ACA: Challenges and Opportunities for Care of the Severely Mentally Ill


ACAWe know the health care system is broken and strained to its limits. Let’s see how the ACA is approaching this challenge, especially for the mentally ill.

When the Affordable Care Act (ACA) is fully implemented in 2019, it will extend health insurance to an estimated 4 million people with severe mental disorders who were previously uninsured. An opinion piece, published in JAMA on October 2, 2013, “Investing in Evidence-Based Care for the Severely Mentally Ill,” by Mark Olfsen, MD, MPH and colleagues, explores the challenges and the opportunities that the ACA poses for care of the severely mentally ill.

Our system of caring for people with mental illness is already stretched to its capacity—witness the long waits for services experienced by psychiatric patients in the emergency departments. An article, “Medical Professionals Say ER Treatment For Psychiatric Patients Is Woefully Inadequate,” by Andrew Stein expresses the strain one state’s hospitals are subjected to with our current health system for the mentally ill. Further, primary care provider (PCP) offices are chock full now, and many are already fearful of the impact of the ACA on their already jammed schedule. An article titled “Where Have All the Primary Care Doctors Gone?” by Pauline Chen, MD explains how the impact of the ACA concerns many PCPs and deters those aiming to become PCPs.


Collaborative Care

One way in which scarce mental health and primary care resources can deliver care more efficiently to patients with serious mental illness is a model called collaborative care. The collaborative care model is an approach to integration of both physical and behavioral health services in which PCPs, care managers, and psychiatric professionals work together to provide care and monitor a psychiatric patient’s progress. This has been proven to be clinically-effective and cost-effective for a number of mental health conditions. According to the article, it also “reduces the burden on primary care physicians by locating a mental health specialist within primary care, establishing simple mental health treatment protocols, providing mental health screenings and education, and conducting ongoing outcome measurement – usually with the assistance of a nurse practitioner or case manager.” However worrisome the scenario of increased demands is, it is important to recognize that the ACA has provisions that can help to mitigate the problem. Listed below are the available programs:

  • Section 2703 encourages states to develop Health Homes for Medicaid enrollees with multiple chronic conditions
  • Section 5405 prompts training of PCPs in the management of psychiatric disorders through primary care extension programs
  • Section 5306 provides mental and behavior education and training that supports teaching mental health professionals new clinical skills
  • Section 2402 reduces several historical barriers by granting states greater flexibility in designing their benefits package and expanding eligibility to their employment service programs
  •  Section 3022 has accountable care organization models that similarly mirror the collaborative care model, which includes a team-based structure, an orientation toward anticipating clinical needs, and care coordination across provider settings


Investment in Evidence-based Care

The authors point out that we need to make a serious investment in evidence-based care for individuals with serious mental illnesses, like bipolar disorder and schizophrenia. This means training physicians in the use of two drugs proven to be life-saving in those conditions: lithium and clozapine. As stated in the article, “lithium is the only medication known to reduce suicidal behavior in those with bipolar disorder.” However, anticonvulsant and antipsychotic medications, which have mood-stabilizing properties but show no reduction to suicidal behavior, are being used instead of lithium due to extensive marketing by pharmaceutical companies.

This in turn results in many psychiatrists and health specialists having less experience with lithium, and thus are reluctant to prescribe it. With training through the ACA, however, they will be able to acquire the necessary experience and confidence to treat their patients with “bipolar disorder and a history of suicidal behavior with lithium, including balancing its benefits against increased risks of reduced renal function, weight gain, hypothyroidism, and hyperparathyroidism.”

Clozapine, on the other hand, is the only antipsychotic medication with effectiveness in treatment-resistant schizophrenia and in reducing suicidal behaviors in schizophrenia. Despite required blood monitoring and concerns over clozapine-associated weight gain, many schizophrenic patients can benefit from it. With the education and trainings grants available through the ACA, psychiatrists will be provided with “expert in-service consultations in pharmacological management of treatment-resistant schizophrenia with clozapine.

The expansion of health insurance under the ACA offers enhanced health benefits for patients with serious mental illness as well as providing for improved infrastructure for a more efficient and better utilized mental health model.


  1. While this is needed, this is what the Navy calls a “Dream Sheet”, where a sea going sailor makes a short list of places for land duty. It seldom happens. With being said, I know that it can work, because it works for my son.

    But I see several problems, the first being the ACLU, and their fierce defense of civil liberties. It’s one of the many reasons that many mentally ill people do not get care, and families cannot get care for family members.

    The next problem is the patient. How long does it take for 3 shrinks to change a light bulb? Nobody knows, because the light bulb must want to change. Several problems that mental patients and their families face are deeper than medication. Often patients feel better and stop taking their meds, which causes relapses of various severity and length. During this relapse, paranoia that’s combined with feelings of inadequacy usually kicks in. It is almost impossible to get the ill friend, family member anywhere for treatment. If the patient was being reasonable, in control of their emotions, nobody would be trying various ways to take the suffering person that’s having a mental crises. Bluntly, this is usually when someone calls 911. The police arrive, and quite often shoot the person that’s suffering from paranoia and an emotional break down.

    What about the set up costs for re-opening state run mental institutions? How can we separate the violent from those that just can’t cope on their own? All of this would be challenged in the legal system.

    The family often isn’t as supportive as they should be. Does a parent, sibling, other relative, or friends offer a drink, a beer, a joint, illegal use of prescription drugs, the use of street drugs? As my son wrote in a poem for the VA, it’s a paraphrase but close to what he wrote–I can’t trust my mind, I lost my navigation, my compass doesn’t work. I see warning lights where there aren’t any. I miss the lighthouses’ warning and run aground. I’m in danger, running through fog and storms.