In this assignment, you will review the case discussing the intersection of public health and mental health found in Chapter 3 of Public Health Ethics (pp. 74-79).
In approximately two pages, your paper should address the following:
Citation for chapter: Daniels N. (2016) Resource Allocation and Priority Setting. In: H. Barrett D., W. Ortmann L., Dawson A., Saenz C., Reis A., Bolan G. (eds) Public Health Ethics: Cases Spanning the Globe. Public Health Ethics Analysis, vol 3. Springer, Cham
3.6 Case 2: Intersection of Public Health and Mental Health: Meeting Family Needs
This case is presented for instructional purposes only. The ideas and opinions expressed are the authors’ own. The case is not meant to reflect the official position, views, or policies of the editors, the editors’ host institutions, or the authors’ host institutions.
The Global Burden of Disease (GBD) compares disease burdens based on epidemiological measures of prevalence, mortality, disability, and associated costs. The GBD for mental illness amounts to 14 % of the world’s total disease burden (World Health Organization 2005). In the United States alone, every fifth child suffers from a mental disorder (Perou et al. 2013).
Although mental illness clearly causes disabilities (Prince et al. 2007), under-service to those with mental illness is commonplace. Lack of access to mental health services counts as the first of many hurdles facing families who have a child with a mental illness.
Stigma and the lack of parity in health coverage for physical and mental illness are other hurdles for these families. Not surprisingly, these hurdles can critically affect the development of children with mental illness.
Lack of access to mental and behavioural health services for children 5 years and younger especially threatens their development. Rapid brain growth occurs in the first 5 years of life, which lays the foundation for cognitive, emotional, and moral development.
Exposure to chronic stress can prompt the release of hormones in the brain that can have enduring consequences for how the adult brain is organised and how it functions (Shonkoff and Phillips 2000). Because poor health can show up in children as developmental delay, access to mental and behavioural health services is critical.
Longitudinal studies demonstrate positive and long-acting effects of early childhood interventions, such as environmental enrichment programs, on a range of cognitive and non-cognitive skills, social behaviours, academic achievement, and adult job performance (Heckman 2008).
The estimated annual rate of return on investment from targeted early childhood development programs is 7 %, and early intervention reduces the predictable need for higher, more costly levels of care in later life (Heckman et al. 2010).
In the United States, Medicaid is a government-funded program that provides health coverage to people with certain disabilities and to low-income adults and their children.
The Federal Medicaid Act (FMA) requires states participating in Medicaid programs to provide medically necessary treatment to eligible children. Under federal Medicaid law, states must provide “early and periodic screening, diagnostics, and treatment,” also known as EPSDT services, to eligible Medicaid recipients under age 21 (U.S.C. § 1396 d(a)(4)(B)).
The definition of EPSDT includes necessary health care, diagnostic services, treatment, and other measures described in the Medical Assistance sub-chapter for the United States Code (42 U.S.C. § 1396 d (a)) (2012) that correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, regardless of whether such services are covered under the state plan (42 U.S.C. § 1396d (r)(5)) (2013).
The medical necessity standard, which is based on clinical standards of care, refers to interventions that may be justified as reasonable, necessary, or appropriate. States must comply with the FMA standard to cover all treatments for a Medicaid-eligible child’s physical or mental condition, even if service coverage is optional for adults covered by Medicaid.
FMA also bars states from arbitrarily denying or reducing the amount, duration, or scope of a required service to an otherwise eligible recipient solely because of the diagnosis, illness, or condition (Nebraska Legislature 2012).
Despite the provisions of FMA, the U.S. Department of Health and Human Services, which oversees the Medicaid program, excludes certain behavioural health treatments for children with developmental disabilities and autism (National Health Law Program 2012; Autism Society of Nebraska 2012).
In addition, some states’ Medicaid contracts allow insurers more freedom than other states to deny payment for services. States also vary in who—the claimant or the insurer—must prove whether coverage provisions are adequate or fall short of federal Medicaid legal standards (Rosenbaum and Teitelbaum 1998).
Differences among states in approval of payment for specific treatments, including mental and behavioral health treatment, illustrate the need for more consistency in Medicaid coverage provisions and the lack of parity between mental and physical health coverage.
Mental health benefits must be offered at parity with medical services to newly eligible recipients as part of the 2010 Patient Protection and Affordable Care Act (ACA), and Medicaid expansion controversy is clear evidence that parity is a work in progress (Mental Health America 2013; U.S. Department of Labor 2008).
Because of inadequate coverage for mental and behavioural health services for Medicaid-eligible children, some parents have no option other than to surrender their child to the child welfare system so that the child will receive full coverage for necessary mental and behavioural health care services.
This results in significant cost-shifting from Medicaid to the state’s child welfare system. That is, when a state provides federally mandated services to Medicaid-eligible children, it receives a financial match from the federal government to pay the costs.
When a state denies federally mandated Medicaid services and a family surrenders a child to state custody so the child can receive care, the state pays the expense of the previously denied Medicaid costs plus the expense of entitlements the child acquires as a ward of the state.
The ACA Medicaid expansion offers a window of opportunity to increase coverage for behavioural health treatment for children with mental illnesses.
Although the federal government will bear the primary financial burden of Medicaid expansion, some states have elected, for political reasons, not to participate in this expansion.
For participating states, ACA Medicaid expansion will replace state and local mental health services funds with federal Medicaid money that will cover a wider range of home and community-based services for mental illness treatment (Bazelon Center for Mental Health Law 2012).
Public health agencies and leaders often provide input for the Medicaid system, helping to develop protocols, criteria, and rules about which treatments are defined as medically necessary. Such decisions about medical necessity affect clinicians, patients, and families because they determine which treatments get recommended at the clinical level and influence which treatments insurers cover.
3.6.2 Case Description
You are the Medicaid director of a state with the country’s highest percentage of children in the child welfare system. Twenty-five percent of children in the state’s foster care system are there not because of abuse or neglect, but because of behavioural problems and mental illnesses. As a state official, you are aware that this results in significant cost-shifting from Medicaid to the state’s child welfare system.
Recently, the case of 4-year-old Sam has come to your attention. Sam’s family cannot afford mental and behavioural health care for Sam, although he is Medicaid-eligible and insured through Magi-scare (a private company with a state contract to administer Medicaid for mental and behavioural health services). Sam’s parents are considering surrendering their boy to become a state ward to get him the mental health services he needs.
Sam, you learn, eats random objects and dirt, throws tantrums, bangs his head on the ground, hits and bites himself and others, and often runs away. Recently diagnosed by his physician as having autism, Sam was referred to a psychologist who recommended outpatient behavioural therapy. Both the physician and the psychologist expect this therapy to be covered through the family’s Magi-scare plan.
Magi-scare denied the psychologist’s requests for payment on the grounds that, for children of Sam’s age, behavioural management is not covered under state law because it is not “medically necessary.”
Magi-scare substantiated their denial of payment because Sam’s behaviours primarily reflect developmental disabilities related to autism, which are not covered under their contract with the state.
When you ask the Magi-scare executive director about this case, she suggests that Sam’s parents could attend therapy sessions to help them cope with their son’s behaviours, but she reasserts that behavioural management is not covered for children as young as Sam under state law because it is not medically necessary.
Members of the state legislature and child mental health advocacy groups are trying to expand access to home-based and community-based mental health services.
They have asked you to support their efforts. You also consider that your governor, who is your boss, has publicly stated his firm opposition to ACA Medicaid expansion, thus denying the state the opportunity to expand coverage for children’s mental and behavioural health treatment through the ACA.
At present, you know that your state is offering limited mental and behavioural health services and that narrow definitions of medical necessity are used to limit access to those services.