The federal government offered U.S. states the option to provide inpatient treatment to more Americans with serious mental illnesses, allowing them to get around a decades-old restriction on reimbursement by their Medicaid programs, which covers the poor.
Health and Human Services Secretary Alex Azar told state Medicaid directors at their annual meeting in Washington on Nov. 13 they could apply for waivers that would lift the restrictions on reimbursement for inpatient treatment at institutions for mental diseases, or IMDs.
An IMD is a hospital, nursing facility or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care to people with mental illnesses, including medical attention, nursing care and related services.
Congress created the restriction on Medicaid reimbursement — the IMD exclusion — to discourage states, which traditionally provided mental illness care, from offloading those responsibilities onto the federal government, Azar said.
What happened, though, was access to inpatient treatment and other options for mental health care for the poor became limited.
"There are so many stories of Americans with serious mental illness and their families that end in tragic outcomes because treatment options are not available or not paid for," Azar said.
The waivers are an opportunity for the federal government to work with states to "right this wrong," he said.
"More treatment options are needed and that includes more inpatient and residential options that can help stabilize Americans with serious mental illness," the HHS secretary said.
Successful program
Azar noted the waivers have been used to provide more flexibility for treating Medicaid beneficiaries with substance-use disorders — a practice first employed by the Obama administration in 2015 to combat the U.S. opioid crisis, an epidemic that claims the lives of about 115 Americans each day.
The Trump administration unveiled an expedited process last year and has since approved 13 waivers, with a "number of others in the pipeline," Azar said.
To date, 17 states have received the waivers, according to the Centers for Medicare and Medicaid Services.
So far, the results of using the waivers have been "impressive," Azar said.
An independent assessment of Virginia's waiver, granted in 2016 by the Obama administration to test a substance-use disorders program, showed there was a 39% decrease in opioid-related emergency-room visits and a 31% decrease in substance-use-related ER visits overall, the health chief said.
In addition, the number of residential treatment centers expanded dramatically, as did the number of opioid-specific treatment programs, he said.
Azar urged the state Medicaid chiefs to apply for the waivers to "help build a system where Americans with serious mental illness and their families can finally find the treatment and support they need."
But he emphasized inpatient treatment was "just one part of what needs to be a complete continuum of care."
Participating states will be expected to take a number of actions to improve their community-based mental health care services, Azar said.
Commitments
In a Nov. 13 letter to state Medicaid directors, CMS laid out a number of goals and milestones the agency expected waiver recipients to meet. They also must report information to the agency on their performance in meeting those measures.
"There are effective methods for treating the seriously mentally ill in the outpatient setting, which have a strong track record of success and which this administration supports," Azar said.
Investments in inpatient and outpatient mental health care are "necessary and both are too hard to access today," he added.
In a statement, CMS said it plans to offer the waivers to up to 12 states that have already expressed interest in expanding access to community and residential treatment services for the full continuum of mental health and substance-use disorders.
The agency noted that about a quarter of individuals with serious mental illnesses also have co-occurring substance-use disorders.