available.) The number of states that have expanded Medicaid includes the District of Columbia, which we refer to as a state of for the purposes of this report. State BHAs are the agencies responsible for planning and operating state behavioral health systems, and they play a significant role in administering, funding, and providing behavioral health treatment. State BHAs manage behavioral-health-related federal grants and may work with other state agencies--such as state Medicaid agencies--to identify and treat mental health and substance use conditions. State BHAs may contract directly with providers to deliver behavioral health treatments or may contract with county or city governments, which are then responsible for the delivery of treatments within their local areas. State BHAs may also play a role in providing Medicaid enrollees with wraparound services--that is, services that state Medicaid programs do not cover, but that may aid in recovery, such as supportive housing. Nationwide, estimates using data from 2008 to 2013 indicated that of 17.8 million low-income, uninsured adults, approximately 3 million (17 percent) had a behavioral health condition prior to the Medicaid expansion in 2014. Specifically, about 1 million low-income, uninsured adults (5.8 percent) were estimated to have a serious mental illness, while nearly 2.3 million low-income, uninsured adults (12.8 percent) were estimated to have a substance use condition. Underlying these national estimates was considerable variation at the state level. In particular, the percentage of low-income, uninsured adults with a behavioral health condition ranged from 6.9 percent to 27.5 percent. Similarly, the percentage of low-income uninsured adults with serious mental illness ranged from 1.3 percent to 13 percent, while the percentage with a substance use condition ranged from 5.9 percent to 23.5 percent. See figure 3 for the states with the highest and lowest estimated percentages of low-income, uninsured adults with a serious mental illness or substance use condition. See appendix I for state-by-state estimates. Of the 3 million low-income, uninsured adults estimated to have a behavioral health condition, nearly half--approximately 1.4 million people, or about 49 percent--lived in the 22 states that had not expanded Medicaid as of February 2015, compared with the approximately 1.5 million people in the remaining 29 states that had expanded Medicaid. The estimated prevalence of behavioral health conditions overall among low-income, uninsured adults was about 17 percent, on average, in both expansion and non-expansion states. State BHAs in the non-expansion states we examined offered a variety of behavioral health treatments for low-income, uninsured adults. These states identified priority populations to focus care on adults with the most serious conditions and used waiting lists for those with more modest behavioral health needs. The non-expansion states we examined--Missouri, Montana, Texas, and Wisconsin--offered a range of behavioral health treatments-- inpatient and outpatient services and prescription drugs--for low-income, uninsured adults. These states used community mental health centers, state institutions, and contracts with providers to deliver treatments, and used a variety of sources, such as state general funds, federal block grants, and Medicaid to fund them. For mental health and substance use conditions, outpatient services that these states offered included evaluation and assessment, visits with medical providers, and individual, family, and group counseling. Treatments also included emergency care, and in most of these states, partial hospitalizations and inpatient psychiatric care for mental health conditions. For substance use conditions, these states also offered detoxification and residential treatment. These states generally made prescription drugs available to uninsured adults as part of the treatment for behavioral health conditions. For example, Missouri, Texas, and Wisconsin included medication- assisted treatment for substance use conditions, and all four of the selected non-expansion states offered prescription drugs for mental health conditions. In addition to treatment, the non-expansion states also offered some supportive services, such as peer support or housing services, for uninsured adults. For two of the states we examined--Wisconsin and Texas--the availability of specific services for behavioral health may vary throughout the state. In particular, the responsibility for administering and providing treatment was divided between the state BHA and local entities, which receive both state and local funding to provide behavioral health treatment. funding for behavioral health, which they can use to fund services of their choosing. The Wisconsin BHA identified a core list of 30 services for behavioral health that it promotes and encourages counties to provide, but the official noted that it may be difficult for a single county to provide all of the services on the list. For example, the Wisconsin BHA reported that about a quarter of counties provided medication-assisted treatment for individuals with substance use conditions in 2013. As another example, Texas offers opportunities for local mental health authorities to compete for funding for specific types of services, such as housing. Local entities are counties for Wisconsin and local mental health authorities in Texas. In contrast, the state BHA is solely responsible for administering behavioral health treatment in Missouri and Montana. coverage. In addition, Wisconsin obtained a Medicaid waiver effective January 2014 that made certain childless adults up to 100 percent of the FPL eligible for Medicaid, which gave them access to Medicaid-covered services and prescription drugs, including behavioral health treatments. Officials from the non-expansion states we examined noted initiatives relevant to low-income, uninsured adults, such as improving crisis response and coordinating care for individuals involved with law enforcement. Texas officials noted that 24 of the 33 local mental health authorities have a facility-based crisis option to treat individuals experiencing a crisis and that they would like to provide the remaining local mental health authorities with similar facilities, which are intended to avoid inpatient care. In Wisconsin, behavioral health treatment includes mobile crisis services to respond to individuals in the community experiencing a crisis. A Wisconsin official told us that there were legislative efforts underway to expand these services, particularly in rural areas. Missouri has hired community mental health liaisons to facilitate access to behavioral health services for individuals who are in frequent contact with law enforcement. The selected non-expansion states established priority populations for providing behavioral health treatment to those with the most severe behavioral health needs. For the states we examined, priority populations for mental health treatment included individuals with serious mental illness and those presenting in crisis. Similarly, all the non-expansion states we examined identified priority populations for receiving treatment for substance use conditions. Specifically, pregnant women and individuals abusing drugs intravenously were among the priority groups that the states identified to receive treatment. As part of setting priorities for those with the most serious behavioral health needs, the non-expansion states included specific eligibility requirements based on diagnosis or impairment, in addition to financial status, for behavioral health treatment for the uninsured. In Montana, individuals aged 18 to 64 diagnosed with a severe, disabling mental illness, and incomes up to 150 percent of the FPL may qualify for the state-funded Mental Health Services Plan. Montana officials told us that their Mental Health Services Plan does not provide treatment to individuals with more moderate behavioral health needs, but that these individuals may get some treatment through community-based "drop-in" centers. In Texas, local mental health authorities are required to provide services to adults with diagnoses of schizophrenia, bipolar disorder, or clinically severe depression, and may, to the extent feasible, provide services to adults experiencing significant functional impairment due to other diagnoses. Individuals who are not members of the identified priority groups are generally not eligible to receive treatment. Three of the states we examined maintained waiting lists for individuals with more modest needs for behavioral health treatment. Texas officials said that they triage individuals eligible for behavioral health treatment, and those with less urgent needs may have to wait. In some cases, individuals may receive a lower level of care than recommended while waiting for treatment due to resource limitations. For example, an individual might receive medication-related services and crisis services as needed, but not recommended rehabilitation services. Texas officials told us that there were over 5,000 individuals waiting for behavioral health treatment as of February 2013, although they were able to move most individuals off waiting lists when they received additional state funding for fiscal years 2014 and 2015. They described this additional funding as "historic," and they reduced the number of individuals waiting to fewer than 300 as of May 2014. In addition to reducing the waiting list, Texas moved 1,435 adults from lower levels of care to more appropriate levels in 2014. A Wisconsin official told us if county agencies run out of funding, they are permitted to establish waiting lists or may only serve clients with Medicaid coverage. The official said there were 1,656 individuals waiting for substance use treatment and 242 individuals waiting for a specific mental health service in 2013, prior to Wisconsin extending Medicaid coverage to certain low-income adults through a Medicaid waiver.all services if they run out of funding, but must always provide emergency care. The official said that county agencies do not have to provide Missouri officials said there were 3,723 individuals on the waiting list for substance use treatment as of January 2015. Missouri state BHA officials noted that Missouri does not maintain a waiting list for mental health services. Selected states generally managed behavioral health benefits for newly eligible Medicaid enrollees separately from physical benefits through carve-outs or separate contracts. Health plans for these enrollees were generally aligned with Medicaid state plans, resulting in comparable behavioral health benefits for newly eligible and existing Medicaid enrollees. According to state officials, expanding Medicaid has increased the availability of behavioral health treatment, although some access concerns continue. The expansion states we examined generally managed behavioral health benefits separately from other benefits through carve-outs or separate contracts. Four of the six states included in our study--Connecticut, Maryland, Michigan, and West Virginia--explicitly carved out or contracted for the administration of behavioral health services or prescription drugs separately from other services and drugs. For example, in Maryland, specialty mental health services have been carved out of its contracts with managed care organizations (MCO) since 1997 and are paid for on an FFS basis. Michigan carved behavioral health services out of its MCO contracts and moved them to a limited benefit plan in 1998. Connecticut, which has an FFS delivery system for newly eligible enrollees, contracted with a behavioral health benefits manager to administer behavioral health services. The other two states contracted with MCOs to provide both physical and behavioral health coverage, but several of these MCOs chose to subcontract with behavioral health benefits managers. See table 2 for information on the expansion states' coverage designs for behavioral health services and prescription drugs. State officials cited various reasons for separately managing behavioral health benefits, including concerns about access, ensuring appropriate expertise, and state law. Maryland officials told us they chose to carve out mental health services and pay for them on an FFS basis through a behavioral health benefits manager due to concerns about beneficiary access under managed care, particularly for more intensive services generally not covered by commercial insurance plans. Maryland also separately carved out mental health prescription drugs on an FFS basis, which officials said was so that the state could align policies for these drugs with the behavioral health benefits manager administering the mental health services carve-out. In Kentucky, three of the five Medicaid MCOs subcontracted behavioral health benefits to a behavioral health benefits manager. Kentucky officials told us that one of the MCOs decided to subcontract these benefits due to a lack of expertise in managing behavioral health prescription drugs. Michigan and Connecticut officials told us that state laws prohibit their Medicaid programs from using certain utilization management techniques for some types of behavioral health prescription drugs. Michigan officials told us that given the lack of utilization management tools available, they decided to pay for behavioral health prescription drugs on an FFS basis rather than to include these drugs in the state's limited benefit plan contracts. Providers have raised concerns about managing behavioral health benefits separately from medical benefits, and some states reported making efforts to make sure care is coordinated. Behavioral health physician groups we spoke with told us that paying for physical and behavioral health care separately makes it difficult to assess the total cost of care for individuals with behavioral health conditions, and does not provide adequate incentives to make investments in one type of care that may reduce costs for another type of care. For example, provider groups said that lack of investment in substance use services could lead to additional costs for emergency medical care. In addition, one physician group raised concerns about managing behavioral health services separately from prescription drugs because of the potential for conflicting utilization management policies to create barriers to care. For example, a pharmacy benefits manager may require outpatient counseling as a condition for receiving medication-assisted treatment for substance use, but such counseling may not be covered by the managed care company that authorizes behavioral health services. The four states we spoke with that explicitly manage behavioral health care separately--Connecticut, Michigan, Maryland, and West Virginia--noted that they were engaged in care coordination efforts. Connecticut officials said that although they have multiple contracts for benefits administration, all claims are processed through a single vendor and the state uses these data to help identify individuals in need of care management. Michigan officials said that the state has implemented claims sharing between the MCOs managing physical health care and the limited benefit plans that manage behavioral health benefits. Michigan is currently working on a demonstration program with CMS that would allow for real-time sharing of clinical information for individuals dually eligible for Medicare and Medicaid. Maryland included financial incentives related to physical health, such as the number of patients who have an annual primary care visit, in the contract with its behavioral health benefits manager. West Virginia officials said that they were working on creating a comprehensive managed care plan for newly eligible Medicaid enrollees that would offer both physical and behavioral benefits, including prescription drugs, under the same plan in order to better coordinate care. In addition, Michigan, Maryland, and West Virginia have established Medicaid health homes to coordinate care for individuals with chronic As of January 2015, conditions, including behavioral health conditions.Connecticut was in the process of developing Medicaid health homes for individuals with behavioral health conditions. Five of the six expansion states included in our study chose to align their alternative benefit plans with their Medicaid state plans--providing at least the same benefits for newly eligible enrollees as existing enrollees received under the state plan--and some states made alignment-related coverage changes. Connecticut, Kentucky, Maryland, Michigan, and Nevada aligned their alternative benefit plans with their Medicaid state plans, which required these states to add to their alternative benefit plans any state plan benefits that were not already included. For example, Michigan officials said they added additional recovery-oriented substance use services, such as peer support services, to the alternative benefit plan to match existing state plan benefits. Although not required, states may also choose to add benefits to their Medicaid state plans to match their alternative benefit plans. As part of the alignment process, Kentucky chose to extend substance use treatment--previously limited to children under 21 and pregnant and postpartum women--to all Medicaid enrollees under its state plan to match the substance use coverage in its alternative benefit plan. West Virginia did not align its alternative benefit plan with its Medicaid state plan, but there were no differences in coverage for behavioral health services and associated prescription drugs. Officials we interviewed from the six expansion states generally reported that Medicaid expansion had resulted in greater availability of behavioral health treatment, and changes were greater in states without previous coverage options for low-income adults. Kentucky, Nevada, and West Virginia did not have any coverage available for low-income childless adults prior to expansion and primarily relied on their states' BHAs to provide behavioral health treatment for the uninsured. Kentucky officials reported a substantial increase in the availability of behavioral health treatment for individuals when they enrolled in Medicaid, as individuals were no longer limited to what state-funded community mental health centers could provide, and could access additional services, such as peer support services. Nevada officials stated that while the state BHA and the state's Medicaid program provide the same array of behavioral health treatments, some uninsured individuals experienced long delays in receiving care prior to enrolling in Medicaid coverage under the expansion. West Virginia officials cited the increased availability of prescription drugs. West Virginia's BHA did not pay for prescription drugs for uninsured individuals except in limited circumstances, whereas newly eligible Medicaid enrollees gained access to the full array of covered drugs under the state's Medicaid program. In contrast, Connecticut, Maryland, and Michigan all had limited coverage available for certain low-income adults prior to expanding Medicaid that paid for some behavioral health services and prescription drugs. For example, Maryland's Primary Adult Care program paid for outpatient mental health and substance use services and prescription drugs for adults up to 116 percent of the FPL. Officials from these three states reported that while the availability of treatment increased when individuals enrolled in Medicaid, the changes were small; for example, officials from two states reported that Medicaid beneficiaries had a greater choice of providers.experienced larger changes; for example, Michigan officials reported that enrollment in Medicaid had resulted in improved access to substance use services, including access to case management, which officials said could help individuals live more successfully in the community. Individuals not enrolled in these coverage programs Officials from the expansion states in our study did report some access concerns for new Medicaid enrollees due to behavioral health professional shortages, which they attempted to address in a variety of ways. Officials from all six states cited behavioral health workforce shortages as a challenge to providing behavioral health treatment for low- income adults in their states. The state officials specifically highlighted shortages of Medicaid-participating psychiatrists and psychiatric drug prescribers. Nevada officials reported conducting a secret shopper study of psychiatrists in the state's Medicaid program in 2014 that found only 22 percent of Medicaid-enrolled psychiatrists were accepting new Medicaid patients. Maryland and Connecticut officials reported difficulties providing Medicaid enrollees with access to certain prescription drugs used for medication-assisted treatment for substance use conditions due to a lack of physicians willing to prescribe these drugs for Medicaid enrollees. States reported taking several steps to address workforce shortages, such as providing reimbursement for telehealth services, expanding the types of providers who can receive reimbursement for providing services in Medicaid, and using peers and other non-licensed providers to deliver some services under the supervision of licensed providers. Michigan chose to address behavioral health needs of its new Medicaid enrollees by leveraging its primary care workforce. The state used a health assessment tool as part of the enrollment process for its alternative benefit plan that included questions about potential behavioral health conditions. Health assessment information was conveyed to each enrollee's primary care provider, who could then address any behavioral health needs or refer for specialty care if needed. State officials reported additional concerns regarding access to behavioral health treatment due to expansion-related budget reductions for state BHAs, which fund treatment for uninsured individuals, as well as non-Medicaid covered treatments for Medicaid enrollees. Officials from four of the six expansion states we spoke with--Connecticut, Kentucky, Michigan, and Nevada--reported that their state's BHA budget had been reduced based on the expectation that uninsured individuals would enroll in Medicaid. For example, Michigan officials reported that the state reduced its state general fund contribution for its BHA by about 10 percent ($116 million) from fiscal year 2013 to fiscal year 2015, and Nevada reported a $33 million reduction to its BHA budget over fiscal years 2014 and 2015 related to the expansion. Some state officials raised concerns about having enough state BHA funding for individuals who would remain uninsured or underinsured following expansion, including individuals who are eligible but do not enroll or re-enroll in Medicaid, immigrants, and certain individuals under 65 who are enrolled in Medicare because of a disability. Officials from two states also expressed concerns about the adequacy of funding for wraparound services--services that are not covered by their states' Medicaid programs, such as supportive housing--for Medicaid enrollees. Officials from the four states that reported BHA budget reductions noted that there were subsequent adjustments to their budgets to lessen the impact of the reductions based on these concerns. For example, Michigan's BHA received an additional $25 million for fiscal year 2015 to address behavioral health needs in certain populations that remain ineligible for Medicaid. (See appendix II for more information on expansion-related changes in state BHA budgets.) Despite concerns about budget reductions, officials from two states noted that when additional Medicaid funds from the expansion were considered as part of the behavioral health budget, much more funding was available overall. Other continuing access problems mentioned by state officials related to inpatient behavioral health treatment. Nevada officials said that lack of psychiatric inpatient capacity has led to patients who were considered a risk to themselves or others being kept in emergency rooms for up to several days before they could secure a bed in a psychiatric hospital. Officials said that an average of 90 to 110 patients per day, predominately Medicaid enrollees, were waiting in emergency rooms. Nevada has made efforts to address the problem, for example, by sending teams of psychiatrists to emergency rooms to assess psychiatric patients to determine whether they could be discharged and treated on an outpatient basis. However, officials noted that discharging such patients carries risks and has led to poor outcomes in the past. Kentucky officials said that they were working to expand capacity for residential treatment programs for substance use. Officials said that given Medicaid's exclusion of payment for treatment for adults at "institutions for mental disease" with 16 or more beds, they were encouraging providers to design any new residential substance use programs to be under that limit. However, they noted that doing so can prevent providers from taking advantage of economies of scale and may make it more difficult to operate some residential treatment programs shown to be effective for substance use conditions. Officials said that the state was working to develop alternatives to inpatient care for Medicaid enrollees, such as transitional housing combined with an intensive outpatient program. We provided a draft of this report to the Department of Health and Human Services for review. HHS provided technical comments, which we incorporated as appropriate. As arranged with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days after its issuance date. At that time, we will send copies of this report to the Secretary of Health and Human Services and other interested parties. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staff members have any questions, please contact me at (202) 512-7114 or yocomc@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Major contributors to this report are listed in appendix III. Estimated number of low-income, uninsured adults Percent (standard error) Number Total 20.3 (2.6) 68,495 337,414 24.9 (4.6) 20.9 (2.7) 19.4 (2.2) 12.5 (1.2) 12.0 (2.0) 13.0 (3.6) 15.7 (1.2) 12.2 (1.8) 21.1 (4.5) 23.7 (3.6) 16.5 (1.4) 27.5 (3.1) 19.2 (3.1) 15.9 (3.3) 15.8 (2.3) 20.3 (2.4) 19.9 (3.8) 21.2 (1.6) 19.5 (4.4) 16.4 (1.7) 17.2 (2.4) 21.0 (3.2) 20.6 (3.3) 21.5 (3.3) 20.4 (4.2) 6.9 (2.3) 13.2 (2.5) Estimated number of low-income, uninsured adults Percent (standard error) Number Total 12.6 (1.6) 85,555 679,004 14.4 (2.1) 27.5 (4.1) 27.4 (2.1) 18.1 (2.7) 20.7 (3.3) 18.9 (2.0) 24.9 (4.0) 22.3 (2.7) 17.5 (3.4) 22.0 (2.5) 13.7 (1.0) 16.6 (3.2) 23.4 (4.6) 23.4 (3.8) 18.1 (2.3) 21.4 (3.8) 19.6 (3.4) 16.7 (0.4) 16.9 (0.5) 16.6 (0.5) State expanded Medicaid as of February 2015 error) 9.8 (2.3) error) 11.7 (1.9) Percent (standard error) 1.2 (0.5) 3,251 10.1 (3.5) 21.9 (4.5) 6.3 (1.7) 17.0 (2.3) 2.4 (1.1) 9.8 (1.8) 13.1 (1.9) 3.5 (1.4) 4.0 (0.6) 9.7 (1.0) 1.2 (0.3) 2.8 (1.0) 9.7 (1.9) 0.5 (0.3) 7.4 (2.8) 7.2 (2.4) 6.0 (0.8) 11.9 (1.1) 2.2 (0.5) 3.6 (1.2) 9.4 (1.8) 0.8 (0.5) 6.4 (2.1) 18.1 (4.3) 3.3 (1.7) 11,231 11.3 (2.1) 15.8 (3.3) 3.4 (1.4) 3.9 (0.7) 13.9 (1.3) 1.3 (0.3) 50,730 13.0 (2.7) 19.9 (2.8) 5.4 (1.5) 6.4 (2.3) 13.4 (2.5) 0.7 (0.3) 3.3 (1.3) 12.8 (2.8) 0.2 (0.2) 6.1 (1.5) 13.4 (2.0) 3.7 (1.2) 6.2 (1.5) 16.3 (2.2) 2.2 (0.9) 8.8 (3.0) 6.1 (2.9) 16.0 (3.6) 4.9 (2.2) 1.6 (1.2) 16.0 (1.3) 2.0 (0.5) 11.7 (2.6) 2.1 (1.0) 7.3 (1.0) 7.2 (1.5) 11.1 (1.6) 1.9 (0.7) 6.1 (1.6) 12.9 (2.2) 1.8 (0.7) 6.5 (1.9) 16.3 (2.9) 1.9 (0.8) 5.5 (1.6) 15.8 (3.2) 0.6 (0.3) State expanded Medicaid as of February 2015 error) 6.9 (2.8) error) 16.1 (2.8) Percent (standard error) 1.5 (0.6) 5.2 (1.8) 17.9 (4.0) 2.7 (1.5) 1.3 (0.8) 5.9 (2.1) 0.4 (0.3) 6.1 (1.7) 10.7 (2.1) 3.6 (1.2) 3.1 (0.9) 10.4 (1.5) 0.9 (0.4) 3.1 (1.1) 13.1 (1.9) 1.8 (0.6) 2,688 10.5 (3.1) 19.7 (3.8) 57,470 11.1 (1.5) 20.5 (1.7) 4.2 (0.9) 7.5 (1.7) 12.4 (2.2) 1.7 (0.8) 6.8 (1.9) 15.9 (2.9) 2.0 (0.9) 6.2 (1.3) 15.4 (1.9) 2.7 (0.9) 6.9 (2.5) 23.5 (3.8) 5.5 (2.3) 33,594 10.4 (2.4) 16.0 (2.5) 4.1 (2.0) 5.6 (1.9) 14.5 (3.1) 2.6 (1.3) 8.5 (1.8) 15.9 (2.5) 2.4 (1.0) 4.2 (0.6) 10.5 (0.8) 1.0 (0.3) 7.4 (2.0) 10.6 (2.3) 1.4 (0.7) 1,041 10.2 (3.2) 15.7 (3.9) 2.5 (1.2) 7.3 (2.4) 16.9 (4.2) 0.8 (0.4) 36,787 10.1 (3.0) 18.0 (3.2) 4.7 (1.8) 9.1 (2.1) 12.7 (1.9) 3.6 (1.4) 22,092 11.3 (3.8) 15.4 (3.7) 7.9 (2.4) 12.4 (2.3) 0.7 (0.3) 17,750,507 1,029,529 523,286 9,022,176 506,243 8,728,331 5.8 (0.2) 2,272,065 5.8 (0.3) 1,190,927 5.8 (0.3) 1,082,313 12.8 (0.3) 13.2 (0.5) 12.4 (0.5) 1.9 (0.1) 2.0 (0.2) 1.7 (0.2) Not reported because percentage was estimated with low precision. However, totals include data for states that are not reported in this table. For the purposes of this report, we refer to the District of Columbia as a state. Totals include data for states that are not reported in this table. Numbers of low-income uninsured adults in expansion and non-expansion states with a given type of behavioral health condition may not sum to the total because the percentages used to calculate these numbers were rounded. Connecticut officials reported that the budget for its state behavioral health agency (BHA) was reduced in fiscal years 2014 and 2015. However, amid concerns about the effects on providers, the BHA absorbed some of these reductions. In fiscal year 2014, the BHA's budget was reduced by $15.2 million, but the agency absorbed this reduction rather than decreasing the amount of grant funding for providers for the treatment of uninsured and underinsured individuals. In fiscal year 2015, there was a $25.5 million reduction in the BHA's budget. The BHA used a one-time $10 million appropriation from the Connecticut legislature plus other sources to limit the reduction in grant funding for providers to $5.4 million. Kentucky officials reported that the BHA's budget was reduced by $9 million in fiscal year 2014. However, one-time funds allowed the BHA to avoid reducing funding for its contracts with community mental health centers. In fiscal year 2015, there was a $21 million decrease in the BHA's budget, which was taken from contracts with community mental health centers. Maryland officials reported that the state has not reduced state general fund support for its BHA due to the expansion of Medicaid. Michigan officials reported that the state reduced the budget for its state BHA due to the Medicaid expansion, but then added some funds based on concerns about certain populations that remain ineligible for Medicaid. Michigan officials reported that state general revenue contributions to its BHA were reduced by $116 million from fiscal year 2013 to fiscal year 2015 (from $1.153 billion in fiscal year 2013 to $1.037 billion for fiscal year 2015). Michigan officials reported that their legislature had appropriated an additional $25 million for fiscal year 2015 to address the needs of individuals ineligible for Medicaid, such as individuals younger than 64 enrolled in Medicare based on a disability and commercially insured children. Nevada officials reported that the state reduced the budget for its BHA, but used one-time funds to ease the transition from state funding to Medicaid reimbursement for substance use providers in fiscal year 2014. Nevada officials reported a reduction of $33 million in the BHA's budget in fiscal years 2014 and 2015. Nevada officials said one-time funds totaling about $690,000 were used in fiscal year 2014 for substance use service providers to maintain services during the transition from state funding to Medicaid reimbursement. West Virginia officials reported that its charity care fund, which reimburses its network of comprehensive community behavioral health centers for the care of the uninsured, was funded at about $15.4 million per year in fiscal years 2013, 2014, and 2015. Officials said that the governor's fiscal year 2016 budget had recommended a $3 million reduction in the charity care fund due to Medicaid expansion. In addition to the contact named above, William Black, Assistant Director; Manuel Buentello; Hannah Locke; Drew Long; Hannah Marston Minter; and Emily Wilson made key contributions to this report.

Summary:
Research has shown that low-income individuals disproportionately experience behavioral health conditions and may have difficulty accessing care. Expansions of Medicaid under PPACA raise questions about states' capacity to manage the increased demand for treatment. Additional questions arise about treatment options for low-income adults in non-expansion states. GAO was asked to provide information about access to behavioral health treatment for low-income, uninsured, and Medicaid-enrolled adults. This report examines (1) how many low-income, uninsured adults may have a behavioral health condition; (2) options for low-income, uninsured adults to receive behavioral health treatment in selected non-expansion states; and (3) how selected Medicaid expansion states provide behavioral health coverage for newly eligible enrollees, and how enrollment in coverage affects treatment availability. GAO obtained estimates of low-income adults who may have a behavioral health condition from the Substance Abuse and Mental Health Services Administration. GAO also selected four non-expansion and six expansion states based on, among other criteria, geographic region and adult Medicaid enrollment. GAO reviewed documents from all selected states, and interviewed state Medicaid and BHA officials to understand how uninsured and Medicaid-enrolled adults receive behavioral health treatment. The Department of Health and Human Services provided technical comments on a draft of this report, which GAO incorporated as appropriate. Nationwide, estimates using 2008-2013 data indicated that approximately 17 percent of low-income, uninsured adults (3 million) had a behavioral health condition, defined as a serious mental illness, a substance use condition, or both. Underlying these national estimates is considerable variation at the state level. The estimated number of low-income, uninsured adults with behavioral health conditions was divided evenly between states that did and did not subsequently expand Medicaid under the Patient Protection and Affordable Care Act (PPACA). Behavioral health agencies (BHA) in four selected non-expansion states offered various treatment options for low-income, uninsured adults, focusing care primarily on those with the most serious behavioral health needs. To do so, BHAs in all four selected states established priority populations of those with the most serious behavioral health needs. Also, BHAs in three of the four states maintained waiting lists for adults with less serious behavioral health needs. Six selected states that expanded Medicaid generally managed behavioral health and physical health benefits separately for newly eligible enrollees, and state officials reported increased availability of behavioral health treatment, although some access concerns continue. Four of the six selected states explicitly chose separate contractual arrangements for behavioral health and physical benefits. Officials from all six selected states said that enrollment in Medicaid increased the availability of behavioral health treatment for newly eligible enrollees. Officials also reported some ongoing access concerns, such as workforce shortages.