Mapping out Medicaid Expansion, Workforce Development and Behavioral Health Needs

Background and Purpose: Since the passage of ACA in 2010, over 15 million Americans (5%) are now covered by insurance and have access to health care through state health insurance marketplaces and Medicaid expansion (Andrews & Brown, 2015). Many of those newly insured have complex medical problems as well as behavioral health disorders. More than 25% of all Americans have multiple chronic health conditions (Anderson, 2010). This takes its toll on population health outcomes and exacerbates health disparities for marginalized groups (Thayer & Kuzawa, 2011). The ACA triggered a renewed focus on prevention and curtailing exorbitant health care costs through integrated models of care that treat behavioral and physical health conditions (SAMHSA, 2013; 2014). In 2014, the Health Resources Service Administration (HRSA) awarded over $27 million to 62 social work (SW) programs to prepare MSW students to work in integrated health care settings (CSWE, 2014). The Department of Labor (2014) projects a nearly 20% increase by 2022 in the need for the social work profession to address health care and behavioral health needs. Despite the increasing federal investments in this area, a gap exists between those who need services and coverage and how states support this expansion. 

Methods: This study assesses the convergence in insurance coverage with federal efforts to expand the behavioral health workforce. Spatial maps were used to identify areas of disparity in coverage and growing workforce demands. ArcGIS (McCoy, 2004) was used to analyze the spatial distribution of states that have adopted Medicaid expansion and states who received HRSA funding to expand the behavioral health workforce through SW programs. Spatial maps examined areas of overlap, disparity in coverage, and growing workforce demands.

Results: As of April 2016, 18 states (35%) out of 51 states did not receive HRSA funding to expand the behavioral health workforce, and 19 states (37%) opted not to expand Medicaid as part of the ACA’s effort to increase the number of insured Americans. We further found that 7 states (14%) neither have HRSA funded SW programs nor adopted Medicaid expansion, whereas 21 states (41%) have both. Additionally, 11 states (22%) do not have HRSA funded SW programs but have adopted the Expansion, whereas 12 states (24%) have HRSA funded SW programs but have not adopted the Expansion. Maps demonstrated that lack of alignment between Medicaid Expansion and HRSA funded SW programs was concentrated in the Middle and Southeastern U.S.

Conclusions and Implications: This study found substantial discrepancies in workforce needs and workforce training. The ACA’s purposes include improving access to services, enhancing quality of care, and lowering costs (Bachman, 2011). However, unmet behavioral health needs have long-term effects on life course outcomes and collective public expenditures for housing, education, employment, disability, income support, criminal justice, and other social welfare services (SAMHSA, 2014). Without Medicaid expansion and a trained workforce, behavioral health needs will continue to be unmet. Future research is needed to demonstrate the impact of workforce training and access to Medicaid on behavioral health outcomes and inform advocacy efforts.