PORTLAND, Ore. — For years, Edd Blott couldn’t hold a steady job — that is until this past summer.
The reason: Oregon, unlike Georgia, chose to expand its Medicaid health program for the poor.
Molested by a neighbor boy at the age of 8, Blott experienced his first psychotic episode as a teenager and holed up in his parents’ basement for long periods. A suicidal Blott landed in a hospital psychiatric ward for the first time in his early 20s. Nearly a dozen more hospitalizations would follow.
Eventually Blott, now 31, was diagnosed with bipolar and borderline personality disorders and post-traumatic stress. Uninsured and desperate for medications to treat his illnesses — medications he couldn’t afford — Blott began entering clinical trials for treatments and drugs he knew nothing about.
That all changed with Medicaid. He now pays $1 for medications that would have cost him $3,000 a month without insurance.
“I can’t do that,” he said. “And without the meds, I very likely would be dead right now.”
The number of Oregon adults receiving treatment for anxiety disorders, major depression, schizophrenia and other mental illnesses has increased by nearly 60 percent since the state expanded Medicaid under the Affordable Care Act in 2014. The number receiving help for substance abuse has more than doubled. Hospitals, charity clinics and other health care providers, meanwhile, have received an infusion of hundreds of millions of dollars to help treat them.
Thirty states have expanded Medicaid under Obamacare. Nineteen — including Georgia — have not.
Gov. Nathan Deal and conservative state legislators have said repeatedly that Georgia cannot afford to expand its already massive Medicaid program, which cost the state about $2.8 billion in fiscal 2015.
Deal is working in other arenas, however, to boost services for mentally ill Georgians.
Since taking office in 2011, Deal has been a key proponent of special mental health courts that seek to get people with psychiatric disorders the treatment they need instead of locking them up in jails. The number of these courts across Georgia has more than doubled in that time to 24.
Legislation passed earlier this year, and supported by the governor, encourages more counties to establish mental health courts by tying their creation to pay increases for judges, public defenders and district attorneys, said Deal spokeswoman Jen Talaber.
Deal is also pushing for similar courts for children and adolescents and established a council on child welfare reform that is looking at ways to treat children with mental illness, Talaber said.
“The governor recognizes the need for services for those suffering from mental health illnesses,” she said. “And he’s working to address it on every level.”
‘We went from zero to 60’
Daylight streamed through wall-to-wall picture windows into the lobby of Sequoia Mental Health Services on an August afternoon in Aloha, a bedroom community west of downtown Portland. A pastel pink and blue quilt that says “welcome” adorned one wall.
But the serene surroundings at the center belie the hectic pace its staff has maintained since Oregon expanded Medicaid in January 2014. The small nonprofit served about 800 people that month; that number jumped to 1,200 eight months later.
“We went from zero to 60 in a few months,” said Sequoia executive director Marcia Hille. “We’re still scurrying to catch up.”
Expansion has strained mental health systems across the nation, with many states already suffering severe shortages of psychiatrists, counselors and other professionals.
Qualified staff is hard to come by, Hille said. Sequoia has increased full-time workers from 60 to 90 since expansion. But the center can’t pay as much as private practices and hospitals, she said. Medicaid typically pays far lower than the actual cost of care — and of what private insurance pays — for both mental and medical services.
Medicaid coverage doesn’t automatically equal access to care, said Chris Bouneff, head of the nonprofit NAMI Oregon, a chapter of the National Alliance on Mental Illness. Affordable housing for people with mental illness also remains scarce.
Despite those challenges, Medicaid expansion has changed the game in Oregon.
“We had a lot of people with no coverage whatsoever,” Bouneff said. “In our state, expansion has been a godsend.”
‘Are they getting better care? We’ll see’
Indeed, mental health professionals in Oregon say Medicaid expansion has been a huge boon to the state, opening up access to care for some of its poorest, most vulnerable citizens.
About one in four Oregonians, roughly 1.1 million people, are now enrolled in the program.
Statewide, emergency department visits by Medicaid recipients have fallen 22 percent since 2011, despite the addition of nearly half a million people to the rolls, a report released in June by the Oregon Health Authority shows. Mental health costs for both inpatient and outpatient hospital care have also declined over that time.
Oregon’s uninsured rate fell to 9.7 percent last year, down from nearly 15 percent in 2013, according to the Census Bureau. (Georgia had the fourth-highest uninsured rate in the country in 2014, at 15.8 percent.)
It will take time to fully analyze how expansion affects access to and the quality of mental health care, said Dr. David Pollack, a psychiatrist and public policy expert at Oregon Health & Science University.
“Are they getting better care?” Pollack said. “We’ll see.”
At Legacy Health, one of Portland’s largest health systems, the percentage of uninsured patients with mental illness has fallen from 25 percent to 6 percent.
“All of these very fragile, very vulnerable people … they’re getting connected to primary care and specialists,” said Chris Farentinos, director of Legacy Health’s behavioral health program. “This is unheard of. It’s unbelievable.”
The health system recently joined with other Portland hospitals to build a new four-floor hospital psychiatric unit. The project will also include a special psychiatric ER designed to create a warm, inviting atmosphere with lots of open space and recliners.
When people with mental illness end up in regular ERs, their condition can actually get worse, increasing their chances of having to be hospitalized, Farentinos said.
The new psychiatric unit and ER are possible, in large part, because the Medicaid expansion and overall health care transformation the state is undergoing has created an atmosphere where providers are working together, she added.
“It is unprecedented,” she said. “I think the Affordable Care Act created this opportunity in many ways.”
‘That would really change the world’
Since 2011, Georgia has pumped roughly $1.14 billion into dozens of new community-based adult mental health services as the result of a federal lawsuit that took aim at the deplorable conditions of state mental hospitals.
The state has met and even surpassed some of those demands, including providing regular and intensive case management for nearly 3,000 people. The governor has also been an important supporter of growing other types of services, such as the mental health courts, said state Sen. Renee Unterman, a Gwinnett County Republican on the state’s Behavioral Health Coordinating Council.
But “the task is so monumental, you can’t blink your eyes overnight and get results,” Unterman said.
Expanding Medicaid, while far from an absolute remedy, would improve access to care for tens of thousands of uninsured Georgians, mental health providers and advocates say. An estimated 233,000 Georgia adults with serious mental illness or substance abuse issues would gain access to health insurance if the state opted to expand, according to a study by the American Mental Health Counselors Association.
People with mental illness die 25 to 30 years sooner than average Americans, mostly because of chronic diseases that go untreated, said Sherry Jenkins Tucker, executive director of the Georgia Mental Health Consumer Network. Medicaid expansion would bring much better access to many more people and improve the quality of their lives, Tucker said.
“That would really change the world for people,” she said.
To serve more people, Georgia has to have more staff, more physicians, said Robyn Garrett-Gunnoe, head of the Georgia Association of Community Service Boards. The boards, which serve as the state’s public mental health system, suffer from a crush of patients every day.
“We’d all be better off if there was additional funding sources from anywhere and everywhere,” she said. “We don’t seem to have a clear answer for that.”
The politics of Medicaid expansion
When the Affordable Care Act was first enacted, nearly every Republican-controlled state refused expansion, seeing it as an unprecedented attack by the federal government on states’ autonomy. But that’s changing.
In the past few years, at least half a dozen red states have changed course to expand their Medicaid programs, including Arkansas and Indiana. Many leaders in those states, Republican and Democrat alike, see the move as a smart business decision. With expansion comes billions of federal dollars to help hospitals stay afloat, create new jobs and boost the economy.
If Georgia expanded, it would receive $35 billion in new funding and create more than 50,000 new jobs in the first decade alone, according to estimates from Georgia State University.
“The state is paying for (adult mental health services) that could have been covered 100 percent by Medicaid,” said state Rep. Pat Gardner, D-Atlanta.
The door to expansion, however, remains firmly shut.
This General Assembly will not approve expansion, said Unterman. Instead, Unterman said she is focused on continuing to fund the new mental health services the state has created and on increasing pay for Medicaid providers.
That will be a challenge as state agencies fight for funding during the legislative session, she said.
“There’s always going to be a tug and pull, and there are always going to be people who say let the homeless take care of the homeless,” she said. “It’s a reflection of our society.”
‘There’s so much I need to say’
Blott, who with Medicaid can afford medication to keep his illnesses in check, got a job this past summer managing an apartment complex part-time.
“I’m really excited about it,” said Blott, who together with his fiancée has three children at home. “It makes me feel proud. I am taking care of my family.”
It’s the first time he’s been able to hold a day job since 2009, when he got fired after flashbacks triggered by past trauma sent him into a tailspin while on the job. He hasn’t been hospitalized in more than a year.
In his spare hours, Blott produces independent films that focus on mental illness and recovery. “A Tale of Delight,” the story of a young illustrator who witnesses his wife’s death, deals with many of the same mental health challenges he has faced in his own life — PTSD, depression and suicide.
“I’ve always been interested in storytelling,” he said. “There’s so much I need to say.”
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