Mental Health and Addiction
Ohio’s community mental health and addiction services system includes both Medicaid and non‐Medicaid services coordinated through local boards of alcohol and drug addiction and mental health (ADAMH) services. Medicaid services are not coordinated by managed care organizations, unlike most of the rest of the program (the “carve‐out”). Starting in the late 1980s, the state and federal governments shifted their policies from utilizing state hospitals to emphasizing treatment in community settings. Sufficient funding did not follow suit, however, leaving gaps not only in treatment services but in wrap‐around supports as well, such as transportation, housing, and employment. The state still maintains six mental health hospitals, mostly for individuals committed through the criminal justice system. State funding for community treatment and related services was decimated in the 2010‐2011 biennium but the funding picture has shifted in recent years. In the 2012‐2013 budget, the responsibility of making the nonfederal share of Medicaid payments for covered mental health services was “elevated” from the local mental health boards to the state Department of Job and Family Services (now these payments are made by the Department of Medicaid). Total Medicaid payments for mental health services were $558.6 million in FY 2012, and will grow substantially because of the Medicaid extension. In previous biennia, local boards used their share of state‐funded Medicaid matching dollars and local levy dollars, if the state dollars did not cover the full amount, to fund the nonfederal portion of Medicaid. With elevation, the state took over this responsibility completely, which freed up local levy dollars to be used to fill in gaps and cover services that are not covered by Medicaid (non‐Medicaid services). The 2014‐2015 biennium began with the merger of the Department of Mental Health (ODMH) and the Department of Alcohol and Drug Addiction Services (ODADAS) into the Department of Mental Health and Addiction Services (MHAS). The agencies that address mental health and alcohol and drug addiction are merged at the national level and at most of the local boards in Ohio. Combining these agencies also helped to align fiscal reporting and policy changes that are required of the local boards by the state.1 In 2014, the Mid‐Biennium Review (MBR) incorporated language requiring local boards of Alcohol Drug Addiction and Mental Health to provide a full array of services defined as a continuum of care. The continuum of care includes specific treatment services for all levels of opioid and co‐occurring drug addiction which must be available by September 2016. The services must include at least ambulatory and sub‐acute detoxification, non‐intensive and intensive outpatient services, medication‐assisted treatment, peer mentoring, residential treatment services, recovery housing, and 12‐step approaches.2
Figure 1 shows the sources of mental health and addiction board service expenditures in 2013. The figure does not include Medicaid. It is clear that local funding, through the county board system, plays an important role in financing community mental health services.
Figure 1
Sources of Mental Health and Addiction Service Expenditures in Ohio, SFY 2013
Source: 040 Board Financial reports for SFY 2013. Does not include Medicaid spending. Figure 2 shows the amount of state funding dedicated to community behavioral health, not including Medicaid. To be consistent, community behavioral health spending is tracked in both ODADAS and ODMH in 2012 and 2013, and in the merged MHAS in 2014 and 2015. This figure follows the same “pots” of money from the separate into the merged agencies, and includes the $47.5 million Community Behavioral Health line item that was added to the FY 2014‐2015 budget in an attempt to compensate for the removal of the Medicaid extension (which was later approved via the State Controlling Board). This line item, and the funding associated with it, was not included in the 2016‐2017 budget proposal. This is evident in the drop in community behavioral health funding in Figure 2. Local 44% State 11% Federal 41% Other 4%
Addiction
Local 71% State 18% Federal 8% Other 3%Mental Health
Figure 2
State Funding for Community Mental Health and Addiction
Source: LSC 2016-2017 Budget in Detail.
Does not include all sources of state funding, only those determined to be community behavioral health.
Does not include Medicaid funding. With the rollout of expanded health coverage under the Affordable Care Act through private insurance plans and Medicaid, treatment needs associated with mental health and addiction issues will be covered for more people than ever before. Expanded coverage will eventually allow state and local funds to be freed up to support maintaining recovery in the community, $20,000,000 $40,000,000 $60,000,000 $80,000,000 $100,000,000 $120,000,000 $140,000,000 $160,000,000 FY 2012 FY 2013 FY 2014 FY
2015-Estimate FY 2016- AsIntroduced FY 2017- AsIntroduced
Early Childhood Mental Health Counselors and Consultation (MHAS) Recovery Housing (MHAS)
Criminal Justice Services (MHAS)
Continuum of Care (MHAS)
Community Behavioral Health (MHAS)
Community Innovations (MHAS)
Local MH Systems of Care (ODMH)
Community Medication Subsidy (ODMH)
Forensic Services (ODMH)
Treatment Services (ODADAS)
otherwise known as supportive or wraparound services. These services include housing, employment, transportation, and education, among others, that are funded by a mix of local levy and state dollars and are not covered under the state’s Medicaid program or by private insurance plans. In SFY 2011, $138.3 million was spent on these services by 46 of the 50 mental health boards in the state.3 With coverage under health reform, it is expected that, in the coming years, more of the local boards’ funding will be dedicated to wraparound services as people are able to access treatment with other payer sources. Impact of Opioid Addiction A major challenge facing MHAS and the local system of alcohol and drug addiction and mental health boards is opioid addiction. Opioids are a class of drugs including heroin and powerful pain relievers such as morphine, oxycodone (e.g., OxyContin), hydrocodone (e.g., Vicodin), and codeine. More than a quarter of ODADAS clients had an opiate diagnosis in 2012.4 As seen in Figure 3, accidental drug overdoses more than quadrupled between 2000 and 2012. Opioids are a growing component in these deaths. In 2000, 48 percent involved opioids. That percentage rose to 66 percent by 2012. Deaths involving prescription opioids decreased for the first time in 2012. This corresponds to the implementation of House Bill 93 (129th General Assembly) in 2011, which shut down pill mills by tightening the regulation of prescribing pain medications. Deaths involving all opioids continued to grow that year, however, indicating an apparent shift from prescription opioids to heroin. Figure 3
Number of Deaths in Ohio from Unintentional Drug Overdose
Note: More than one drug is usually involved in a single death.
Source: ODH Office of Vital Statistics
All drugs, 1,914 All Opioids, 1,272 Prescription opiods, 697 200 400 600 800 1,000 1,200 1,400 1,600 1,800 2,000 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Rising opiate abuse also harms the younger generation. Neonatal Abstinence Syndrome (NAS) occurs when a child who is prenatally exposed to opioids experiences withdrawal upon birth. Hospitalization rates for NAS in 2013 were more than eight times greater than in 2004, increasing from 14 to 125 hospitalizations per 10,000 live births. House Bill 315, signed by the governor in April, 2014, will require hospitals to report incidences of NAS to the Ohio Department of Health. Figure 4
NAS Inpatient Hospitalization Rate, per 10,000 live births
Source: Ohio Hospital Association.
