Alan, a 30-year-old man, sits in the waiting room of our clinic, his eyes darting around the room as he clutches a worn spiral notebook. He’s a regular patient here, known for his frequent visits and the intricate, tiny writing that covers every surface of his notebook. Alan’s story is a familiar one in our clinic, a tale of a life unraveled by mental illness and substance use.

Once a promising chemistry major at UC Berkeley, Alan’s life took a sharp turn when he began experiencing symptoms of schizophrenia in his early 20s. As his mental health deteriorated, he turned to drugs and alcohol to cope, leading to a cycle of homelessness, incarceration, and emergency department visits.

Today, Alan is here for a moment of lucidity, seeking help and support. As we sit down to talk, he opens his notebook, revealing pages filled with complex chemical formulas and disjointed thoughts. It’s a glimpse into his brilliant mind, now clouded by the fog of mental illness and addiction.

Alan’s story is not unique. In our clinic, we see countless individuals who have fallen through the cracks of a fragmented healthcare system, bouncing between the streets, jails, and emergency rooms. It’s a stark reminder of the challenges we face in providing comprehensive, integrated care for those with mental health and substance use disorders. To understand the challenges we face today, it’s important to look back at the history of how Americans have treated people with mental illness and substance use disorders. In the past, the predominant approach was institutionalization, as depicted in the iconic novel and film “One Flew Over the Cuckoo’s Nest.”

In the early to mid-20th century, individuals with mental illness or substance use disorders in the US were often confined to psychiatric hospitals or asylums. These institutions were notorious for their inhumane conditions, lack of effective treatments, and widespread abuse. Patients in these facilities were subjected to cruel and degrading treatments, such as lobotomies, electroshock therapy without anesthesia, and physical restraints. Overcrowding, poor sanitation, and lack of privacy were common, creating a dehumanizing environment for those in need of care.

In the 1950s and 1960s, a shift began towards deinstitutionalization, driven by several factors. Exposés like Albert Deutsch’s “The Shame of the States” and the work of advocates like Clifford Beers brought attention to the deplorable conditions in psychiatric institutions.

Advances in psychopharmacology, particularly the development of new psychiatric medications like chlorpromazine, made it possible to manage mental illness in outpatient settings. Legal and policy changes, such as the landmark Wyatt v. Stickney case (which required more humane and individualized treatment) and the Community Mental Health Act of 1963, established rights for patients and provided funding for community-based mental health services.

Fiscal pressures also played a role, as state governments faced increasing costs associated with maintaining large psychiatric institutions. This prompted a move towards community-based care as a more cost-effective alternative.

As a result of these factors, many psychiatric hospitals and asylums were closed or downsized, and patients were transitioned into community-based treatment programs, group homes, and outpatient clinics.

While the deinstitutionalization movement aimed to improve the lives of those with mental illness or substance use disorders, it also presented new challenges. Community-based services often lacked adequate funding and resources, leading to gaps in care and support.

Many individuals transitioning out of institutions struggled to find affordable housing and supportive services, contributing to increased homelessness and incarceration rates among those with untreated mental illness or substance use disorders. Stigma and discrimination against individuals with mental health or substance use issues also persisted, creating barriers to accessing care and integrating into the community.

Despite these ongoing challenges, the deinstitutionalization movement marked a significant shift towards a more humane and community-oriented approach to treating mental illness and substance use disorders. However, it also highlighted the need for comprehensive, integrated services to address the complex needs of this vulnerable population.

For many individuals with untreated mental illness or substance use disorders, deinstitutionalization led to a new cycle of recurrent crises. Without adequate support and resources, they often find them-selves trapped in a revolving door between the streets, jails, and emergency departments.

Homelessness is a common experience for those with severe mental illness or addiction. Studies have shown that approximately 20-25% of homeless individuals have a serious mental illness, and 50-70% have a substance use disorder. Living on the streets exacerbates mental health symptoms and makes it difficult to access consistent care and support.

Incarceration is another frequent outcome for those with untreated mental illness or addiction. It is estimated that 37% of prisoners and 44% of jail inmates have a history of mental health problems. Substance use disorders are also highly prevalent in the criminal justice system, with 65% of inmates meeting the criteria for a substance use disorder.

Emergency departments often serve as a safety net for individuals in crisis, but they are ill-equipped to provide the comprehensive, long-term care needed to address underlying mental health and substance use issues. This leads to a cycle of repeated emergency visits and hospitalizations, without addressing the root causes of the problem.

The fragmentation of mental health, substance use, and primary care services contributes to this cycle. Patients may receive piecemeal care from different providers, without coordination or communication between them. This lack of integration makes it difficult to address the complex, interrelated needs of individuals with co-occurring disorders.

Medicaid stands tall as the largest payer for mental health services in the country, a safety net stretched thin across 84 million Americans among whom a staggering 12 percent of adult beneficiaries grapple with substance use disorders. Medicaid’s coverage for behavioral health needs hardly ensures that individuals receive care without serious barriers to access, quality or discrimination.

Yet multiple legislative efforts over the last few decades have sought to provide better coverage for behavioral health needs under Medicaid. Coverage in general was mandated by the Mental Health Parity andAddiction Equity Act in 2008, requiring that certain types of health plans cover mental health and substance use disorders no less generously than the way they cover other healthcare. For those battling the demons of opioid addiction, the subsequent SUPPORT Act of 2018 further fortified Medicaid’s arsenal, mandating coverage for additional medications like narcan (to reverse overdoses) and buprenorphine, which caps the opioid receptors of the brain, acting as a temporary opioid vaccine that dissolves under the tongue and renders a person neither high nor low—an elusive stability for those whose lives were previously a roller-coaster of addiction.

As with any tapestry, the threads of Medicaid’s behavioral health coverage are not woven evenly across the nation. The colors and patterns of care vary from state to state, creating a patchwork of services and support that can leave some individuals with more comprehensive coverage than others. This variability is a reminder that access to care is not just a matter of insurance, but also of geography. In states that have not expanded Medicaid under the Affordable Care Act, countless low-income individuals with mental health and substance use disorders find themselves in a no man’s land, caught between the eligibility limits of Medicaid and the threshold for marketplace premium tax credits (to pay for commercial insurance coverage). For them, the promise of affordable health insurance remains an elusive dream.

Even for those securely within Medicaid’s embrace, barriers to care persist. The Institutions for Mental Diseases (IMD) exclusion, a hid-den passage in the original 1965 Medicaid law designed to assure that states rather than the federal government maintained primary responsibility for funding inpatient psychiatric services, stands as a sentinel, barring the gates to federal funding for residential treatment facilities with more than 16 beds. This exclusion has cast a long shadow over access to inpatient and residential care for Medicaid enrollees with severe mental health and substance use disorders, leaving them to navigate a fractured landscape of waivers and workarounds.

Amidst these challenges, some practitioners providing services to Medicaid beneficiaries, and supportive state officials, have developed strategies to improve behavioral health services—often by integrating behavioral healthcare with primary care settings as part of “whole-person” care efforts.

In the tapestry of Medicaid’s behavioral health coverage, a new thread has emerged, shining bright with the promise of transformation. Certified Community Behavioral Health Clinics (CCBHCs) have taken root across the nation, weaving together the strands of mental health, substance use, and physical healthcare into a seamless garment of comprehensive support.

Imagine a place where the doors are always open, a sanctuary for those navigating the tempestuous waters of behavioral health challenges. Within these walls, a multidisciplinary team of professionals stands ready to guide patients through the full continuum of care, from crisis intervention to targeted case management, from psychiatric rehabilitation to the integration of primary care.In Missouri, a CCBHC called the Compass Health Network has become a beacon in the night, with a 24/7 crisis line and mobile response teams at the ready, catching individuals before they fall, before the threads of their lives unravel completely. The impact has been nothing short of remarkable—a staggering 66% decrease in requests for crisis intervention services, a testament to the power of proactive, comprehensive care.

For the patients who walk through these doors, the CCBHC model offers a path to resilience, a chance to reclaim the narrative of their lives. No longer are they mere passive recipients of care, but active participants in their own healing journey. The clinic becomes a second home, a place where they can shed the weight of stigma and shame, and embrace the possibility of a brighter tomorrow.

Across the nation, in the evergreen state of Oregon, another CCBHC called the Mid-Columbia Center for the Living has forged an unlikely alliance, bridging the gap between behavioral health and the criminal justice system. In partnership with a local jail, this clinic transitions incarcerated individuals grappling with mental health and substance use disorders back to the community. Through comprehensive treatment and support services, both within the confines of the jail and upon release, the CCBHC has saved $2.5 million in estimated prison costs through reduced recidivism.

What happens at a CCBHC? Sarah, a young patient who has been grappling with the dual demons of depression and alcohol use disorder, walked me through the experience. When she walked into her local CCBHC, she was greeted by a peer support specialist, someone who has walked a mile in her shoes and emerged from the other side.This connection, forged in the fires of shared experience, set the tone for Sarah’s visit. She began cognitive behavioral therapy, delving into the roots of her depression and exploring new coping strategies—less like sitting in a one-armed couch to talk about her mother, and more about building a toolbox of mental strategies and worksheets to remind herself of what to do when she faced swirling negativity or cravings.

Together with a therapist, Sarah mapped out a plan for her recovery. Next, Sarah had an appointment with the clinic’s primary care provider. In this integrated model of care, her physical health was not an afterthought, and she worked through discussion of how to avoid liver cirrhosis, what testing she needed to improve her sleep patterns and nutrition, and starting treating her high blood pressure and neuropathic foot pains that were likely due to her alcohol use.

Throughout the day, Sarah participated in group sessions, and met with the ‘rapid action street team’ who responded instead of police officers when people in distress were reported by concerned people around town.

For Sarah and countless others like her, the CCBHC is not just a clinic, but a lifeline. It is a place where they can come to heal, to grow, and to reclaim the narrative of their lives. And while the specific services and supports may vary from one CCBHC to another, the core philosophy remains the same: to provide comprehensive, compassionate, and integrated care that meets each patient where they are and walks with them on the path to recovery.

Despite initially positive results, the threads of financial sustainability for CCBHCs are fraying at the edges. Many CCBHCs have been funded by the Prospective Payment System (PPS) and temporary demonstration program funding. The PPS, designed to cover the anticipated costs of providing comprehensive services, remains available as long as the CCBHCs meet stringent requirements related to staffing, service availability, and quality reporting. By contrast, the Demonstration Program Funding, established by the Protecting Access to Medicare Act of 2014, has ended. Under this program, participating states received enhanced federal Medicaid reimbursement to support their certified CCBHCs during a demonstration period. The Substance Abuse and Mental Health Services Administration (SAMHSA) has provided grant funding to prevent some program closures, but such patchworks of grants require continuous congressional reappropriation.

As the threads of federal funding begin to unravel, the burden of sustaining CCBHCs falls on the states. Some states have taken steps to independently implement CCBHCs statewide in their Medicaid programs by submitting a state plan amendment. Four states have used this option to expand CCBHC participation beyond the initial federal demonstration program funding. Instead of relying solely on Medicaid funding, these states considered reallocating resources from other areas, such as the criminal justice system, to support CCBHCs. The evidence reviewed by supportive policymakers revealed that investing in behavioral health services can reduce incarceration rates, lower recidivism, and improve public safety.

Despite the success of the CCBHC model, it is not widely available to most patients receiving Medicaid. One of the biggest challenges is the shortage of behavioral health providers, particularly in rural and underserved areas. Many communities struggle to attract and retain the multidisciplinary staff needed to provide the full range of services offered by CCBHCs, including psychiatrists, therapists, case managers, and peer support specialists. Many providers are reluctant to work with individuals with serious mental illness or substance use disorders, citing concerns about safety, salary, and daily challenges of the work.

This shortage of behavioral health providers is particularly acute for individuals enrolled in Medicaid, which is the largest payer for behavioral health services in the United States. According to a report from the National Council for Mental Wellbeing, there is a nationwide shortage of more than 6,000 mental health providers, with some states having fewer than one mental health provider per 1,000 residents. For Medicaid beneficiaries, the situation is even more dire, with only about 43% of psychiatrists accepting new Medicaid patients, compared to 73% accepting new private insurance patients.

One promising solution to the shortage of behavioral health providers is the Collaborative Care Model, which aims to integrate behavioral health services into primary care settings. Under the Collaborative Care Model, the expertise of behavioral health providers is leveraged while keeping care rooted in the primary care setting, where most individuals first seek help for mental health concerns. One of the key advantages of the Collaborative Care Model is that it does not require the physical presence of a psychiatrist or other behavioral health provider. Instead, the model relies on regular, structured communication between a patient’s primary care provider and the behavioral health specialist, often through telephone or video consultations. This allows for the sharing of expertise and the development of personalized treatment plans, even in areas where access to behavioral health providers is limited.

The effectiveness of the Collaborative Care Model has been demonstrated in numerous studies, including the landmark IMPACT study, which involved more than 1,800 older adults with depression (not to be confused with the IMPACT model for community health workers mentioned in an earlier chapter). The study found that patients who received collaborative care were more than twice as likely to experience a significant reduction in their depression symptoms compared to those who received usual care. In fact, 45% of patients in the collaborative care group had a 50% or greater reduction in their symptoms, compared to just 19% in the usual care group.

Other studies have shown similar results, with collaborative care leading to greater improvements in depression and anxiety symptoms, higher rates of treatment response and remission, and lower overall healthcare costs compared to usual care. A systematic review of 79 studies found that collaborative care was particularly effective for racial and ethnic minority populations, with a 63% greater likelihood of treatment response compared to usual care.

The Collaborative Care Model has also been shown to be cost-effective, with one study finding that it resulted in lower overall healthcare costs of $3,363 per patient over a four-year period compared to usual care. Another study found that patients receiving collaborative care had an additional 115 depression-free days over a two-year period, leading to an estimated $864 in higher employment earnings (due to greater days spent productively at work) compared to usual care.

While the Collaborative Care Model has traditionally been implemented in primary care settings, interestingly, some practitioners have adopted a “reverse integration” approach, in which primary care services are embedded within behavioral health settings. Under this model, individuals with serious mental illness or substance use disorders who are already receiving care in a mental health setting would have access to primary care services on-site, allowing for greater coordination and integration of care.

As we look to the future of behavioral health care in the United States, it is clear that we need a multifaceted approach to address the growing crisis of unmet need. While the CCBHC model has shown great promise in improving access to care, it is not a one-size-fits-all solution, particularly in areas with a shortage of behavioral health providers.

The Collaborative Care Model offers a promising complement to the CCBHC model, allowing for the integration of behavioral health services into primary care settings and the expansion of access to care in underserved areas. By combining the strengths of these two models, we may be able to create a more comprehensive, coordinated system of care that meets the needs of all individuals with mental and physical health care.

Several Medicaid plans now provide reimbursement for the Collaborative Care Management (CoCM) billing codes. Under these billing codes, primary care providers can bill for the time spent by the behavioral healthcare manager in providing care coordination and management services, as well as for the time spent by the psychiatric consultant in providing consultation and oversight.

In addition to the CoCM billing codes, Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) can also bill for Collaborative Care Model services using a special billing code, which allows these safety-net providers to receive reimbursement for the costs associated with implementing the Model, including the salaries of behavioral healthcare managers and psychiatric consultants.

In addition to these national payment models, many states are also implementing the Collaborative Care Model through legislation, Medicaid waivers, and state-funded programs. These initiatives help to support the adoption of the model in specific geographic areas or patient populations, and provide valuable lessons for other states looking to expand access to integrated care.

One notable example is Washington State’s Mental Health Integration Program (MHIP), which is a large-scale collaborative care program implemented in safety-net clinics across the state. The program, which began in 2008, showed significant improvements in depression outcomes and reductions in healthcare costs.

Another example is Minnesota’s DIAMOND program, which used collaborative care principles to develop patient-centered medical homes for individuals with depression. Other states, such as Oregon, Arkansas, and Nevada, have pursued Medicaid Section 1115 waivers to support the implementation of integrated care models.

Despite the growing evidence base for the Collaborative Care Model, many Medicaid programs have been slow to adopt this approach, citing concerns about cost and feasibility. Advocates argue that the model can actually help to reduce costs in the long run by improving outcomes and reducing the need for more expensive interventions, such as hospitalizations and emergency department visits.

According to a recent analysis by the American Psychiatric Association, it is estimated that $26-48 billion could be saved annually by effectively integrating mental health and medical care. This analysis suggests that the Collaborative Care Model, which is one of the most well-studied and effective approaches to integrated care, could play a significant role in achieving these savings.

To make the economic case for the Collaborative Care Model, advocates are urging Medicaid programs to consider the long-term benefits of investing in this approach. By providing reimbursement for the Model, investing in state-specific initiatives, and pursuing innovative payment models, Medicaid programs can help to support the adoption of this evidence-based model and improve outcomes for individuals with mental health and substance use disorders.

Achieving this vision will require a sustained commitment from policymakers, providers, payers, and advocates. It will require us to think differently about how we deliver and pay for behavioral healthcare, and to prioritize the integration of physical and mental health services. It will also require us to invest in the training and support of mental health and substance use service providers who are willing to care for the Medicaid population.