Week 6 substance abuse services

III. Type of Service (Model) Provision and Rationale
There are a variety of models for providing services for substance abuse services from community mental health centers to free-standing facilities. Based on your market analysis, potential competition, and the ACA-expanded provisions for coverage for substance abuse services, what type of service (model) do you believe would be the best for your organization to provide? Include your rationale and potential market competition.

IV. Ethical Issues
While ethical issues may not be part of every business plan substance abuse treatment necessitate special attention to ethical precautions. As a health care executive considering expanding your substance abuse services, you should be considering the ethical implications.
As you are expanding your services with the specific model you have chosen, are there any ethical challenges that need to be considered? For example: Are you expanding from adult to pediatric services? How might this present different ethical issues? Are you expanding from inpatient to outpatient services? How might this present different ethical issues? Are you treating ex-offenders? Are you using methadone?

© 2016 Laureate Education, Inc. Page 1 of 2

Mental Health/Substance Abuse Expansion
Business Plan Template

I. Executive Summary:

II. Market Analysis:

Discuss how economic principles relate to investment in the expansion of mental
health/substance abuse services including the following:

 Macro- and micro-economic implications of market competition

 The mental health/substance abuse services that are currently provided
within a 25-mile radius of your healthcare organization

 The specific implications of the expanded provisions of the Affordable Care
Act (ACA) for health care organizations and mental health and substance
abuse programs

III. Type of Service (Model) Provision and Rationale

There are a variety of models for providing services for mental health/substance abuse
services from community mental health centers to free-standing facilities. Based on your
market analysis, potential competition, and the ACA-expanded provisions for coverage
for mental health/substance abuse services, what type of service (model) do you
believe would be the best for your organization to provide? Include your rationale and
potential market competition.

IV. Ethical Issues

While ethical issues may not be part of every business plan, mental health and
substance abuse treatment necessitate special attention to ethical precautions. As a
health care executive considering expanding your mental health/substance abuse
services, you should be considering the ethical implications.

As you are expanding your services with the specific model you have chosen, are there
any ethical challenges that need to be considered? For example: Are you expanding
from adult to pediatric services? How might this present different ethical issues? Are
you expanding from inpatient to outpatient services? How might this present different
ethical issues? Are you treating ex-offenders? Are you using methadone?

V. Financial Analysis:

Capital Requirements

To estimate the total funds required for your expansion prior to commencement of
operations, what are the specific issues (e.g., number of rooms, dining space,
recreation space, etc.) you must consider when expanding mental health/substance
abuse services? Detail the information pertinent to your services based on the model of
service you intend to provide.

Professional Staff

© 2016 Laureate Education, Inc. Page 2 of 2

What types of professional services will be required in your model? Are there specific
numbers of professionals required per number of patients treated? What are the fee
structures/reimbursement schedules that are utilized by these professionals?

Non-Professional Staff

What other staff is required to operate your mental health/substance abuse model of
service? Are there specific numbers of staff required per number of patients treated?

VI. Certification

What type of certification is required for your service delivery model? Who do you apply
to obtain certification? What is the timeline for obtaining certification?

© Meharry Medical College Journal of Health Care for the Poor and Underserved 26 (2015): 49–61.


Remaking the American Health Care System:
A Positive Reflection on the Affordable Care Act

with emphasis on Mental Health Care

Babatunde Ogundipe, MD, MPH
Farzana Alam, MD

Lalitha Gazula, MD, MPH
Yetunde Olagbemiro, MD, MPH

Kenneth Osiezagha, MD
Rahn K. Bailey, MD, DFAPA

William D. Richie, MD, DFAPA

Abstract: Health care reform under the Patient Protection and Affordable Care Act (PPACA,
ACA) of 2010 may be the most significant health care- related legislation enacted since
the establishment of Medicare and Medicaid several decades ago. Over two years ago the
U.S. Supreme Court upheld the constitutionality of the individual mandate of the Patient
Protection and Affordable Care Act. This legislation has emerged as a significant and ambi-
tious undertaking for all levels of the U.S. government. With the need to accommodate the
estimated 30 million people projected over time to become newly insured it is increasingly
important to understand the necessity of reform, how the legislation has been interpreted
and implemented to fit the goals of the federal, state, and local governments, and what the
potential benefits and consequences of changing the system are, in particular, as it relates
to mental health care.

Key words: Health care, health reform, Affordable Care Act, health insurance, state- based
health insurance marketplaces, mental health care.

Under the Obama Administration health care reform has become a reality through
two separate pieces of legislation designed to improve the structure of health care

delivery and the quality of health care. These include: (1) The Patient Protection and
Affordable Care Act of 2010 (PPACA, or ACA), and (2) The Health Care and Educa-
tion Reconciliation Act of 2010 (HCERA). Focused on cost containment and improved
access, these two legislative acts define changes made within the health care system
and have the potential to affect other important facets of United States (U.S.) society
both politically and economically.

The authors are affiliated with Meharry Medical College. Please address correspondence to William D.
Richie, MD, DFAPA; Meharry Medical College, 1005, Dr. D.B. Todd Jr. Blvd., Nashville, TN 37208;
wrichie@mmc .edu; (615) 327‑6823.

50 Remaking the American health care system

The Patient Protection and Affordable Care Act was designed to extend insurance
coverage through an expansion of Medicaid, as well as through state- run marketplaces
(exchanges) for health insurance supplemented by tax relief for middle- income par-
ticipants who qualify for assistance.1 The Patient Protection and Affordable Care Act
has provided federal funding to enable states to expand the availability of Medicaid to
people who previously did not qualify (either because they had too high an income or
were single, non- disabled adults). Those individuals under 133% of the federal poverty
level are now eligible for Medicaid in states that have chosen to expand. Many states,
however, have not yet accepted this offer from the federal government resulting in gaps
where the poorest of the uninsured are remaining uninsured while those who have
somewhat higher incomes have been able to purchase insurance on the federal health
insurance exchange.2 In an effort to increase participation of healthy people in both
Medicaid and the newly created exchanges a critical piece of the mechanism, known
as the individual mandate, requires citizens to carry health insurance. In effect, this
means that citizens who are uninsured must either sign up for Medicaid or if they earn
too much to qualify for it, must purchase health insurance for themselves. Failing to
purchase their own insurance would result in a tax penalty. Provisions also exist for
the enforcement of penalties on employers with 50 or more full- time (or full- time
equivalent) workers who do not provide health insurance coverage for their employees.
Originally set to begin in 2014, the employer mandate has been delayed until 2015/ 2016.1

The health insurance marketplaces established through the Patient Protection and
Affordable Care Act were set up so that small businesses and individuals could compare
plans and purchase private insurance coverage that covers all the “essential health benefits,”
including services in: ambulatory care, emergency room, mental health, substance use
disorders (counseling and psychotherapy), laboratory studies, rehabilitation, maternity/
newborn care, prescription drugs, preventive medicine/ wellness, pediatrics, and hos-
pitalization.3,4 More details are available at the federal government’s website for the
program, https:// www .health care .gov/ what- does- marketplace- health- insurance- cover.

When a few of the specific policies set forth through the PPACA were disputed, the
U.S. Supreme Court investigated the claims and on June 28, 2012, ultimately upheld
the constitutionality of much of the ACA including the individual mandate for eligible
individuals and the Medicaid expansion. The court, however, did not agree for any
individual state to be penalized for not implementing an expansion of its Medicaid
program. Most significantly, the decision of the U.S. Supreme Court confirmed that
many policy changes coming to the U.S. Health Care System were inevitable and would,
as part of the timeline included in the ACA, take effect by late 2013 through 2015.4 In
view of all of this it is increasingly important to understand the ACA especially due to
the numerous daily changes being made by the federal and state governments for the
implementation of its programs. This article aims to provide a brief overview of what
the problems have been within the U.S. health care system; highlight the need for health
care reform by describing the consequences of being underinsured or uninsured in the
United States; discuss the overall goals of the ACA; examine the potential beneficial
effects of the ACA on health care in the United States, and in particular the impact
that the ACA should have on mental health care.

51Ogundipe, Alam, Gazula, Olagbemiro, Osiezagha, Bailey, and Richie

Problems with the U.S. Health Care System

There were numerous problems faced by the health care system in the United States
prior to the ACA. Rising costs of health care coupled with lack of access to health
insurance affected many Americans.5 The uninsured rate for children under the poverty
line was 13.8%, while the overall rate was (9.4%). Nine million children were without
insurance.6 According to the U.S. Census Bureau report, titled Income, Poverty, and
Health Insurance Coverage in the United States: 2011, there were 48.6 million people,
15.7% of the U.S. population, who were uninsured in 2011.5 Additionally, the lack of
health insurance has been found to result in more than 44,000 deaths each year.7 In
2006 Massachusetts passed comprehensive health care reform with the goal of near
universal coverage. Its law resembles the Affordable Care Act in expanding Medicaid,
offering subsidized private insurance, and creating an individual mandate. A recent
study published in the Annals of Internal Medicine found that health reform in Mas-
sachusetts was associated with significant reductions in all- cause mortality and deaths
from causes amenable to health care.8

Prior to 2014, many individuals had trouble finding providers that would accept
their insurance or were declined service because providers were no longer accepting
new patients. Working class families worried about becoming ill or getting injured
because they could not afford health insurance or basic health care. Others were turned
away by insurance companies because of a pre- existing medical condition or illness.
Additionally, many who were previously insured lost their health insurance when they
changed jobs or were laid off from work.9

The mixed public- private health care system in the U.S. is the most expensive in
the world, with per capita costs higher than those of any other nation. Data from the
Organization for Economic Co- operation and Development (OECD) of the 34 member
countries show that in 2010, the U.S. spent 17.6% of its gross domestic product (GDP)
on health care while other member countries spent far less. (See Table 1.) The U.S. was
followed by the Netherlands, which spent 12% of its GDP, and Germany and France,
both of which spent 11.6% of their GDP on health care. More details are available at
http:// www .oecd .org/ els/ health- systems/ health- data .htm. Within the United States,
data from the Centers for Disease Control and Prevention (CDC) indicate that health
care spending per capita (in dollars) climbed sharply from $147 in 1960 to $6,868 in
2005 and $8,402 in 2010.10

Consequences of Being Uninsured

The increasing costs of the U.S. health care system highlight many problems springing
from the old model of health care, most importantly the effects it had on the uninsured.
The Biennial Health Insurance Study (BHS) from the Commonwealth Fund found that
75 million people were carrying medical debt and 80 million were unable to afford
care in 2012.11 It can be inferred that when individuals have no health insurance they
miss wellness or preventive visits and avoid physician visits until they are unavoidable.
Without the use of various cost- effective preventive health maintenance services such





















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s 2








a h


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– s













a .


53Ogundipe, Alam, Gazula, Olagbemiro, Osiezagha, Bailey, and Richie

as routine physical examinations and laboratory tests, individuals tend to be subjected
to more invasive and expensive procedures and therapies and to make more frequent
visits to the emergency department. Consequently, there are worse health outcomes
for patients accompanied by greater financial burden and extended financial liabilities,
which are often passed on to the hospital, the community, and the government to cover
gaps in payment for services.7

Goals of the Affordable Care Act

The purpose of health care reform is to increase access to health care while reducing
or eliminating many of the consequences of not having health insurance. The Afford-
able Care Act ultimately seeks to provide health care coverage to more than 30 million
Americans. It is to do this through provisions and plans for programs to improve the
access to health insurance as well as to the quality of care. Two prominent goals of the
ACA are to give American consumers more options for their health care and to prevent
insurance companies from continuing potentially detrimental and unfair practices, such
as denying coverage for pre- existing conditions. It is expected that these changes will not
only provide more affordable options for health insurance but also greater coverage.12

As we suggested earlier, an important feature of the ACA is granting tax credits to
both individuals and families (legal resident aliens and eligible citizens) to help make
insurance affordable. Specifically, through the ACA refundable tax credits became
available for Americans with incomes between 100% and 400% of the federal poverty
line (FPL) (400% being approximately $88,000 for a family of four). These credits are
to be calculated on a sliding scale, beginning at 2% of household income for those at
100% of the FPL and phasing out at (9.8%) of household income for those at 300– 400%
of the FPL. Tax credits are also being provided for employees choosing the insurance
plan offered by their employers. If the insurance plan premium offered by a company

Figure 1. Importance and impact of health reform goals.
Source: Towers Watson © 2010

54 Remaking the American health care system

exceeds 9.8% of a worker’s family income, or the employer contributes to less than
60% of the premium, the employee is eligible to enroll in an exchange and receive tax
credits in order to help pay part of their insurance premiums. Additionally, the out-
of-pocket maximum payments ($5,950 for individuals and $11,900 for families) have
been decreased by one third for those with an income between 100– 200% of FPL,
by one half for those with incomes between 200– 300% of FPL, and by two thirds for
those with incomes between 300– 400% of FPL. Furthermore, a new credit for up to
50% of the total premium cost is applied to assist small business owners that employ
fewer than 25 workers.13

Health Insurance Exchanges in the ACA

A health insurance marketplace (i.e., an exchange) is a “one- stop shop” that allows
individuals and small businesses the opportunity to compare and contrast several
affordable health insurance plans that cover the essential health benefits enumerated
earlier, and to choose the best one for their needs. The first open enrollment for state’s
marketplaces ran from October 1st 2013 to March 31st 2014. Open enrollment for 2015
runs from November 15th 2014 to January 15th 2015. States have either implemented
a state- run exchange, or let the federal government run the health insurance exchange
for them (through the U.S. Department of Health and Human Services). Some states
have crafted their systems slightly differently by working with another state or the fed-
eral government. More details in this connection are available at http:// obamacarefacts
.com/ state- health- insurance- exchange .php. Each individual state remains the primary
regulator of its health insurance marketplace and the key player to enforce the federal
laws put in place through the ACA to ensure that consumers are adequately protected.14
Although states have the primary responsibility of enforcing federal health insurance
law, federal regulators reserve the right to enforce proper operation of a marketplace
in the event that a state fails to “substantially” enforce it. Furthermore, federal involve-
ment could subject insurers to significant fines for failure to comply with the law.15

The Marketplace consists of plans for both individuals and small businesses; each
state- run marketplace has created two exchanges: an American Health Benefits exchange
for individuals, and a Small Business Health Options (SHOP) exchange for businesses
with up to 100 employees. Individuals and small business employers can shop for
health insurance from a range of health plans in each exchange. The marketplace is
especially crucial for access to affordable and quality health care for those living in
rural areas where many are uninsured. Rural areas also tend to have greater numbers
of small businesses, as well as inhabitants who purchase health insurance on the indi-
vidual market. If many of the issues states face as they develop their marketplaces are
addressed successfully, then the necessary programs should be accessible for residents
of all areas in the U.S. including those in rural areas.16

Impact of the ACA: Benefits and Drawbacks

The Congressional Budget Office (2013) estimates that the ACA will result in 37 mil-
lion uninsured Americans gaining coverage. This foundation of increased insurance

55Ogundipe, Alam, Gazula, Olagbemiro, Osiezagha, Bailey, and Richie

coverage has been built on redesign and expansion of the small group and individual
health insurance market (described above in health insurance marketplaces) as well as
in an expansion of Medicaid (earlier discussed in our introduction).17 Besides having
the overarching effect of covering more individuals, the ACA has made a provision of
$15 billion for a Prevention and Public Health Fund. Administered over the next 10 years,
the fund is expected to improve health status through emphasis on preventive care.18
Improved health status of the population should lead to cost savings for both states as
well as the federal government.5

There are many other changes implemented through the ACA for primary care
providers and preventive health services. Such changes will allow for evaluation of the
effect of the Affordable Care Act on the field of Preventive Medicine.19 Those oversee-
ing the field will be able to consider the principal provisions of the ACA, differentiate
rates of preventive health services, and examine the coverage of preventive health
services under the Act. The new health insurance plans already cover recommended
preventive services without cost- sharing, enabling more patients to receive essential
health maintenance services.20 Under the ACA, Americans now have better access to
services such as blood pressure monitoring, diabetes and cholesterol screening, cancer
screening, routine vaccinations, pre- natal care, and regular wellness visits for infants
and children. The elimination of copayments, co-insurance, and deductibles should
improve access to quality health care and help prevent or detect serious conditions
before they are untreatable.21

The stipulation in its law that insurance companies are not to withhold coverage
to individuals based on pre- existing conditions, mentioned earlier, is a central accom-
plishment of the ACA.22,23 Additionally, the new law ensures health coverage for young
adults under the age of 26 who are now able to stay on their parent’s private insurance
plan.24 Furthermore, data provided by the White House show that more than 105 mil-
lion  Americans no longer have lifetime limits on their coverage, which means that
costs will no longer be shifted to insured patients who accumulate expenses exceeding
the dollar limits imposed by their insurance plans. Insurance companies may also not
arbitrarily terminate an insured’s policy without due cause. For more details on this
point, visit http:// www .whitehouse .gov/ healthreform/ health care- overview.

The ACA should improve the quality and efficacy of medical care in the U.S. at the
very least for legal U.S. residents (there is currently limited federal coverage for lawfully
present immigrants and undocumented immigrants), in particular those enrolled in
Medicare and Medicaid (including many homeless people). The new law was written
to strengthen the nation’s primary care foundation by raising reimbursement rates for
providers and introducing innovative delivery models such as patient- centered medical
homes. A key provision of the law provides a 10% primary care bonus to clinicians who
participate in the Medicare program. Medicaid payment rates to primary care physi-
cians have also been increased to match Medicare levels. Patient- centered medical care
homes will improve patient access to a regular source of primary care, provide a stable
and ongoing relationship with a personal clinician as well as timely and well- organized
health services that emphasize prevention and chronic care management. The Center
for Medicare and Medicaid Innovation (CMMI) has been set up to conduct innovative
payment and delivery system models that show promise for improving or maintaining

56 Remaking the American health care system

the quality of care in Medicare, Medicaid, and the Children’s Health Insurance Program
(CHIP) while slowing the rate of cost growth.21

While there has been significant support and hope for the future of health care due
to the successes already realized by the ACA, there has also been significant debate,
opposition, and disapproval since its passage and implementation. One key issue involves
states being allowed to opt out of Medicaid expansion. According to the Health Care
Advisory Board, as of May 22, 2014, 27 states (including the District of Columbia) are
participating, four states are considering expansion, and 20 states are not participating
in Medicaid expansion. More details on this point are available at http:// www .advisory
.com/ daily- briefing/ resources/ primers/ medicaidmap.

As previously noted, Medicaid expansion under the ACA has states receive substantial
federal funding to expand Medicaid to all residents with incomes at or below 133%
(with an additional 5% income allowance, thus making the standard 138%) of the FPL
(an income of about $31,809 for a family of four in 2012), thus expanding Medicaid
coverage to individuals who had previously been left out of the program. With health
insurance exchanges available to all legal residents and Medicare providing coverage
for elderly adults, the addition of all low- income, non- elderly adults to Medicaid by the
ACA should give almost the whole population access to affordable health insurance.
The June 2012 Supreme Court decision in National Federation of Independent Business v.
Sebelius, while largely upholding the constitutionality of the ACA, included protection

Figure 2. Where the states stand on Medicaid expansion.
Source: ©2014 The Advisory Board Company. All rights reserved.

57Ogundipe, Alam, Gazula, Olagbemiro, Osiezagha, Bailey, and Richie

for states that chose not to expand their Medicaid programs. This provision has resulted
in a substantial gap where the ACA as originally signed into law would have ensured
much more comprehensive coverage for residents of the states choosing to opt out of
Medicaid expansion. States not expanding Medicaid not only deny impoverished citizens
the coverage that the federal government is willing to finance, but also leave many who
are above the tax- filing threshold subject to the new tax on the uninsured. (There are no
tax subsidies provided by the ACA to individuals below 100% of the poverty level given
that these people were supposed to be covered by Medicaid.25) Another negative effect
of states opting out of Medicaid expansion is that disproportionate- share hospitals in
these states will feel more financial stress. These hospitals have been receiving payments
from the federal government for the high proportion of uninsured persons for whom
they provide, but will now see a drop in Medicaid and Medicare Disproportionate Care
Hospital funds (due to the assumption by the ACA that the number of uninsured and
underinsured would fall in all 50 states and D.C. beginning in 2014).26 Because a huge
proportion of the uninsured are mentally ill, the changes are likely to shut out needed
access for this group that would have been otherwise covered had the state opted to
expand Medicaid. Acute psychiatric care centers, and residential and outpatient services
are also expected to be negatively affected.27

Impact on Psychiatric Services

According to the National Alliance of the Mentally Ill (NAMI), in 2011 there were 45.6
million adults with mental health or substance use disorders. Prior to implementa-
tion of the ACA, over 11 million (24%) of U.S. adults were affected by mental illness
and lacked health coverage. The ACA offers new choices for quality, reliable, low cost
private health insurance while opening up coverage to more people living with mental
illness through the expansion of Medicaid. For more details, see http:// www .nami .org
/ Content/ NavigationMenu/ Inform_Yourself/ About_Public_Policy/ Issue_Spotlights
/ Health_Care_Reform/ ACA- FactSheet1_HealthReformMH .

The ACA builds on the Mental Health Parity and Addiction Equity Act of 2008
(MHPAEA) which had been the first step in bringing care for people with mental
health and addiction disorders into the mainstream of the U.S. medical care system
by requiring parity in behavioral health coverage (benefits for mental health and sub-
stance abuse equivalent to all other medical and surgical benefits). Going beyond the
federal parity law, the ACA requires that Medicaid plans as well as plans operating
through the state- based insurance exchanges cover behavioral health services as one
of the 10 required components of the essential benefits package. In combination the
two laws mandate coverage of mental health and substance abuse services on a par
with medical and surgical care for all those gaining coverage through the exchanges
and the Medicaid expansion. Additionally, the ACA’s delivery- system reforms seek to
address long- standing system fragmentation. There has been a lack of integration of
primary care and specialty behavioral health care and poor coordination for patients
with coexisting mental health and addiction disorders.28 Clinical trials of integrated
behavioral health and primary care models have demonstrated improvements in
physical health as well as mental health. People with mental illness and substance use

58 Remaking the American health care system

disorders have high mortality, poor health outcomes, and face significant barriers to
care. They experience high incidence and prevalence of preventable physical health
conditions including cardiovascular and respiratory diseases, diabetes, and HIV. Co-
occurring disorders are associated with high levels of both emergency department
use and unmet treatment needs. Under the ACA there are provisions that may lead
to greater integration and in turn bode well for improving coordination and quality of
care. Croft organizes these elements into three domains: increasing access, financing
and reimbursement changes, and infrastructure enhancements.27 Access is a critical
prerequisite to successful integration of care. The ACA should increase access through
expanding Medicaid, extending essential health benefits (including mental health
care at parity), and researching and tracking disparities to shape future policy and
practice changes for improving access. Patient- centered medical homes, accountable
care organizations (ACOs, groups of health care providers that enter in collaborative
agreements to share responsibility to improve quality and control costs), increased
reimbursement for primary care providers (described above in the section on the
impact of the ACA), and co-location of primary care and behavioral health services
are all changes in the financing and reimbursement structure that have the potential to
move systems toward integration. Finally, several elements of the ACA may enhance
infrastructure supporting integrated care. The Community- based Collaborative Care
Network Program established under the ACA promises to support a consortium of
providers to coordinate and integrate services for low- income uninsured and under-
insured populations. Additionally, the Federal Coordinated Health Care Office monitors
progress and provides technical assistance to states health plans, and to physicians to
develop more integrated programs of care, in particular, helping the mentally ill disabled
who are dually eligible for Medicare and Medicaid services to navigate both insurance

Preventive psychiatric services are also an area of focus, and some of the new provi-
sions for services include alcohol misuse screening and counseling for adults; depression
screening for adults and adolescents; domestic and interpersonal violence screening and
counseling for all women; tobacco use screening for all adults and cessation interven-
tions; alcohol and drug use assessments for adolescents; autism screening for children
18-24 months; behavioral assessments for children of all ages; developmental screening
for children under age three years, and surveillance throughout childhood. These new
provisions clearly increase access to behavioral health care and should go a long way
towards narrowing health care disparities.9

Alegria and colleagues conclude that the ACA’s policies and provisions to improve
patient education and the availability of community clinics, combined with insurance
coverage should reduce service disparities across racial/ ethnic groups. However, even
with expanded insurance coverage, approximately 10% fewer African Americans with
need for behavioral health services are likely to receive services compared to non- Latino
Whites (Latinos have no measurable disparity). This suggests that it may be necessary
to employ targeted services to reduce barriers to different groups, by such measures
as the creation of more community health centers in areas predominantly populated
by African Americans.29

59Ogundipe, Alam, Gazula, Olagbemiro, Osiezagha, Bailey, and Richie


The Affordable Care Act promises to make the health care system better for millions of
Americans, most notably by allowing young adults to remain on their parents insurance,
ending lifetime limits to insurance coverage, and the ability of insurance companies to
deny coverage based on pre- existing conditions. In taking measures to improve access
to insurance, strengthen Medicare and Medicaid, reduce health care expenditures, in
part, by placing greater emphasis on preventive care, the ACA should positively affect
the system of health care delivery in the United States. The provisions for expansion
of mental health care on a par with other kinds of care combined with the initiatives
for integration of behavioral health and primary care that should improve coordina-
tion and quality of care, in turn, should improve both physical health as well as mental
health. Disputes continue over many issues, in particular the continued lack of access
caused by states opting not to expand the Medicaid program. Weighing both sides, the
question remains if the reality of the policies instituted can live up to the great promise
of the ACA, and ultimately strengthen the U.S. health care system.

1. Blumberg LJ, Holahan J, Buettgens M. Its no contest: the ACA’s employer mandate

has far less effect on coverage and costs than the individual mandate. Washington,
DC: The Urban Institute, 2013. Available at: http:// www .urban .org/ UploadedPDF
/ 412865-ACA- Employer- Mandate .

2. Greenhalgh M. The Affordable Care Act: Medicaid expansion & healthcare
exchanges. Washington, DC: American Academy of Family Physicians, 2014:1– 13.
Available at: http:// www .aafp .org/ dam/ AAFP/ documents/ advocacy/ coverage/ aca
/ ES- MedicaidExpansion .

3. Chockley N, Murphy B, Schoenman J. Understanding the uninsured: tailoring policy
solutions for different subpopulations. Washington, DC: National Institute for Health
Care Management Research and Educational Foundation (NIHCM), 2008.

4. Garfield RL, Lave JR, Donohue JM. Health reform and the scope of benefits for mental
health and substance use disorder services. Psychiatr Serv. 2010 Nov;61(11):1081– 6.
http:// dx.doi .org/ 10.1176/ appi.ps.61.11.1081; PMid:21041345

5. DeNavas- Walt C, Proctor BD, Smith JC. Income, poverty, and health insurance cover-
age in the United States: 2011. Washington, DC: U. S. Census Bureau, 2012.

6. Baicker K, Congdon WJ, Mullainathan S. Health insurance coverage and take-up:
lessons from behavioral economics. Milbank Q. 2012 Mar;90(1):107– 34. http:// dx.doi
.org/ 10.1111/ j.1468-0009.2011.00656.x; PMid:22428694 PMCid:PMC3385021

7. Wilper AP, Woolhandler S, Lasser KE, et al. Health insurance and mortality in US
adults. Am J Public Health. 2009 Dec;99(12):2289– 95. Epub 2009 Sep 17. http:// dx.doi
.org/ 10.2105/ AJPH.2008.157685; PMid:19762659 PMCid:PMC2775760

8. Sommers BD, Long SK, Baicker K. Changes in mortality after Massachusetts health
care reform: a quasi- experimental study. Ann Intern Med. 2014 May 6;160(9):585– 93.
http:// dx.doi .org/ 10.7326/ M13-2275; PMid:24798521

9. Gauthier A, Cullen A. Reforming health care delivery thorough payment change
and transparency: Minnesota’s innovation. Washington, DC: National Academy

60 Remaking the American health care system

for State Health Policy, 2010. Available at: http:// www .nashp .org/ sites/ default/ files
/ Health_Care_MN_2010 .

10. National Center for Health Statistics. Health, United States, 2011: with special feature
on socioeconomic status and health. Hyattsville, MD: National Center for Health
Statistics, 2012. Available at: http:// www .cdc .gov/ nchs/ data/ hus/ hus11 .

11. The Commonwealth Fund. New health insurance survey: 84 million people were
uninsured for a time or underinsured in 2012; nearly decade- long trend of rising
uninsured rates among young adults reversed. Washington, DC: The Commonwealth
Fund, 2013. Available at: http:// www .commonwealthfund .org/ ~/ media/ files/ news
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The ACA and behavioral health: A look ahead
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