Introduction to the Special Section

Earlier this year, the Office of the Assistant Secretary for Planning and Evaluation (ASPE), the policy research arm of the U.S. Department of Health and Human Services, commissioned three papers, each addressing a key question for the organization and financing of mental health and substance abuse care under the Patient Protection and Affordable Care Act (PPACA): How should the "market" for new health insurance plans be set up? Will coverage of mental health services be adequate? Can the quality and efficiency of care be improved through better integration of mental and physical health care? Together, these papers are a primer for mental health clinicians and policy makers about what to look for, hope for, and watch out for as the rubber meets the road in health care reform.

PPACA primarily reforms health insurance, not health care. The centerpiece of PPACA, and arguably the provision with the most far-reaching implications, is creation of the new exchanges, state-run markets for individual private health insurance (that may also be accessible to small groups). The authors of the first article remind us that individual private health insurance markets have not done well by persons with mental illness ( 1 ). Persons with mental illness tend to be "bad risks" from the standpoint of the health plan, and it is in the interest of the plan to discourage them from joining. Health plans in the exchanges will have to cover mental health care at parity with general medical care; however, this regulation of the nominal benefit package provides incentives for plans to "manage" mental health care tightly. Previous experience in private health insurance implies that states should consider policies to protect plans against drawing an "adverse selection" of the risks, so that the plans, in turn, will compete for all potential enrollees by offering high-value coverage.

Medicaid expansions to previously ineligible low-income individuals and the state-level exchanges will together extend health insurance coverage to an additional 32 million people. That's the good news. The bad news is that the coverage for persons with mental illness may in many cases be inadequate, and it may even be less generous than the de facto coverage that is currently provided through state-funded programs for the uninsured. In the second article, Garfield and colleagues ( 2 ) review coverage of mental health services under typical commercial (employer-based) coverage as well as Medicare, Medicaid, and other publicly funded programs, and they assess the options for addressing likely gaps in coverage that will arise under reform. States are not uniform in their Medicaid and other programs, but persons with serious mental illness getting care through these payers generally have access to a wider range of services, including nontraditional medical services, than do enrollees in commercial coverage or Medicare. Under the PPACA, states can offer Medicaid "lite" to the newly covered, and indeed, there is no "maintenance of effort" clause requiring states to maintain Medicaid benefits even for the previously eligible. Coverage in state exchanges features parity, but these will be basic health insurance plans with plenty of cost sharing. It is uncertain—and even doubtful—whether these plans will cover much in the way of nontraditional benefits crucial for many with mental illnesses.

Improving quality and containing costs will ultimately require reorganization of care, and PPACA includes several provisions that aim to accelerate the reform of care. Persons with mental illness often have chronic and complex health care needs that would benefit from disease management, and they have much to gain from reorganization. Medical homes, whether these are located in primary care—or in a mental health care setting for persons whose psychiatric condition dominates their medical need—offer promising models. In the third article, Druss and Mauer ( 3 ) review the experience of integrating primary and mental health care and provide a guide to the demonstration initiatives that Medicare and Medicaid are expected to administer in the near term. In general, the focus is on payment of monthly management fees to accountable care organizations, with less reliance on procedure-based billing. Success means different things for payers, providers, and patients in these demonstrations, and it remains to be seen whether a win-win-win is possible within the constraints of existing public-payer financing structures.