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Alexandria, VA – Mental Health America (MHA) responded today to the Administration’s new Medicaid initiative with concern that it will set off a “race to the bottom” for states, by encouraging them to cut future Medicaid costs at the expense of people with serious mental health and substance use conditions.

The Center for Medicare and Medicaid Services (CMS) issued a Dear State Medicaid letter today encouraging states to apply to block grant their Medicaid programs as they seek to cover expansion populations.  Although the Administration argues that these are “healthy” adults, data show that a substantial percentage of this population has mental health and substance use needs.  According to a GAO study of 4 expansion states, between 20 and 34 percent of those enrollees newly eligible for Medicaid used a behavioral health treatment in 2014. In 2 of these states, 1 in 3 enrollees under the expansion used a behavioral health treatment.

This proposal comes at a time when the nation is facing a suicide and opioid crisis.  With over 48,000 deaths by suicide and nearly 70,000 deaths from overdoses in 2018, it is time to increase resources to the states, not offer ways to reduce costs and treatment.

“We are losing too many people to suicide and opioids. We need more resources in Medicaid, not less, especially for people with mental health and substance use needs,” said Paul Gionfriddo, CEO of Mental Health America. “Block grants block resources and accountability.”

He added that “allowing states to get credit for so-called ‘maintenance of effort’ while incentivizing them with a promise of new ‘shared savings’ funding to cut services budgets by up to 20 percent could also set off a race to the bottom, with terrible impacts on the people with serious mental health conditions who would be affected – and are supposed to be helped – by these new block grants.”

MHA is also concerned that the ability of states to limit retroactive eligibility will be especially harmful to people with serious mental illness and substance use. “Symptoms can interfere with ability to gather paperwork,” Gionfriddo explained. “Often providers must do intensive outreach to build trust that allows for care and coverage. In addition, providers who serve people during crisis or after serving jail time need reimbursement for previous services once eligibility is determined.” 

Block grants have historically reduced resources over time because states are not protected from increased demands due to new threats. This is especially important in behavioral health. For example, the increase in fentanyl has further exacerbated the opioid crisis. According to the Centers for Disease Control and Prevention, suicide has increased nearly 30% between 1999 and 2016. These changes are often not predictable and under a block grant, resources will not expand to address them.

Individuals and families struggling with mental health and substance use conditions also find that “community engagement” requirements do not support work and volunteering. Many mental health and substance use disorders make it difficult to complete the bureaucratic paperwork that often accompanies these requirements, especially when experiencing symptoms.

Gionfriddo concluded, “So, when they most need coverage, people are most at risk. The Administration and states should instead focus on making Medicaid more effective by increasing rates for providers, including peer support specialists, using what we’ve learned from past Medicaid 1115 waivers to incorporate proven cost-saving and service-enhancing measures into the broader Medicaid program, and expanding access to services that are effective in helping people with mental health and substance use conditions experience recovery.”