The number of adults getting treatment has nearly doubled since the state expanded the health care program, and wait times are swelling.
By: Joe Lawlor
Greg Lavertu has struggled with his mental health for decades and has been hospitalized at least a dozen times. But he said he wasn’t correctly diagnosed with schizophrenia and given the medication and therapy he needed until this year, when Maine expanded Medicaid.
“This has saved my life in so many ways,” said Lavertu, 44, of Rumford. “I now have some semblance of stability in my life.”
But the surge in mental health patients under Medicaid expansion is straining the state’s treatment system. Leaders of some nonprofit agencies say they are struggling to meet the demand for services, which has led to lengthy waiting lists and a call for higher reimbursements, which would encourage mental health providers to accept more Medicaid patients.
Mental health treatment is the No. 1 service being used among the expansion population. The increase in patients has caused a near-doubling of the number of adult Medicaid patients using mental health services.
Through Oct. 31, 16,398 new Medicaid enrollees – or about 40 percent of the expansion population – are getting mental health treatment. The expansion population stood at 43,659 through Dec. 13, according to the Maine Department of Health and Human Services. The second-most used service from Medicaid expansion is substance use disorder treatment, with 6,532 patients.
Maine is one of 33 states that expanded Medicaid, but it was the last New England state to do so when Gov. Janet Mills implemented it in January. Some states have had expanded Medicaid – which covers people up to 138 percent of the federal poverty line, or $28,676 for a family of three – for five years
About 330,000 Mainers have Medicaid, and 37,918 non-disabled adults receive mental health services through the program. They obtain treatment for conditions that range from depression, PTSD and anxiety to schizophrenia and other psychotic disorders. Of the non-expansion population, 21,520 of 55,000 adults receive mental health services. The usage for comparable populations – non-expansion to expansion – is similar at about 40 percent of enrollees, excluding certain population groups, such as seniors dual-enrolled in Medicaid and Medicare.
Lavertu said he did receive some limited mental health help while he was uninsured, but therapy sessions were infrequent and, because he had to pay out-of-pocket for medications, all he could afford was lithium, which cost $20 a month.
With Medicaid, Lavertu said he was given a comprehensive mental health evaluation in February, which led to the proper diagnosis of schizophrenia. He now takes a specialized anti-psychotic medication with a $3 copay that would cost $3,000 monthly out-of-pocket, and he sees a therapist weekly.
Lavertu, who has Social Security disability because of his mental health condition, said his social life has improved since he started his new treatment. He volunteers more often and spends more time with his hobby, photography. He also finished an online bachelor’s degree in business administration from Purdue University Global.
“It’s opened all kinds of doors to me now that I’m doing better,” Lavertu said. “It’s like night and day.”
Dr. Jessica Pollard, director of Substance Abuse and Mental Health Services for Maine DHHS, said getting people into mental health treatment will have a number of benefits for thousands of Mainers
“Getting the support you need when you have a need is key. To have the ability to go and get treatment before a crisis, and get ongoing support, allows people to remain in the community,” Pollard said. “And it’s less costly for everyone involved.”
Pollard said some of the expansion population was receiving treatment through a program at SAMHS designated for the uninsured. While it’s unclear how many have so far been shifted from the SAMHS program to Medicaid, it’s likely in the thousands, according to DHHS. About 4,600 were using the SAMHS mental health program for the uninsured in 2018-19, but that includes those receiving services prior to when Medicaid expanded in January. Pollard said that will free up tax dollars – it’s not clear yet how much – for other support programs for people with mental illness, such as housing support or training.
Malory Shaughnessy, executive director of the Maine Alliance for Addiction and Mental Health Services, which represents nonprofit agencies that provide mental health services, said Medicaid expansion is a benefit to the state, but nonprofits need reimbursement-rate increases or there will be a chronic lack of access to therapy.
“It’s very difficult to get an appointment to see a therapist if you have MaineCare (Maine’s name for Medicaid),” Shaughnessy said. “We knew there was going to be a big surge, but our capacity is not meeting the need. With the opioid crisis, there was a real concerted effort to improve access to prepare for Medicaid expansion. On the flip side, DHHS was paying less attention to the mental health side of things.”
Pollard said DHHS is going to be conducting a rate study in early 2020 to determine what fair reimbursement rates should be across an array of Medicaid services.
Meanwhile, nonprofit agencies say they haven’t had a meaningful rate increase in about a decade
“We don’t have enough capacity, but we do the best that we can,” said Tom McAdam, CEO of Kennebec Behavioral Health, which has offices in Augusta and several other locations, including Winthrop and Waterville.
McAdam said waiting lists for mental health are hundreds deep and wait times to get an appointment for Medicaid patients can be 15-30 weeks. He said about 25 percent of the lengthy waits are caused by the expansion, but other longstanding problems, such as a workforce shortage and low reimbursement rates, also contribute to the wait lists. McAdam said that about a decade ago, Medicaid wait lists for mental health services at Kennebec Behavioral Health were about four to six weeks.
Catherine Ryder, CEO of Tri-County Mental Health Services in Bridgton, said that they are “definitely seeing an uptick” in mental health referrals after the expansion.
“We have waiting lists for the first time in years,” Ryder said. While the waiting lists can result in some patients waiting about two weeks for care, the agency is “used to being able to see people when they walk in the door.”
Ryder said the workforce shortage combined with the low reimbursement rates are constricting the supply of clinicians to see mental health patients. At Tri-County, it costs about $120 per hour to serve a mental health patient, but Medicaid will reimburse $84. Ryder said they have to pay therapists a competitive rate, so the agency will end up absorbing the reimbursement loss for Medicaid patients. But Ryder said that means some programs that lose the most money can be put in jeopardy. Ryder said they haven’t had to cut programs yet, but the state can’t continue to have stagnant reimbursement rates and expect good access to mental health care for Medicaid patients.
“We haven’t closed programs, but it has become increasingly more difficult,” Ryder said
Rachel Garfield, vice president of the Kaiser Family Foundation, a Washington-based health policy think tank, and an expert on Medicaid, said expanding Medicaid “reduces unmet needs and leads to health improvements.”
“Once they get into mental health treatment, people may find that they had physical health needs that they were unaware of, such as high cholesterol,” Garfield said.
Garfield said she’s not aware of research from the Medicaid expansion in other states about improvements in mental health outcomes after a state expanded Medicaid, but she pointed to a study in Oregon.
In Oregon in 2008, before the Affordable Care Act became law in 2010, the state expanded Medicaid on its own. Oregon held a random drawing to determine which of the previously uninsured would be eligible, due to state budget constraints. That dynamic allowed social scientists to compare similar demographic populations of thousands who gained Medicaid and a control group of those who did not. After two years, researchers found that those who gained health insurance through Medicaid had a 9.2 percent reduction in depression. Also, 25 percent more of the newly insured population in Oregon reported themselves to be in good or excellent health compared with the control group.
A Kaiser Family Foundation analysis from 2017 estimates that 20 percent of the adult population has a mental illness, and Medicaid coverage helps millions get into treatment.
“Medicaid coverage of mental health services is often more comprehensive than private insurance coverage,” according to the foundation. “The Medicaid expansion has enabled many low-income individuals with mental health conditions to obtain coverage and access treatment.”
In some categories, Maine’s mental health is worse than the national average. For instance, suicide rates in Maine were 19.3 per 100,000 population from 2014-16 compared with a national average of 14.8 suicides per 100,000. Overall, Maine’s mental health is slightly better than the national average, ranking 19th out of the 50 states, according to Mental Health America, a Virginia nonprofit. The ranking looks at a number of mental health indicators, including adults and children reporting a mental illness, instances of severe depressive episodes, system capacity and other factors.
This article appears in the Portland Press Herald.