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Behavioral Health: Options for Low-Income Adults to Receive Treatment in Selected States

GAO-15-449 Published: Jun 19, 2015. Publicly Released: Jul 20, 2015.
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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.

Estimated Percentage of Low-Income, Uninsured Adults with Behavioral Health Conditions Based on 2008 to 2013 Data, Highest and Lowest Five States

Estimated Percentage of Low-Income, Uninsured Adults with Behavioral Health Conditions Based on 2008 to 2013 Data, Highest and Lowest Five States

Note: Analysis of highest and lowest five states excludes four states that were not reported because percentages were estimated with low precision.

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.

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.

For more information, contact Carolyn L. Yocom at (202) 512-7114 or

Full Report

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AdultsCommunity-based mental health servicesDisadvantaged personsHealth care programsHealth care servicesLabor shortagesManaged health careMedicaidMedically uninsuredMental health care servicesMental illnessesPatient care servicesPrescription drugsSubstance abuse