ACA Decision: Implications for the Field

The Supreme Court decision has been handed down. The field can now focus and re-dedicate energy and time to preparation for monumental changes that take full effect in 2014. Here’s a brief listing of what you can expect:

1. Coverage for the uninsured expands vastly via the Health Insurance Exchanges established in each state by the State or the Federal government. Americans will be able to shop for insurance coverage in an open and transparent marketplace, able to compare one health insurer to another and able to qualify for subsidies based on their income. For the most part, this population (expected to grow to 15 million Americans) will constitute a market reachable by way of contracting with commercial health insurers, managed care and managed behavioral healthcare organizations.
2. Coverage of the uninsured expands via Medicaid Expansion. The Supreme Court ruled that the only part of the Affordable Care Act that is unconstitutional is the Medicaid expansion, but only to the extent that it is mandated upon states and imposes a penalty (that penalty being forfeit of federal funding for the entire Medicaid program). The mandate and the penalty are unconstitutional. In effect, the Supreme Court decision makes the ACA’s Medicaid expansion an option for states. Many states will continue on the path toward Medicaid expansion in order to relieve the poor of crippling healthcare costs; relieve providers of the burden of uncompensated care; and bolster the numbers of people in Medicaid managed care plans – all of which is a means of keeping the 100% Federal match in 2014 in their states. These states understand that the Federal match is reduced to only 90% by 2019 so the incentives far outweigh the costs. Some reluctant states may wait and see a little longer, curious to learn who is elected President and which party will control Congress later this fall. They’re betting the six month wait may find the Law being repealed though those odds are slim. Medicaid Expansion will produce the most significant impacts for those in the field who have historically focused on the indigent uninsured. Understand that most of the Medicaid expansion will materialize in Medicaid Managed Care Plans so it will in fact be quite a private sector phenomenon. 
3. Block Grants and other grant funding sources will very likely be re-purposed over time to cover the people and services left uncovered by plans covering people under the ACA. For the most part, we can expect that community-based wrap-around services and recovery supports will become the focus of grant funding.
4. Behavioral health benefits will be managed closely. Expanded coverage will be a boon for insurers and providers both yet will require rigorous benefit management in order to make the most of finite resources. Providers must prepare for private sector behavioral healthcare business requirements like credentialing, contracting, eligibility determination, understanding health insurance policies, obtaining prior authorization, and billing for services.
5. Behavioral Medicine – whole health, person-centered care – will expand in order to address the costs associated with people suffering from Multiple Chronic Conditions. Everybody needs to understand that highly integrated delivery systems, collaboration, care coordination and access to health information are absolutely necessary if we hope to “bend” the cost curve.  The opportunity for behavioral healthcare providers is terrific where conditions like obesity and diabetes, heart disease and chronic pain have behavioral components that desperately need attention and cooperation between providers.
6. New partnerships and business models need to be conceived, nurtured and deployed. Behavioral healthcare providers can now dedicated themselves to new partnerships, new affiliations, joint ventures and participation in health and medical home models as well as Accountable Care Organizations (ACOs) and Coordinated Care Organizations (CCOs). The future will about surprising mergers, joint ventures and exciting innovation. Network-based business models will make the most sense for many behavioral health providers. This field needs to look back to the origins and evolution of medical group models, independent practitioner associations (IPAs) and management services organizations (MSOs) for clues as to how small providers can achieve strength in numbers.
7. The market for behavioral healthcare will grow dramaticallyas will the need to recruit and retain a professional workforce. Assuming all stakeholders cooperate in the redesign of the system of care around the country, the need to treat vast swaths of untreated mental health and substance use disorders will produce unprecedented opportunities for growth in the field. However, 35 million newly insured Americans will stress and strain the aging behavioral healthcare workforce. Waiting lists are no longer acceptable so business process and workflow efficiencies and an attractive career path will become essential to meeting the unmet needs of Americans. Understand that commercial insurers and Medicaid managed care plans will effectively raise the standards for professionalism, credentialing and accreditation.
8. Health information technology will continue to be key to organizational success in emerging business environments. Health IT is critical to trade with payers and insurers and provides the backbone for collaboration between healthcare providers. The business and clinical reasons driving investment and implementation are stronger than ever and time is running short. Behavioral healthcare providers must re-focus their time and efforts to identify, select and adopt certified systems.
9. The Mental Health Parity and Addiction Equity Act (MHPAEA) and Essential Health Benefits need to be interpreted and defined at the state level. Providers must cooperate, agree on terms and take a firm position that can be shared with other stakeholders. The field must take its place at the table and argue for a well-rounded scope of services, compliance with MHPAEA, and strong linkages between coverage and social services. The field also needs to know when to press for compliance and regulators at the Federal and state levels need to make Final Rules in these areas a high priority. Bear in mind that Essential Health Benefits must include mental health and substance use disorders treatment coverage, apply to both Health Insurance Exchanges and Medicaid Expansion and both new forms of coverage must comply with MHPAEA. Medicaid managed care plan compliance with MHPEA is especially crucialnow. Federal leadership is needed yet the field needs to find and take its position and work toward unison following many years of fragmentation. 
10. Financial savvy and a willingness to assume some financial risk will prove advantageous. As healthcare reforms continue to unfold, the spate of reimbursement reforms – pay-for-performance, shared savings, global payment – will increase. The hybridization of payors and providers in models like ACOs will increase. Behavioral healthcare providers need to expand their financial base, gain access to capital and reserves, and access financial expertise to navigate these new waters.