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Nearly 4 Million Seriously Mentally Ill Still Without Insurance

The 24 states that refused the Medicaid expansion have nearly 4 million people with severe mental illness without insurance.

Photo Credit: Stokkete / Shutterstock


Some might consider Kelly Troyer of South Carolina lucky. She isn’t one of them.

Thanks to the generosity of her church and family members, she receives some treatment for the depression and post-traumatic stress disorder she suffers as a result of the sexual assault she endured in 2012. But Troyer, 45, said her lack of health insurance and other uncovered medical costs, including a hospitalization and all her medications, has forced her into personal bankruptcy.

She lives in one of the 24 states that chose not to expand their Medicaid programs, offered under the Affordable Care Act. Those decisions have left about 3.7 million Americans with serious mental illness, psychological distress or a substance abuse disorder without health insurance, according to a recent  report from the  American Mental Health Counselors Association (AMHCA), a group that represents mental health professionals.

In states that agreed to expand Medicaid, about 3 million people who have those conditions and were uninsured are now eligible for coverage, according to the report.

“It makes no sense that this state would not accept the Affordable Care Act,” Troyer said. “Don’t say no and then don’t offer another option. There are people who are homeless now because they don’t have health insurance. I could be one of them.”

See how many people are uninsured

Option Offered

Medicaid, the federal-state health care program for the poor, is the primary means by which states pay for mental health care for the poor. Medicaid beneficiaries are entitled to comprehensive care for mental illness and substance abuse.

Originally, the federal health care law enacted in 2010 required  all states to expand Medicaid benefits to  adults with annual incomes below 138 percent of poverty or $15,521 for an individual in 2014.

A 2012 U.S. Supreme Court decision gave states the option of not participating in the eligibility expansion. Most, but not all, states with Republican governors or Republican-controlled legislatures opted out, even though the federal government is paying 100 percent of the costs of the expansion in the first three years before tapering down to 90 percent after 2019.

The federal health law could have added as many as 18.7 million more Americans to the Medicaid rolls. With only 26 states now participating, that number is down to about 8.1 million. If the 24 states that opted out of the Medicaid expansion continue to do so, they will forgo a total of $61.9 billion in federal revenues by 2022, according to a December  Commonwealth Fund report. Governors in those states say they don’t trust the federal government to come up with the promised money and worry the states will be left having to make up the difference.

“It is really a tragedy,” said Joel Miller, executive director of AMHCA. “When uninsured people with mental health conditions, such as depression, gain Medicaid coverage, they become healthier and life expectancy increases, but in states that refuse to expand Medicaid, citizens will see their hopes dashed for a better life and better health.”

The report gives state-by-state numbers of people with serious mental illness or substance abuse disorders who would have received Medicaid if their states had opted in to  Medicaid expansion. The report covers 25 states, although since it was published, one of them, New Hampshire, decided to reverse course and join the expansion states.

Funding Cuts

Separate from Medicaid, many states have also funded community mental health programs, but they have also sharply reduced spending on those programs in recent years. The  National Association of State Mental Health Program Directors estimated that in the four years ending in 2012, states reduced mental health spending by a total of $4.35 billion.

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