My recent Circle – How Many Consumers With An SMI Or Addiction Will Be Covered Under Medicaid Expansion? all members – garnered quite a bit of attention from readers. Namely, some of them questioned the validity of estimates by The Substance Abuse and Mental Health Services Administration (SAMHSA) for the prevalence of serious mental illness (SMI) and substance use disorder (SUD) in populations newly covered under Medicaid expansion – largely non-disabled adults.
These readers’ “on the ground” experience led them to believe SAMHSA’s estimates are way too low. For example, using San Diego and the state of California as reference points, the reader is “spot on” – no statewide estimate for California is going to capture San Diego’s local (densely populated and urban) realities. So with this in mind, I re-framed the analysis for a “back of the envelope” approach that brings these estimates closer to an organization’s service delivery “home.”
Three important points about the SAMHSA prevalence estimates to keep in mind:
They exclude institutionalized populations so that those with SMI and/or SUD who cycle in and out of correctional settings (or are in psychiatric institutions) are not captured.
Homeless living in group quarters (for example, shelters) are included, but homeless not in group quarters (for example, on the streets or in corrections) are not captured.
The estimates are made at the state level and will understate prevalences in urban areas where the uninsured (and homeless) tend to be concentrated and overstate prevalences for rural areas.
So how to adjust? In the case of California, the California Institute of Mental Health (CIMH) has published a series of briefs on the likely impact of Medicaid expansion on mental health utilization and provides estimates by county. Other states may have associations or advocates who have also developed similar supporting documentation. If you are looking (and not finding) this information for your state, there are some “ball park” approaches for adjusting that can help you capture your own client-base demographics and likely service demand.
Step One: Access the federal Census Bureau’s American FactFinder website. To make this easy, I have done the work for you by identifying a supremely useful and exciting FactFinder table that details the number of individuals by income and insurance status for each Metro (and Micro) Area for 2012. The dataset includes 1,054 areas arranged alphabetically from Aberdeen, Washington to Zanesville, Ohio. (Note: Like the SAMHSA survey, the Census Bureau data sets also exclude institutionalized populations.)
Step Two: Sum the data for your service area for adults ages 18-64 with no health insurance within three categories of income – under 0.50 of poverty threshold, 0.5-0.99 of poverty threshold, and 1.0-1.37 of poverty threshold – in order to capture the numbers of uninsured individuals newly eligible for Medicaid in 2014.
Step Three: Pull SAMHSA’s estimate for SMI and SUD prevalence for the Medicaid expansion population for your state.
Step Four: Multiply!
The table below captures the results following this approach for the San Diego metropolitan area:
|San Diego-Carlsbad-San Marcos, CA Metro Area, 2012, Ages 18-64|
|Income||No Health Insurance||# With SMI(SAMHSA Estimate: 4.4%)||# With SUD (SAMHSA Estimate: 10.3%)|
|˂0.50 of poverty level||54,444||2,396||5,608|
|0.50-0.99 of poverty level||57,787||2,543||5,952|
|1.00-1.37 of poverty level||62,066||2,731||6,393|
|Total (Newly Medicaid Eligible)||174,297||7,669||17,953|
Implications for providers? Although this approach cannot capture those with SMI and/or SUD who are homeless or cycling through correctional facilities, these individuals are not likely to be present among those newly covered by Medicaid in 2014. Issues with engaging individuals who are homeless on a consistent (i.e., non-crisis) basis will remain as will the ineligibility of individuals who are ineligible for Medicaid while incarcerated. That said, you can combine SAMHSA’s prevalence estimates with Census Bureau numbers for a “back of the envelope” handle on the number of newly insured who may access your services in 2014 and for use in your planning and grant-writing efforts.
For another free resource, see: Health Care Reform Update: State Medicaid Expansion Calculus all members