In 2010, the Patient Protection and Affordable Care Act, also known as the Health Care Reform Bill, created a federal infrastructure to integrate primary care and behavioral health services and to provide guidance for behavioral health services  parity requirements in Medicaid programs.  The Act provides funding for care demonstrations and new financing models that bundle payment to support care integration.  Descriptions of these efforts are listed in the federal agencies below.

Previously, federal efforts have been framed by the findings of the New Freedom Commission. Established in 2002 to address health disparities for mental health services, this commission has reviewed public and private systems and conducted hearings to seek public input. Its published report lays out a set of goals to transform mental health systems, including a variety of strategies to address stigma and improve services and the alignment of federal programs. Impacting primary care clinics is its recommendation to increase mental health and co-occurring disorders screening and include mental this screening in primary care settings. This report has formed the underpinning for much of the efforts at the federal and state levels to integrate health, mental health and substance abuse services.

Though the landscape has changed considerably since then, for a 2008 overview of Federal activities in the integrated care arena, see the “Compendium of Primary Care and Mental Health Integrated Activity Across Various Participating Federal Agencies”.

Federal Agencies

Agency For Healthcare Research And Quality (AHRQ)

One of twelve agencies within the Department of Health and Human Services, AHRQ supports research that helps people make more informed decisions and improves the quality of health care services. In 2009, AHRQ funded a Collaborative Care Research Network Research Development Conference, culminating in the publication of several papers  establishing a research agenda for collaborative care among primary care and mental health clinicians. In 2011, AHRQ published data underscoring that the need to increase the primary care workforce is a top priority in healthcare.

The Center For Medicare And Medicaid Innovation 

Created by the 2010 Affordable Care Act, the Center for Medicare and Medicaid Innovation tests innovative payment and delivery system models.   In 2012, the Center is awarding $1 billion in grants nationwide to improve care coordination. Among their many programs is the Comprehensive Primary Care Initiative. In this program, Medicare works with commercial and state health insurance plans and offers bonus payments to primary care doctors who better coordinate care for their patients. Practice demonstrations are expected to show how the patient-centered medical home model can improve quality of care, promote better health, and lower costs. Their demonstrations include the Federally Qualified Health Center (FQHC) Advanced Primary Care Practice demonstration for primary care clinics.

In concert with Medicare/Medicaid Coordination Office, the Center has provided up to $1 million for Dual Eligible Integrated Care Demonstrations in California and fourteen other states. This program allows states more flexibility in adopting new practices to provide better and more coordinated care for beneficiaries of both Medicare and Medicaid.  In California, the Department of Health Care Services (DHCS) has designated Los Angeles, Orange, San Diego and San Mateo as the initial counties to participate in the demonstration.

Human Resources and Service Administration (HRSA)

The Human Resources and Service Administration implements its goals of improving access, quality, health care, public health, health outcomes and eliminating health disparities by providing federal funding to a wide range of services. It has ramped up its efforts to improve mental health services by awarding a series of grants to agencies playing a part in the safety net of health care, including primary care clinics. It also awarded more than $2.7 million in grants to fund the planning, development and implementation of graduate education and training programs in behavioral and mental health to 26 health professions schools, universities, medical centers and nonprofit organizations across the country. HRSA has run the Health Disparities Collaborative, a national effort to achieve strategic system change in the delivery of primary health care. Depression has been one of the conditions the collaboratives have focused on, along with diabetes, asthma, and cardiovascular diseases. Since 1998, over 450 Bureau-supported health centers have participated in the collaboratives.

In concert with SAMHSA (below) HRSA has also sponsored the Center for Integrated Healthcare Solutions, described in the NATIONAL EFFORTS section of this website.

The Bureau of Primary Health Care under HRSA funds community health centers and has included expansion funding for mental health and substance abuse services as a priority within the presidential initiative to expand access to care.  As part of its focus on demonstrating treatment impact on health outcomes, the Bureau coordinates disease collaboratives and registries for specified chronic conditions, including depression, among its grantees.

National Institute of Mental Health (NIMH)

As its website states, the National Institute of Mental Health (NIMH) “is the largest scientific organization in the world dedicated to research focused on the understanding, treatment, and prevention of mental disorders and the promotion of mental health.” It is thus a rich resource for finding which treatment approaches are evidence-based. Among its many funded studies impacting integrated care was one published December 2007 in the Journal of the American Geriatrics Society which found that mental health-related topics were raised in 22% of primary care visits by elderly patients, but typically lasting only two of the average 16 minutes devoted to the visit. The researchers concluded that primary care doctors need more support in how to identify, treat and refer patients to mental health specialists.

Substance Abuse and Mental Health Services Administration (SAMHSA)

The Substance Abuse and Mental Health Services Administration is providing leadership to integrate services for people who have co-occurring disorders -mental illness and a substance abuse addiction – to encourage service delivery for these highly correlated conditions at the same time in one setting. A toolkit SAMHSA developed for this type of integrated treatment can be found here.  SAMHSA has recently compiled a national registry of evidence-based programs for treating both substance abuse and mental disorders  and has also partnered with HRSA to fund the Center for Integrated Healthcare Solutions (described in the NATIONAL EFFORTS section of this website).

For more information about their substance-abuse programs and material, go to THE SUBSTANCE ABUSE CONNECTION of this website and visit  their Center for Substance Abuse Treatment (CSAT)  and Center for Substance Abuse Prevention (CSAP) websites.

To address the shocking fact that persons with mental disorders are dying 25 years earlier than the rest of the population, SAMHSA as undertaken a 10 X10 Wellness Campaign, focusing on wellness activities to increase life expectancy of this vulnerable population. With the goal of improving the physical health status of people with mental illnesses and addictions, SAMHSA developed the Primary and Behavioral Health Care Integration (PBHCI) Program. Through this program, SAMHSA provides support and grants to communities to coordinate and integrate primary care services and community-based behavioral health settings.  In 2013, the RAND Corporation evaluated the success of these programs.  PBHCI outcomes from California grantees and additional California PBHCI information can be found on the Center for Integrated Health Solutions website. 

Federal Legislation

The Patient Protection And Affordable Care Act

The Act reforms health care insurance, expands coverage, and redesigns the healthcare delivery system.  Within each of these categories, the transformations impact the ability of states, health plans and providers to better coordinate care and integrate behavioral health into primary care.

• Insurance Reform precludes health plans from denying coverage due to pre-existing conditions, includes behavioral health treatment as an essential benefit, builds upon Mental Health Parity and Addictions Act of 2008, and requires that health plans provide essential benefits for substance use disorders within the benchmark plans for newly covered Medicaid recipients.
• Coverage Expansion to childless adults enfranchises a population with higher behavioral health needs. The Center for Medicare and Medicaid Services approved coverage expansion and enrollment demonstration pilots in locations throughout the country, including California, that require Medicaid behavioral health benefits.
• Delivery System Redesign includes the future provider mandate to implement evidence-based practices for mental health and substance abuse conditions. The Center for Medicare and Medicaid Services (CMS) is approving health home pilots that require care coordination and improved outcomes for a set of chronic conditions, including mental health and substance use disorders.
• Payment Reform includes testing bundled payment for complex patients, thus creating a single payment for primary care and behavioral health. Among the initiatives is three-year demonstration program designed to evaluate whether the advanced primary care practice model – commonly referred to as the patient-centered medical home – can effectively improve care, promote health, and reduce the cost of care provided to Medicare beneficiaries served by Federally Qualified Health Centers (FQHCs).

Mental Health Parity And Addiction Equity Act

To help end discriminatory insurance coverage of mental health and substance use services, Congress passed the Wellstone-Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008.  The Act, which went into effect in 2010, requires private health insurance plans to provide equal coverage for mental and physical health services. The law applies to all group health insurance plans for more than 50 employees that provide mental health or substance use disorder benefits as part of the plan.

The Excellence In Mental Health Act 

On March 31, 2014, Congress passed the Protecting Access to Medicare Act, which includes provisions of theExcellence in Mental Health Act. The latter will increase access to community mental health and substance use treatment services while improving Medicaid reimbursement for these services.  Among its other provisions, the Act creates “Certified Behavioral Health Clinics” which are required, along with other steps, to form partnerships with Federally Qualified Community Behavioral Health Centers.