Mental illness affects many Americans and disproportionately affects low-income vulnerable families, who typically have less access to treatment even for serious problems. Its effects can be two-generational, with untreated mental illness in a parent potentially affecting children, thus expanding even further the potential importance of effective treatment. Depression, which is highly treatable, is a prime example of a parental mental illness that affects large numbers of families and poses risks to children’s safety and cognitive development when untreated.
Last month, CLASP submitted comments to the U.S. Senate Finance Committee in response to its letter soliciting recommendations on how to improve the mental health system. CLASP’s comments highlighted both barriers in the current mental health system and opportunities for improvement.
While low-income parents experience a relatively high risk of depression and other mental health problems, they unfortunately are less likely to get treatment than higher-income adults. A number of barriers in today’s health financing and service systems help explain this disparity:
- Eligibility gaps for low-income adults. Many state Medicaid programs prior to the Affordable Care Act (ACA) only cover parents when their income is extremely low – a fraction of the poverty level. Pregnant women are eligible up to somewhat higher income levels, but the result is that mothers may lose Medicaid eligibility shortly after their child is born, when they are no longer eligible under that higher threshold.
- Fragmentation of mental and physical health services and fragmentation of services for children and their parents. Health care providers, particularly primary care providers like family doctors, may be in the best position to build trust on sensitive issues like mental health but are generally not well-connected to mental health providers. Additionally, care for adults and care for children are also fragmented and not designed with a two-generation approach.
- Access. While Medicaid is a crucial provider of mental health services to low-income people, access to necessary services may be limited by complex billing and reimbursement issues (which vary by state) and by an insufficient supply of qualified and trained providers. Another potential barrier is stigma related to mental illness, causing those affected to withhold information or only tell someone they trust.
- Mutual lack of understanding between health/ Medicaid agencies and human services and youth-serving agencies (such as those administering child welfare) that serve vulnerable families and individuals. While public agencies could collaborate to overcome some of these other barriers, program complexity and the pressure of deadlines often get in the way.
Today, there are important opportunities to address these barriers, help low-income parents get treatment, and strengthen children’s development as a result. Among the key opportunities arising from the passage of the Affordable Care Act and other related innovations in health care are the following:
- Simplified Enrollment provisions in the ACA, which build on lessons learned from national and state initiatives to streamline and simplify enrollment into Medicaid and CHIP.
- Opportunities for integrated care that will address fragmentation of services and utilize a two-generation approach.
- Workforce Initiatives to increase the number of skilled, qualified providers.
- Home visiting services that provide the opportunity to identify and engage isolated or hard-to-reach families who have mental health concerns, particularly maternal depression.
- Federal technical assistance, guidance, and support for Medicaid – mental health – child welfare partnerships. These partnerships could overcome the barriers of fragmentation and lack of common understanding across the system.