This number includes an estimated 1.3 million adults with  a serious mental illness who did not receive any mental health services. Patient Protection and Affordable Care Act

The number of states that have expanded Medicaid includes the District of Columbia,  which we refer to as a state of for the purposes of this report. State  BHAs manage behavioral-health-related federal grants and may work  with other state agencies—such as state Medicaid agencies—to identify  and treat mental health and substance use conditions. An Estimated 3 Million Low-Income Uninsured Adults Had a Behavioral Health Condition, with Half Living in States that Have Not Expanded Medicaid

Nationwide, estimates using data from 2008 to 2013 indicated that of   17.8 million low-income, uninsured adults, approximately 3 million   (17 percent) had a behavioral health condition prior to the Medicaid  expansion in 2014. Underlying these national  estimates was considerable variation at the state level. The estimated prevalence of behavioral health conditions overall among  low-income, uninsured adults was about 17 percent, on average, in both  expansion and non-expansion states. Selected Non- Expansion States Offered Treatment Options for Uninsured Adults, but Primarily Provided Treatment to Those with the Most Serious Behavioral Health Needs

State BHAs in the non-expansion states we examined offered a variety of  behavioral health treatments for low-income, uninsured adults. coverage. States Set Priorities to Focus Care on Those with the Most Serious Behavioral Health Needs and Used Waiting Lists for the Remaining Individuals

The selected non-expansion states established priority populations for  providing behavioral health treatment to those with the most severe  behavioral health needs. Texas officials said that they triage individuals eligible for behavioral  health treatment, and those with less urgent needs may have to wait. Selected Expansion States Generally Managed Behavioral Health Separately from Other Benefits, Reporting Increased Treatment Availability, but Some Continuing Access Concerns

Selected states generally managed behavioral health benefits for newly  eligible Medicaid enrollees separately from physical benefits through  carve-outs or separate contracts. According to state officials, expanding Medicaid has increased  the availability of behavioral health treatment, although some access  concerns continue. Selected Expansion States Reported Increased Availability of Behavioral Health Treatment, but Cited Some Ongoing Access Concerns

Officials we interviewed from the six expansion states generally reported  that Medicaid expansion had resulted in greater availability of behavioral  health treatment, and changes were greater in states without previous  coverage options for low-income adults. Officials from all six states cited behavioral health workforce  shortages as a challenge to providing behavioral health treatment for low- income adults in their states. Agency Comments

We provided a draft of this report to the Department of Health and Human  Services for review. HHS provided technical comments, which we  incorporated as appropriate.
Why GAO Did This Study

Research has shown that low-income individuals disproportionately experience behavioral health conditions and may have difficulty accessing care. Expansions of Medicaid under PPACA raise questions about states' capacity to manage the increased demand for treatment. Additional questions arise about treatment options for low-income adults in non-expansion states.
GAO was asked to provide information about access to behavioral health treatment for low-income, uninsured, and Medicaid-enrolled adults. This report examines (1) how many low-income, uninsured adults may have a behavioral health condition; (2) options for low-income, uninsured adults to receive behavioral health treatment in selected non-expansion states; and (3) how selected Medicaid expansion states provide behavioral health coverage for newly eligible enrollees, and how enrollment in coverage affects treatment availability.
GAO obtained estimates of low-income adults who may have a behavioral health condition from the Substance Abuse and Mental Health Services Administration. GAO also selected four non-expansion and six expansion states based on, among other criteria, geographic region and adult Medicaid enrollment. GAO reviewed documents from all selected states, and interviewed state Medicaid and BHA officials to understand how uninsured and Medicaid-enrolled adults receive behavioral health treatment. The Department of Health and Human Services provided technical comments on a draft of this report, which GAO incorporated as appropriate.

What GAO Found

Nationwide, estimates using 2008-2013 data indicated that approximately 17 percent of low-income, uninsured adults (3 million) had a behavioral health condition, defined as a serious mental illness, a substance use condition, or both. Underlying these national estimates is considerable variation at the state level.
The estimated number of low-income, uninsured adults with behavioral health conditions was divided evenly between states that did and did not subsequently expand Medicaid under the Patient Protection and Affordable Care Act (PPACA).
Behavioral health agencies (BHA) in four selected non-expansion states offered various treatment options for low-income, uninsured adults, focusing care primarily on those with the most serious behavioral health needs. To do so, BHAs in all four selected states established priority populations of those with the most serious behavioral health needs. Also, BHAs in three of the four states maintained waiting lists for adults with less serious behavioral health needs.
Six selected states that expanded Medicaid generally managed behavioral health and physical health benefits separately for newly eligible enrollees, and state officials reported increased availability of behavioral health treatment, although some access concerns continue. Four of the six selected states explicitly chose separate contractual arrangements for behavioral health and physical benefits. Officials from all six selected states said that enrollment in Medicaid increased the availability of behavioral health treatment for newly eligible enrollees. Officials also reported some ongoing access concerns, such as workforce shortages.