Behavioral and Mental Health Care

Policy and Practice A Biopsychosocial

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Moniz and Gorin’s Behavioral and Mental Health Care Policy and Practice could not be more timely. In their usual
comprehensive and insightful fashion, the authors analyze the core issues in this complex and increasingly important
arena of policy and practice. This book is a valuable resource for faculty teaching in this area and for current and future
practitioners in the field.
—Michael Reisch, Ph.D., MSW, Daniel Thursz Distinguished Professor of Social Justice, School of Social Work,
University of Maryland

Moniz and Gorin’s new companion piece to their successful health policy book adds a timely policy analysis of the
behavioral and mental health fields. The authors present a critical view of policy development from the Kennedy-Johnson
days to the chaotic Trump era, followed by practice recommendations to improve access to underserved populations.
Faculty and students alike will appreciate this judicious offering.
—Cathleen Jordan, Ph.D., LCSW, Professor, School of Social Work, University of Texas at Arlington

2
Behavioral and Mental Health Care Policy and
Practice
Cynthia Moniz and Stephen Gorin’s Behavioral and Mental Health Care Policy and Practice: A
Biopsychosocial Perspective is a new mental health policy textbook that offers students a
model for understanding policy in a framework that addresses policy practice. Edited to read
like a textbook, each chapter is written by experts on an aspect of mental health policy. The
book contains two parts: Part I chronicles and analyzes the evolution of mental health policy;
Part II analyzes current policy and teaches students to engage in policy practice issues in
different settings and with diverse populations.

Cynthia D. Moniz is Professor Emeritus of Social Work and former Department Chair at
Plymouth State University in New Hampshire.

Stephen H. Gorin is Professor Emeritus of Social Work at Plymouth State University in New
Hampshire.

3
Behavioral and Mental Health Care Policy
and Practice
A Biopsychosocial Perspective

Edited by
Cynthia Moniz and Stephen Gorin

4
First published 2018
by Routledge
711 Third Avenue, New York, NY 10017
and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2018 Taylor & Francis
The right of Cynthia Moniz and Stephen Gorin to be identified as the authors of the editorial
material, and of the authors for their individual chapters, has been asserted in accordance with
sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilized in any
form or by any electronic, mechanical, or other means, now known or hereafter invented,
including photocopying and recording, or in any information storage or retrieval system,
without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered trademarks,
and are used only for identification and explanation without intent to infringe.
Library of Congress Cataloging-in-Publication Data
Names: Moniz, Cynthia, editor. | Gorin, Stephen H., editor.
Title: Behavioral and mental health care policy and practice : a biopsychosocial perspective /
edited by Cynthia Moniz and Stephen Gorin.
Description: New York, NY : Routledge, 2018. | Includes bibliographical references and index.
Identifiers: LCCN 2017041165 (print) | LCCN 2017042234 (ebook) | ISBN 9781315641379 (ebook)
| ISBN 9781138189881 (hardback : alk. paper) | ISBN 9781138189898 (pbk. : alk. paper) | ISBN
9781315641379 (ebk)
Subjects: | MESH: Mental Health Services | Mental Disorders | Health Policy | Insurance,
Health | Medical Assistance | United States
Classification: LCC RA418 (ebook) | LCC RA418 (print) | NLM WM 30 AA1 | DDC 362.1—dc23
LC record available at https://lccn.loc.gov/2017041165
ISBN: 978-1-138-18988-1 (hbk)
ISBN: 978-1-138-18989-8 (pbk)
ISBN: 978-1-315-64137-9 (ebk)
Typeset in Stone Serif
by Apex CoVantage, LLC

5
Contents

Preface

Part I Where We Are and How We Got Here

Chapter 1 Behavioral Health and the Affordable Care Act

John Orwat and Whitney Key

Chapter 2 The Origins of Federal Mental Health Policy: Kennedy-Johnson Great

Society
Eileen Klein

Chapter 3 The Decline of Community Mental Health Under Reagan and Bush
Alexander Sawatsky

Chapter 4 Clinton’s Efforts to Respond to Escalating Costs and the Emergence of

Mental Health Parity
Alexander Sawatsky

Chapter 5 Financing and Delivery of Behavioral Health in the United States

John Orwat, Shveta Kumaria, and Michael P. Dentato

Part II Policy Practice: Advancing Access to Behavioral and Mental Health

Care

Chapter 6 Social Workers and Policy Practice: Affecting Policy and Achieving Policy
Action
Cynthia Moniz

Chapter 7 Analyzing the Problem: Access to Care

Christine M. Rine

Chapter 8 Analyzing the Problem: Disparities in Behavioral Health Services for People
of Color and Latinxs
Tenesha Littleton, Megan Lee, and Llewellyn Cornelius

Chapter 9 Analyzing the Problem: Gender Disparities in Behavioral and Mental Health
Care

6
 Whitney C. Sewell, Whitney Key, and Sarah Gehlert

Chapter 10 Analyzing the Problem: Disparities in Behavioral and Mental Health Care
for Children and Youth
John Orwat and Whitney Key

Chapter 11 Analyzing the Problem: Disparities in Behavioral Health Care for Older
Adults
Kyeongmo Kim, Amanda J. Lehning, and Paul Sacco

Chapter 12 Analyzing the Problem: Disparities in Behavioral and Mental Health Care
for Lesbian, Gay, Bisexual, and Transgender (LGBTQ) Individuals
Eileen Klein

Chapter 13 Conclusion: Advocating for Policies That Address Inequities and Disparities
in the Behavioral and Mental Health Care System in the U.S.
Cynthia Moniz

About the Authors

Glossary
Index

7
Preface

The first part of this text provides an historical overview of the behavioral and mental health
system in the U.S., from the early days of mistreatment of people with emotional and mental
health problems to the current effort by the Trump administration to “repeal and replace” the
Affordable Care Act (ACA). The U.S. Congress first made progress in expanding access to
mental and behavioral health coverage in 2008 by passing the Wellstone-Domenici Mental
Health Parity and Addiction Equity Act. The legislation required that large-group plans cover
mental health and substance use treatment on a par with other medical and surgical care
coverage. In 2010, the ACA extended the equity act to include individual and small-group
plans and Medicaid. Since January 2016, all individual and small-group plans have been
required to cover behavioral health services with no annual or lifetime dollar limits and no
annual or lifetime cap on spending for benefits. The Medicaid expansion program under the
ACA increased access, provided marketplace exchange subsidies to individuals with incomes
between 100 and 400 percent of the poverty level, and significantly increased access for low-
income individuals and people of color. Throughout the first part of the text, where
historically appropriate, the authors incorporate the positive impact of the parity legislation
and the ACA and discuss the potential harm if efforts to repeal rather than improve the ACA
occur.
The second part of the text addresses the inequities and disparities in behavioral and mental
health that exist for populations-at-risk in the U.S., including people of color and Latinx,
women, children and youth, the LGBT community, and people living in poverty. These
chapters examine the behavioral and mental health of these populations, identify and analyze
problems in the delivery of behavioral and mental health services to these groups, and offer
policy recommendations for reform. The final chapter briefly considers advocating for policies
that address inequities and disparities and building a better system of behavioral and mental
health care.

8
Purpose of the Book
In 2002, we published the first edition of our textbook, Health Care Policy and Practice, to
address the lack of textbooks available for social work educators to teach health care policy.
Social policy, in general, can be a challenging subject to teach to social work students who
want to focus on becoming effective practitioners, and health care policy may seem even more
narrow a focus. However, with increasing attention being paid to the social determinants of
health and mental health, there is increasing awareness of the importance of the role of social
policies in the health and well-being of individuals, communities, and populations. With this
text in its fourth edition (soon to be fifth edition), we wanted to create a companion text that
focused on behavioral and mental health policy. Here too there are few social work textbooks.
We thought it might be useful to instructors and students to frame this text in a fashion
similar to the health policy text. For social work schools and programs that have a combined
health and mental health concentration or courses, this would serve as complementary
resource.
The book attempts to provide a comprehensive overview of behavioral and mental health
policy, policymaking, and related behavioral and mental health practice. It includes an
historical examination of the evolution of mental health policy in the U.S., the role of major
substantive policies (public health, community mental health centers, Medicare, Medicaid,
parity legislation, and the Affordable Care Act), the policymaking process, and health
disparities and inequities for populations-at-risk. Each of the chapters on populations-at-risk is
structured to address basic questions of policy analysis:

What is the social problem?

Who is affected? What is the extent of the problem?

What are the dimensions and boundaries of the problem?

What evidence is there that a problem exists?

How serious is the problem?

What is the perceived cause of the problem?

What explanations exist for the problem?

The chapter authors are social work scholars and educators who have applied their knowledge
and experience to provide an historical analysis of mental health policy in the U.S. and the
current state of behavioral and mental health for people of color and Latinx, women, children
and youth, the LGBT community, and people living in poverty. The development of this book
would not have been possible without the contributions of these colleagues who graciously
agreed to contribute to the project. We appreciate their hard work, knowledge, and
commitment and thank them for their willingness to share their expertise.

9
10
Part I

Where We Are and How We Got Here

CHAPTER 1 BEGINS WITH CURRENT FEDERAL POLICY FOCUSING on the Affordable Care Act to introduce
students to the current state of behavioral and mental health policy in the United States. It
provides a brief overview of the social and political policy environment, including the Trump
administration’s effort to “repeal and replace” the ACA, and examines the role of the ACA in
improving access, quality, and cost related to behavioral health. This discussion includes
parity, as well as the expansion of insurance, efforts at system redesign to include integration
of primary care and behavioral health, and issues related to the workforce.
Chapter 2 then takes us back to early efforts to establish mental health policies, programs,
and initiatives beginning in the 1800s with the mental hygiene movement. The chapter
examines treatments that evolved in the 1940s and 1950s through the National Mental Health
Act of 1946 and systemic changes that were the result of the Mental Retardation and
Community Mental Health Center Construction Act of 1963. The role of Medicaid, Medicare,
and other government benefits in the deinstitutionalization movement are discussed.
Additional government initiatives in mental health treatment, including gaining of awareness
of the role of co-occurring alcohol and substance abuse in mental health and the influence of
the National Institute on Drug Abuse (NIDA), which began in 1972, are covered. The chapter
concludes with a review of mental health initiatives that began with the 1977 Community
Support Program and the 1980 Mental Health Systems Act.
Chapter 3 addresses the Reagan and Bush years, which were characterized by decreasing
mental health funding, deinstitutionalization of mental hospitals, and shifting responsibility to
the states to provide care. Managed care mechanisms, including health maintenance
organizations (HMOs), became a popular means of cost containment. Community mental
health was imperiled by the ongoing devolution policies of the Republican administrations in
the 1980s and early 90s, and states were forced to create their own responses to decreased
funding to community mental health centers.
Chapter 4 focuses on the valiant but failed effort to achieve universal health care through
the Health Security Act by the Clinton administration and its impact on mental health policy
and behavioral managed health care. With the failure of the act, a three-tiered mental health
system structure emerged with public, private for-profit, and private not-for-profit
components, putting the near-poor at greatest risk for lack of access to care. The emphasis in
mental health policy shifted to cost containment, efficiency, and effectiveness, including the
application of a managed care model to mental health services, accountability, wraparound
services, and evidence-based practice. In 2002, under George W. Bush, the President’s New
Freedom Commission on Mental Health was enacted to undertake a comprehensive review of

11
the mental health system, but little funding was available to pursue the commission’s
recommendations. By the mid-1990s, policy reform efforts shifted to mental health parity with
passage of the Mental Health Parity Act (MHPA) of 1996, which unfortunately had little
impact until passage of the Paul Wellstone Mental Health and Addiction Parity Act (MHPAE)
of 2008.
Chapter 5 provides an overview of the complexity of behavioral healthcare provision and
delivery structures in the U.S., the fragmented financial system (Medicare, Medicaid, private
insurers, fee-for-service, managed care), and the impact of recent legislation on behavioral and
mental health care, including the Mental Health Parity and Addictions Equality Act
(MHPAEA) of 2009, Affordable Care Act (ACA) of 2010, Comprehensive Addiction and
Recovery Act (CARA) of 2016, and 21st Century Cures Act (Cures) of 2016. The chapter
concludes with areas not covered by existing policies and offers suggestions for future policy
actions.

12
Chapter 1

Behavioral Health and the Affordable Care

Act
John Orwat and Whitney Key

13
Introduction
WITH THE INCLUSION OF INDIVIDUALS RECEIVING INPATIENT CARE for mental health needs, the cost of
mental health care in the United States exceeded $201 billion in 2013 (Roehrig, 2016). The
Patient Protection and Affordable Care Act (ACA) is the largest piece of health care legislation
since Medicare (Public Law 89–97) in 1965. It touches on every aspect of healthcare to include
payers, providers, purchasers, and consumers. The ACA targets three performance concerns in
health care: the need to increase access, improve quality, and manage costs. In this chapter, we
examine the approach taken by the ACA regarding behavioral health, which is inclusive of
mental health and substance use disorders. The environment for behavioral health
encompasses a patchwork of federal, state, and local policies and funding streams. In
alignment with the grand challenges of social work, outlined by the Academy of Social Work
and Social Welfare, we will include the suggestions for a transdisciplinary approach to
prevention while integrating systemic collaborative partnership.
For the purposes of this chapter, we focus on federal efforts, with a specific concentration
on the ACA. This chapter starts with a brief overview of the policy environment with regard
to behavioral health. Then, it spotlights specific aspects of the ACA as they pertain to
improving access, quality, and cost related to behavioral health to include the conditions to
which the ACA responds (impetus) and a review of the current state of behavioral health
services. This discussion includes parity, as well as the expansion of insurance, efforts at
system redesign to include integration of primary care and behavioral health, and issues
related to the workforce. We conclude by describing possible next steps.

14
The Policy Environment
People with behavioral health problems were drastically overrepresented among the
uninsured population prior to the Affordable Care Act (Frank, Beronio, & Glied, 2014). Under
the ACA, behavioral health services have been drastically broadened by the expansion of
access to include wider access to health insurance and the inclusion of behavioral health in the
ten essential benefits required of health plans. However, definitions of behavioral health are
varied, which leads to challenges in the identification of patients as well as the delivery of
services. According to the Substance Abuse and Mental Health Services Association
(SAMHSA) (2014), behavioral health is defined as “mental/emotional well-being and/or
actions that affect wellness.” Mental health is characterized as “changes in thinking, mood,
and/or behavior. These disorders can affect how we relate to others and make choices.”
Serious mental illness, or SMI, is “at any time during the past year, a diagnosable mental,
behavioral, or emotional disorder that causes serious functional impairment that substantially
interferes with or limits one or more major life activities.” Serious emotional disturbance is
used to refer to children and youth who have had a diagnosable mental, behavioral, or emotional disorder in the past year,
which resulted in functional impairment that substantially interferes with or limits the child’s role or functioning in
family, school, or community activities.

Substance abuse occurs when “the recurrent use of alcohol and/or drugs causes clinically
significant impairment, including health problems, disability, and failure to meet major
responsibilities at work, school, or home.” Co-occurring disorders are the coexistence of both
mental health and substance abuse disorders. While all definitions are similar, they are
thought of differently from a medical standpoint and are subsequently funded and treated
differently by providers.
Coverage has been sporadic prior to the ACA for mental health and substance abuse
disorders, and to some extent continues to be. This is the result of the view that behavioral
health is different from physical health and a moral problem. Traditionally, mental health care
and substance abuse treatment have been considered specialty care and not necessarily
integrated into the primary care setting, in many cases funded separately, and often came
with different benefit structures to include limits on mental health and substance abuse
treatment, higher copayments, etc. Because of this, many practitioners failed to understand the
complexities of each disease and ultimately inadequately treated the patient. These
differentiations are counterintuitive in thinking, considering research that shows that there are
many similarities between the different diseases, and there is value in the understanding and
treatment of conditions. It was not until the 1990s when parallels were identified between
behavioral health problems and other chronic physical diseases (e.g., diabetes, cardiovascular
disease) (McLellan, Lewis, O’Brien, & Kleber, 2000). Despite continued popular belief that
behavioral health problems are related to moral deficiencies, researchers and physicians
increasingly treat such issues from a medical standpoint. Treatment for substance abuse was
also applied to chronic disease management, suggesting that a lifetime of monitoring the
disease was important for quality of life. However, individuals of lower socioeconomic status
or having a co-occurring disorder were the most vulnerable, as coverage for such treatments

15
were not adequately covered by private insurers or federal programs such as Medicaid or
Medicare. This, combined with stigma, made access and utilization of care more difficult for
patients and therefore only increased the stigma of mental health disorders.
Prior to the ACA, when behavioral health disorders were diagnosed, treatment was more
likely out of pocket, as many private insurers did not cover such services, particularly on the
individual market (Frank et al., 2014). Private insurers placed more limitations on mental
health services to include lifetime caps and created higher copayments for mental health care.
Many policies also did not include mental health coverage or offered coverage at extreme
prices (Montz et al., 2016). In 1996, the Mental Health Parity Act (MHPA) required annual or
lifetime dollar limits on mental health benefits to be no lower than any such dollar limits for
medical and surgical benefits offered by a group health plan or health insurance issuer
offering coverage in connection with a group health plan. Prior to MHPA and similar
legislation, insurers were not required to cover mental health care and so access to treatment
was limited, underscoring the importance of the act. In 2008, the Paul Wellstone and Pete
Domenici Mental Health Parity and Addictions Equity Act (MHPAEA) extended the MHPA to
now include substance abuse disorders (Frank et al., 2014).
With regard to substance abuse treatment, the Treatment Research Institute in Philadelphia
reports that there are approximately 12,000 addiction treatment programs nationally
(Treatment Research Institute, 2017). Of these programs, 80% are outpatient based, 10% are
residential, and 10% are methadone clinics. Sixty-six percent of the programs are nonprofit
and often dependent on government block grants to help cover the actual costs of providing
services. When grant monies are reduced, waiting lists or even closures may occur. Policies
vary for individual coverage and types of substance abuse treatment. Many insurance policies
will state they cover 30 days of inpatient treatment, but rarely does an individual have all 30
days covered (Treatment Research Institute, 2017). In the MHPAEA and the ACA, coverage of
such disorders expanded, as the MHPAE mandates that coverage of mental and behavioral
health disorders must be covered the same amount as medical care under commercial insurers.
The ACA also mandates that no insurance company can deny coverage based on a preexisting
condition, such as mental health and substance abuse. This coverage was a major economic
relief for many families that suffered from either a mental health disorder or substance abuse,
and many times both disorders.

16
The Patient Protection and Affordable Care Act
The ACA employs a variety of interventions to increase access, improve quality, and manage
costs. Certainly, a full description of the legislation is beyond the scope of this chapter. Here,
we focus on four interventions of particular salience to behavioral health: expansion of health
insurance, making behavioral health an essential benefit for health insurance plans, system
redesign to include parity, and workforce issues.

Health Insurance
Health insurance is the strongest predictor of access and outcomes to health care. Payers
design the behavioral health care delivery system through their network development and
benefit design activities. Those with health insurance have greater access and better process
and outcomes (Han, Gfoerer, & Colliver, 2010). However, obtaining health insurance has been
difficult for the non-group market (e.g., those without group [employer]-based health
insurance). Obtaining health insurance on the individual market was problematic, because it is
difficult to spread risk, a key to any insurance, among an individual or unknown group. To
manage this possibility, health insurers did not enter the non-group or individual market. If
they did, the plans excluded those with preexisting conditions and had limited benefits,
narrow networks of providers, and lifetime limits. This led to health plans that were very
expensive and did not provide many benefits, if they were available at all.
This is particularly true of behavioral health. Prior to the ACA, only one-third of health
plans on the individual market offered any type of substance use disorder benefit, and those
that did had strict controls with regard to cost sharing, lifetime limits, provider networks, etc.
(Montz et al., 2016). However, these coverages did not include mental and behavioral health
packages, therefore treatment and subsequent coverage was not active during this time.
Medicaid was no exception. Although Medicaid programs differ, most plans covered little
more than detoxification from alcohol or the illicit drug and follow-up, and continuous
treatment was limited at best. Mental health and substance abuse were treated as two separate
diseases, whereas today we know that the two are intrinsically related.
Authorized in 1965 by the Social Security Amendments (Pub.L. 89–97, 79 Stat. 286),
Medicaid is the largest payer for behavioral health services, eligibility for which was expanded
through the ACA. Medicaid is a public health insurance program for people who are low-
income U.S. citizens or legal permanent residents, and may include low-income adults, their
children, and people with certain disabilities (Kaiser Family Foundation, 2017a). The program
is jointly funded by the state and federal governments and is administered by the states within
specific federal parameters. Although states are not required to participate in Medicaid, every
state does. Under the Affordable Care Act, Medicaid was expanded to include those with
incomes below 138% of the federal poverty level, thus removing any categorical constraints
and increasing income eligibility. Medicaid expansion is also optional for states, and 32 states
(including the District of Columbia) have adopted the expansion (Kaiser Family Foundation,
2017a). Expansion, however, puts a heavier burden onto the states because the federal

17
government only reimburses a percentage of those on Medicaid. Individuals diagnosed with
behavioral health issues cost Medicaid nearly four times more than individuals without
behavioral health issues (MACPAC, 2015), suggesting that there is a higher need among this
population for coverage and care.
A formative evaluation of the expansion of Medicaid assessed the effects of coverage,
access, utilization, affordability, and health outcomes. Studies have demonstrated that the
expansion of Medicaid resulted in a significant increase of coverage and a reduction in
uninsured rates, specifically in low-income and vulnerable populations, such as young adults,
prescription drug users, mothers, children, and early retirees (Kaiser Family Foundation,
2017a). This increase in enrollment was seen mostly with adults who did not previously
qualify for the program and only in states that participated in the expansion. Similarly, rates
of uninsured decreased across all racial and ethnic groups, which could suggest that the
expansion has helped reduce income- and race-related disparities (Kaiser Family Foundation,
2017a). The expansion has led to a positive impact on access to care and utilization of services,
specifically with behavioral health services. Research implies that there was a larger reduction
in out-of-pocket medical spending for states that adopted the expansion, as well as a decline of
the inability to pay major medical bills (Kaiser Family Foundation, 2017a). Although long-
term health outcomes have not yet been discovered with the expansion, preliminary reports
found improvements in perceived health outcomes due to individuals receiving life-saving or
life-altering treatments (Kaiser Family Foundation, 2017a).
The ACA attempted to fill the non-group market gap by the expansion of coverage and
access to and utilization of healthcare services. For those who do not qualify for Medicaid
under the ACA expansion and did not have commercial or private insurance, government
exchanges were available for purchase. These exchanges offered tiered levels of care that were
appropriate and (arguably) affordable for the person or family. These exchanges operated on
an income-based cost, where an individual with a lower income paid less than someone who
made more. The ACA expanded coverage to young adults by allowing children to remain on
parents’ health plans until age 26. This took the economic burden from young adults who may
not be covered under their employers and who are not eligible for Medicaid.
Along with the proposed expansion of coverage came the proposed expansion of providers.
The Affordable Care Act required health centers to adapt a model that is patient centered,
something that was not widely accepted. The patient-centered medical home (PCMH) is a
health care model that integrates medical professionals, patients, and patients’ families into
healthcare decision-making. This model incorporates technology, health literacy, and personal
care to facilitate health information exchange in a culturally and linguistically appropriate
manner (NCQA, 2012). The goal of the PCMH was to provide coordinated care through a
health home for individuals with chronic conditions. The PCMH is an expansion of the
evolving “chronic care model” that used to focus on tertiary care rather than primary or
preventative care (Ortiz & Fromer, 2011), yet in recent years has moved towards an integrated
behavioral health and primary care model. One main feature of the PCMH is the chronic
disease management that works with the individual on preventative care and treatment. The
health centers will do this by comprehensive care management, care coordination, health
promotion, comprehensive transitional care (including follow-up from inpatient to other
settings), patient and family support, and referral to community and social support services for

18
the use of health information technology (Ortiz & Fromer, 2011). A type of PCMH is a
federally qualified healthcare center (FQHC) that can provide a wide range of services, from
primary care to women’s health to mental health care.
Mental health practitioners vary from state to state based on state requirements. States
credential those in the workforce through licensure; however, each state has its own standards
for licensure, therefore not allowing licensed professionals to operate nationally or state by
state (unless the professional is licensed in each state). States also regulate medications based
on the insurer (private vs. public exchanges and Medicaid). Traditionally, states had the
autonomy to decide health plan coverage for its citizens, but under the ACA, the federal
government is now mandating coverage for all via Medicaid expansion or the marketplace,
which puts a strain on state resources and independence. However, little attention was paid to
mental health because it was not seen as a significant issue, as behavioral health is not seen as
a significant cost. Most often, behavioral health disorders were estimated as 5% of
expenditures; however, it was found to be much higher (40%) when including impact on other
health conditions (Kaiser Family Foundation, 2017b). Because behavioral health was not seen
as a significant cost driver, it was often ignored.

Essential Benefits and Parity

Fostering the sentiment from the Mental Health Parity Act, the Paul Wellstone and Pete
Domenici Mental Health Parity and Addictions Equity Act extended the MHPA to now
include substance abuse disorders (Frank et al., 2014). Historically, parity legislation has been
on the state level; however, the Employee Retirement Income Security Act of 1974 (ERISA)
hampered this because it exempts large national employers from state legislation. This lead to
parity only being applied to plans sold on the non-group market. It was not until MHPA that
employers were required to include parity.
Individuals with serious mental illness, behavioral health issues, and substance abuse
disorders have been disproportionately uninsured. Prior to the MHPAEA, nearly two-thirds of
individuals with employer (commercial) insurance had special limits on inpatient behavioral
health coverage, and three-quarters had limits on outpatient care (Barry et al., 2003). The
rationale behind this capitation was that mental and behavioral health disorders were viewed
as a “moral hazard” (Frank et al., 2014). Many view mental illness and substance abuse as a
moral deficiency, meaning that one can control and fix the illness on their own, despite
literature citing the contrary. These beliefs have stemmed from Puritan laws of the eighteenth
century that criminalized the mentally ill, because individuals with a mental illness do not
conduct themselves in accordance to society (meaning individuals may break laws, self-
medicate with drugs or alcohol, or have trouble obtaining and sustaining employment)
(Eastman & Starling, 2006). This lead to an increase of individuals with mental health issues
becoming engaged with the criminal justice system.
The MHPAEA aims to reduce the stigma of mental and behavioral health disorders and
increase access and care for all those who need it. It does this by requiring commercial
insurers to ensure that the “financial requirements” and “treatment limitations” for mental and
behavioral health problems are no more restrictive than for a physical medical condition. The
four main conditions of the MHPAEA are:

19
 1. It does not mandate coverage for mental and substance use disorder services. It only
requires that financial requirements and treatment limitations are no more restrictive
than for a physical condition, depending on the behavioral health services being
covered.
2. It only addresses larger employer group insurance arrangements (those with 51
employees of more).
3. It regulates behavioral health insurance benefits by analogy. That is, the statute
requires that coverage for behavioral health be judged against the standard of
coverage for medical-surgical services.
4. It identifies a range of methods for rationing care that are used by health plans to
limit use of services. These include copayments, coinsurance, and deductibles under
the heading “financial requirements.”

The MHPAEA also addresses the limitation of frequency of treatment, number of visits,
days of coverage, and other capitated services by comparing them to medical coverage. The
caveat with the MHPAEA is that it only addresses commercial insurers and does not require
mental health coverage for those on Medicaid, Medicare, or independent (individual or
commercial) plans.
With the implementation of the ACA, health insurance coverage was expanded by
requiring individuals and employers to purchase insurance. By expanding the opportunities
for coverage, the ACA names coverage a crucial element. The ACA created Essential Health
Benefits defined by ten components: ambulatory services, emergency, hospitalization,
maternity/newborn care, pediatric care, prescription drugs, preventive/wellness,
rehabilitative/habilitative, laboratory services, and mental health and substance abuse care
(Frank et al., 2014). By naming behavioral health (with substance abuse as a provision) as an
essential benefit, insurance providers cannot deny services for this care.
This comes at a critical time, as for the past decade there has been an opioid abuse epidemic
in the United States. In 2014, more people died from a drug overdose than any other year on
record, with over 60% involving an opioid (Health and Human Services, 2016). The rise of
opioid abuse stems from the drastic increase of the abuse of prescription drugs.
Health and Human Services (2016) claims that on an average day in the U.S.:

more than 650,000 opioid prescriptions are dispensed

3,900 people initiate opioid use
580 people initiate heroin use
78 people die from an opioid overdose

Because of these staggering rates, a national initiative was implemented to address the
opioid epidemic and to expand evidence-informed strategies that would yield the largest
impact. Three key areas are opioid prescribing practices, medication-assisted treatment, and
Naloxone, a drug used to combat opioid overdoses in primary care outpatient locations.
Results from this initiative have yet to be determined but look promising (Health and Human
Services, 2016).
Without the assistance of the ACA, resources for treatment would be limited to a
significant portion of the United States’ population, because treatment is expensive and

20
difficult to access. In Kentucky alone, treatment services for substance use increased by 740%
for Medicaid expansion beneficiaries over the 30 months from the beginning of 2014 through
mid-2016 (Foundation for a Healthy Kentucky, 2016). Although this is a large increase in
utilization of services under the ACA, Kentucky has also seen a rise in opioid usage, so these
results could also be a sign of how severe the epidemic really is.
Particularly vulnerable to the opioid epidemic are people of color. The Kaiser Family
Foundation (2015) demonstrates that although the deaths for White people have significantly
increased over the past few years, rates for individuals of color have relatively stayed the
same. In 2014, the total of opioid related deaths was 28,647; Whites made up 82%, while Blacks
and Hispanics made up about 8% each (Kaiser Family Foundation, 2015). Although these
numbers are unequally distributed to the White population, opioid addiction is rarely
discussed among politicians. In fact, it wasn’t until the increase in White deaths that the
federal government intervened, calling this an epidemic. Disparities still exist and should not
be ignored.

System Redesign
Overall, there was a movement away from quantity of care to a value-based care system. This
movement required shifts in how care is reimbursed from a fee-for-service system to other
payment systems. The fee-for-service system (FFS) is a payment model in which services are
not packaged together, meaning that doctors and other health care providers receive a fee for
each service, such as an office visit, test, procedure, or other health care service, and payments
are issued after the services are provided (Baker, 1997). This created an incentive for providers
to provide quantity care, or the more services a provider provided, the more the provider was
reimbursed. The FFS model was the predominant payment model in the United States, because
it allowed practitioners to be paid directly for each service they delivered. Since it was based
on the premise of providing services without regard for quality or outcomes, it created a large
conflict of interest with patients as FFS incentivized the overutilization of sometimes
unnecessary treatments without regard to the cost of the treatment (Mark et al., 2016). Private
insurance companies would provide a higher reimbursement rate than Medicaid and Medicare
would, causing some private practices to decline patients with those coverages. Specialty care
practices were more likely to do this, because the cost of their treatment and care is higher
than that of primary care (Baker, 1997). Fee-for-service models discouraged coordinated or
integrated health care, because FFS rewards individuals for performing separate treatments,
since only one physician can claim or be reimbursed for the treatment given.
This movement from FFS to a more managed care approach was founded on chronic care
models that see the system as a whole rather than in parts. The chronic care model (CCM) is
an organizational approach to caring for individuals with a chronic disease in a primary care
setting. CCM includes community care, public health, system design, decision support, and
clinical information systems that operate as one to best care for the patient. It does this by
creating a system that focuses on quality care; empowers patients to manage their own care;
pledges effective and efficient care; fosters research-driven care with patient preferences; and
shapes data that supports effective and efficient care (Improving Chronic Illness Care, 2017).
The CCM approach improves the patient/provider relationship and focuses on the quality of

21
care with regards to an integrated methodology.
Taking a public health approach that aims for prevention would aid the system and curb
negative outcomes. One such approach advocates for an improvement of the current system
by focusing on three key areas for the implementation of preventative services: traditional
clinical prevention, innovative clinical prevention, and total population/community-wide
prevention (Auerbach, 2016). Traditional clinical prevention is typically implemented in a
clinical setting and utilizes evidence-informed practices, such as mammograms, colonoscopies,
and flu shots. Such interventions have strong efficacy and cost-effectiveness and are mandated
under the ACA and private insurers, so they are covered. Innovative clinical preventative
services are implemented outside of the clinical setting (e.g., home) and can identify
environmental triggers that cause chronic disease. These services are customized to the client
and include home-based educational counseling designed specifically for prevention and
chronic disease management. Community-wide prevention targets an entire population or
community rather than a single client, like the other two do. Examples of these types of
interventions are increased taxes on cigarettes, smoking bans, and the use of commercial
advertising.
The ACA provided a shift for more congruent care of individuals through patient-centered
medical homes and accountable care organizations (ACOs). As described earlier in this
chapter, PCMH increases access and care to those who are most vulnerable. Similarly, ACOs
are groups of doctors, hospitals, and other health care providers, who come together
voluntarily to give coordinated high-quality care to their Medicare patients (DeVries et al.,
2012). ACOs financially incentivize doctors to keep their patients healthy by avoiding
unnecessary tests and procedures. For ACOs to work, they must seamlessly share information.
Those that save money while also meeting quality targets keep a portion of the savings. Care
coordination is an essential component of the PCMH and ACO. Care coordination requires
additional resources, such as health information technology and appropriately trained staff, to
provide coordinated care through team-based models. Additionally, payment models that
compensate PCMHs and ACOs for their functions devoted to care coordination activities and
patient-centered care management that fall outside the face-to-face patient encounter may
help encourage further coordination.
Integrated health care was a main goal of the ACA, because collaborative and coordinated
care would keep costs low and increase quality patient care. One of the cornerstones of
integrated healthcare is that it reduces barriers to access, barriers that include the stigma of
mental health care. Integrated care works especially well with individuals with mental health
disorders. Persons with serious mental illnesses (SMI) are now dying 25 years younger than
the general population. While suicide and injury account for about 30–40% of excess mortality,
60% of premature deaths in persons with schizophrenia are due to medical conditions, such as
cardiovascular, pulmonary, and infectious diseases (Newcomer & Jenkins, 2007). There are
many modifiable health risk factors that attribute to this statistic, such as smoking, alcohol
consumption, poor nutrition/obesity, lack of exercise, “unsafe” sexual behavior, IV drug use,
and residence in group care facilities and homeless shelters. This population also has a higher
vulnerability due to higher rates of victimization/trauma, unemployment, poverty,
incarceration, social isolation, and homelessness (Drake, Bond, Goldman, Hogan, & Karakus,
2016). Individuals with SMI also have poor access to and utilization of healthcare and

22
decreased adherence to medications, and many face poverty.
Integrated healthcare helps mitigate the side effects of a fragmented system to increase
quality of care. Before primary care settings were the gatekeepers to the behavioral health
system, primary care providers needed support and resources to screen and treat individuals
with behavioral healthcare needs. One model for manifesting an integrated approach would
be to have a mental health professional, such as a psychiatrist, psychologist, or social worker,
be physically present in a primary care setting. This would not only improve access and
utilization of care to the most vulnerable, but also decrease the stigma of mental health
disorders in the healthcare system. This model forces medical professionals to break out of
their training silos and work together for the best care of the patient.
A more community-based approach would be beneficial to a larger population because the
medical professional could increase access to care to those who have limited healthcare
options. This could be screening by dieticians in community centers that include brief
interventions and recommendations for follow-ups to healthcare centers that accept sliding
scale payments (such as Federally Qualified Healthcare Centers). For children, integrated
healthcare models could take place within the school system for universal care. For example,
African American children are more likely to use school-based health centers than primary
care (Bains & Diallo, 2016). By bringing healthcare out of traditional care centers and into the
community, it could improve population health outcomes.
Social determinants of health are “the structural determinants and conditions in which
people are born, grow, live, work and age” (Marmot et al., 2008). They include factors like
socioeconomic status, education, the physical environment, employment, and social support
networks, as well as access to health care. Racial minorities and low-income and other
vulnerable communities experience health disparities more than the general population does.
The Kaiser Family Foundation (2017a) defines health disparities as “differences in health
outcomes that are closely linked with social, economic, and environmental disadvantage.”
Researchers have discovered that social factors, such as education, race, and socioeconomic
status, account for over a third of total deaths a year (Heiman & Artiga, 2015). As time
progressed, these determinants started to be recognized as factors in physical health and
finally into mental health and substance abuse; however, funding for primary or tertiary care
for these effects have yet to happen. This is mostly because the reimbursement system
influences the delivery of care, and it is hard to reimburse for medical services that are not
medical in nature. Understanding how the built environment impacts health, especially mental
health care, is vital for the treatment of patients. This expansion of healthcare services
addressed the economically vulnerable – those who are at a higher risk for developing mental
health and substance abuse disorders.
One way to broaden the scope of quality care to utilize telemedicine. Telemedicine is the
use of telecommunication and information technology to provide clinical health care from a
distance. It helps eliminate distance barriers and can improve access to medical services that
would often not be consistently available in distant rural communities (Øvretveit, Scott,
Rundall, Shortell, & Brommels, 2007). This can be beneficial to patients in isolated
communities who must travel great distances to receive care. Recent developments in mobile
collaboration technology can allow healthcare professionals in multiple locations to share
information and discuss patient issues as if they were in the same place. Remote patient

23
monitoring through mobile technology can reduce the need for outpatient visits, potentially
significantly reducing the overall cost of medical care (Goh, Gao, & Agarwal, 2011).
Telemedicine would also alleviate the issue of mental health workforce shortages, specifically
in child psychiatry. The use of telemedicine can also facilitate medical education by allowing
emerging practitioners to observe experts in their fields and share best practices more easily.
However, there are limitations to the use of telemedicine, such as the high costs of
telecommunication and data management equipment and of technical training for medical
personnel who will employ it. Virtual medical treatment also entails potentially decreased
human interaction between medical professionals and patients, an increased risk of error
when medical services are delivered in the absence of a registered professional, and an
increased risk that protected health information may be compromised through electronic
storage and transmission (Kern & Jaron, 2002). There is also a concern that telemedicine may
decrease time efficiency due to the difficulties of assessing and treating patients through
virtual interactions; for example, it has been estimated that a consultation via technology can
take up to 30 minutes, whereas 15 minutes is typical for a traditional consultation (Kern &
Jaron, 2002). Additionally, the potentially poor quality of transmitted records, such as images
or patient progress reports, and decreased access to relevant clinical information are quality
assurance risks that can compromise the quality and continuity of patient care for the
reporting doctor. Other obstacles to the implementation of telemedicine include unclear legal
regulation for some telemedical practices and difficulty claiming reimbursement from insurers
or government programs in some fields.
Although improvements to the healthcare system have been made, there is still a long way
to go. As the diversity of the United States population keeps growing, this diversity should
also be reflected in our medical care professionals. Finding a practitioner that speaks one’s
language, shares one’s culture, has the right specialty, is located nearby, and accepts insurance
can be a challenge. Managed care organizations and narrow networks hamper the ability of
clinicians who may provide culturally congruent treatments. In regards to individuals with
mental health disorders, care must be taken to continue to employ psychosocial interventions
with medications.

Workforce Development
The major providers of behavioral health in the United States are specialty behavioral medical
professionals, general medical/primary care professionals, and professionals in the human
services sector (school-based counseling services, criminal justice/prison-based systems) and
the voluntary support network sector (self-help groups, NA, AA). Broadly speaking, this set of
professionals works in the private sector, public sector, and community mental health centers.
Specialty behavioral medical professionals like psychiatrists, clinical psychologists, and clinical
social workers generally practice in a clinic or a hospital. Nationally, it was estimated in 2000
that there was one specialty behavioral medical professional for every 529 individuals
(McLellan et al., 2000), and even fewer for specialty care practitioners for children and
adolescents.
There is an increasing shortage of psychologists and psychiatrists in the U.S. The number of
active psychiatrists has declined from 1 per 7,825 people in 2008 to 1 per 8,476 people in 2013

24
(Olfson, 2016). One hypothesis for this decline is that psychiatry and psychology are highly
specialized fields that are time and cost intensive. Also, doctors are compensated more in other
medical specializations. In addition, Medicaid reimbursement for mental health services is
often low, so psychiatrists are not incentivized to take on Medicaid patients. This shortage is
also exacerbated by geographic maldistribution – a greater choice of provider is more likely in
an urban setting than a rural one. To remedy this, Olfson (2016) recommends four policy
proposals: (1) expanding loan repayment programs for mental health professionals to practice
in underserved areas; (2) raising Medicaid reimbursement for treating serious mental illness;
(3) increasing training opportunities for social workers in relevant evidence-based
psychosocial services; and (4) disseminating service models that integrate mental health
specialists as consultants in general medical care. These suggestions can mitigate the demand
from the consumer and create a workforce that would be able address current deficits.
With the move towards integrated care, more medical professionals are expected to
collaborate in interdisciplinary teams, which can be challenging. Training the medical
workforce to work within newly designed systems to include interprofessional teams and
current research and data can be an issue, as creating these teams and systems costs a
significant amount upfront. Professionals now must understand not only the clinical
components of care, but also policy, payment models, and more, which creates additional
strain. Practitioners also must not only evaluate new clinical models of care, but also
implement them (implementation science). Implementation science has been integral for
public health practitioners for years, as it has incorporated multiple determinants of health
and health behavior (Glanz & Bishop, 2010). Implementation science is rooted in the health
belief model, the transtheoretical model, social cognitive theory, and the ecological model,
which have shaped public health and social work professions. This science puts increasing
pressure on training programs to provide adequate and proficient clinical training.
Ways the ACA has engaged this science is by promoting interdisciplinary care models,
which has shifted the paradigm from a hospital-centric system to a health- or physician-
centric system. The ACA incentivizes this by offering different funding opportunities to
educational institutions. Health Professional Opportunity Grants through the Administration
of Child and Families (ACF) provide education and training to recipients of temporary
assistance for needy families (TANF) and other low-income individuals for occupations in the
health care field that pay well and are expected to either experience labor shortages or be in
high demand (ACF, 2017). Roles include certified medical assistant, certified nursing assistant,
and registered nurses.
The ACA promotes opportunities for nonprofits and universities to be creative with
interprofessional training. One model that demonstrates this implementation has medical,
nursing, and social work experts come together to implement screening, brief intervention,
and referral to treatment (SBIRT) in primary care settings. The goal of this model and
implementation is to identify, reduce, and prevent problematic use, abuse, and dependence on
alcohol and illicit drugs (SAMHSA, 2017). This evidence-based model increases primary
preventative services while decreasing costly tertiary outcomes.
Culturally informed decision-making is also integral to workforce development.
Practitioners must take into consideration the stigma associated with the diagnosis and
treatment of a mental illness. They also must be aware that trust between a physician and

25
patient may not exist, thus causing a barrier between access and utilization of care. For
example, African Americans may be skeptical of medical professionals because of the
exploitation of African Americans during the Tuskegee Syphilis Study (Gamble, 1997). There
needs to be cultural congruity between clinicians and clients, possibly more along the lines of
cultural humility, in which clinicians are not making assumptions about clients, not imposing
their own cultural views, and allowing clients to be the master of their own narrative.

26
Current and Future State of Healthcare
The Affordable Care Act provides one of the largest expansions of mental health and
substance use disorder coverage in a generation, by requiring that most individual and small
employer health insurance plans, including all plans offered through the Health Insurance
Marketplace, cover mental health and substance use disorder services. Rehabilitative services
that can help support people with behavioral health challenges are also required. These new
protections build on the Mental Health Parity and Addiction Equity Act of 2008 provisions to
expand mental health and substance use disorder benefits and federal parity protections to an
estimated 62 million Americans (Kaiser Family Foundation, 2017a).
There are many challenges in the ACA that need to be addressed. Although “repeal and
replace” appears to be the mantra, it may be more about repair. The ACA aimed to cover most
Americans; however, many are still without insurance. In addition, many legislators do not
care for the individual mandate, saying that it a socialist move. If the individual mandate of
the ACA is removed, then there is no penalty for healthy individuals to not have health
insurance and they may drop out. If the healthy individuals do drop out of the insurance
marketplace, it would drive up costs for the sick (Jost, 2017). Some legislators are exploring an
incentive plan for individuals who maintain their health insurance (i.e., lower premiums);
however, there has been no agreement on what this incentive plan would look like. The ACA
is also costly for both the federal and state governments to cover. However, many argue that it
would be costlier to go back to how healthcare was covered before.
Medicaid block grants have been introduced as a possible way to allow states flexibility to
develop programs based on their unique needs, which may lead to innovation and manage
costs. Medicaid block grants are fixed-sum federal grants to state and local governments that
give them broad flexibility to design and implement designated programs (Kaiser Family
Foundation, 2017b). Federal oversight and requirements are light, and funds are allocated
among recipient governments by formula. These block grants could allow states to be
innovative with the way Medicaid is implemented and distributed. The issue is how to allow
states to innovate, which has been historically thru waivers. However, if the state surpasses
the original block of money that the federal government gives it, cost of care will significantly
rise. Block grants may be the future, but will be problematic if the federal government’s block
is not enough to cover adequate care, which makes the federal distribution of funds clunky for
states. Recent proposals suggest that states could create per capita block grants (e.g., a block
grant for each individual), which allows flexibility for economic changes in that state. If the
block grant is lower than the cost of care, however, the residual costs are deflected onto the
individual, who may or may not be able to afford it (Rosenbaum, Schmucker, Rothenberg, &
Gunsalus, 2016).
Capitated block grants would allow states to get a fixed amount of money each year;
however, that sum is calculated based on how many people are enrolled in Medicaid. Within
this approach there are options: the federal government could set a single per-enrollee cap that
applies to all Medicaid recipients, including children, adults, the elderly, and persons with
disabilities; it could set different caps for each group; or it could exempt certain groups from

27
the cap (Rosenbaum et al., 2016). This could be difficult, because the main cost to Medicaid is
the cost of the elderly and individuals with disabilities. The caps could be structured to cover
only certain services in Medicaid, such as the exemption of prescription drug coverage, which
could mitigate the costs (Rosenbaum et al., 2016). That would, however, leave vulnerable
individuals without adequate care. In theory, a per capita caps system would increase funding,
but if an expensive new drug enters the market, or a costly new disease emerges, Medicaid
budgets would not be able to reflect that.
Another proposal is to expand the use of health saving accounts, which are a tax-
advantaged medical savings account available to taxpayers in the United States who are
enrolled in a high-deductible health plan. Unlike a flexible spending account (where unspent
money would be forfeited to the employer at the end of the year), health savings account
funds roll over and accumulate year to year if they are not spent. Under the ACA, individuals
can put $3,400 and families can put $6,750 into a tax-free health savings account (Kaiser
Family Foundation, 2017b). Although these tax-free accounts are suitable for individuals and
families, many do not have the luxury of saving this kind of money, and ultimately must pay
higher out-of-pocket expenses.
There needs to be a greater integration of community care. Overall, health care is moving
from clinical/acute care to community care, including other groups that provide behavioral
health care. Community-wide prevention targets an entire population or community rather
than a single client, as in the past. It is estimated that through community interventions, the
behavioral health and substance abuse incidence and prevalence rates can drop by 20% in the
next decade (Hawkins et al., 2015). These community interventions need to be
transdisciplinary in action and collaborative in spirit. They can ultimately save the country
billions of dollars that are currently being spent on coverage and treatment. To address the
grand challenges of behavioral health prevention, social work proposes three ways that
prevention can be implemented in a community-wide approach: universal programs that seek
to reach all children and youth without regard to level of risk exposure; selective programs
that focus on young people who have been exposed to elevated levels of risk, but who do not
yet manifest behavioral health problems; and indicated programs that focus on youth who
evidence early symptoms of behavioral health problems (Hawkins, et.al., 2015). When all three
are implemented correctly, the stigma of behavioral health disorders is reduced and positive
well-being is created.
One example of the way this has been successfully implemented is in the criminal justice
system. Individuals diagnosed with a mental health problem are overrepresented in the
criminal justice system, with 11–31% of incarcerated individuals diagnosed with a mental
health disorder and 14% with a serious mental illness (Kennedy-Hendricks, Huskamp, Rutkow,
& Barry, 2016). Such efforts to mitigate this issue include diverting individuals with mental
illness from the criminal justice system by utilizing mental health courts. Capitalizing on an
interdisciplinary team, professionals can identify criminal behaviors and the intersection of
mental health and substance abuse disorders to separate out those in need of mental
healthcare assistance. Some states are exploring the use of preventable jail stays as a quality
metric within outpatient treatment.
Technology offers important new approaches to getting resources and information about
mental health diagnosis and treatment to providers and patients. Telemedicine not only

28
enhances provider collaboration but also increases effectiveness of treatment. In a day where
almost everyone has a smartphone and connection to the internet, it would make sense for the
medical field to work with technology. A study conducted in 2011 found over 200 unique
mobile apps that address a variety of behavioral health issues, most commonly depression,
anxiety, smoking, substance abuse, relaxation, fitness, spirituality, and general well-being
(Luxton, McCann, Bush, Mishkind, & Reger, 2011). Many of these apps are free or offered at a
reasonable price, making them readily available for consumer use. By creating a universal
platform that could reach anyone regardless of insurance status, one can hopefully reduce
adverse health outcomes and promote a healthy society.

29
Another random document with
no related content on Scribd:
 of David. And Hezekiah prospered in all his
works.
30. stopped] Compare verses 3, 4.

Gihon] The upper spring of Gihon is represented to-day by St

Mary’s Well; compare Bädeker, Palestine⁵, pp. 25, 83, and note on
verse 3 above.

on the west side of the city] Render, westwards to the city. The
direction followed by the tunnel through which Hezekiah brought the
waters from the upper spring of Gihon (St Mary’s Well outside the
city) to the Pool of Siloam within the walls is roughly west or south-
west; see G. A. Smith, Jerusalem, 1. 102 f.

³¹Howbeit in the business of the ambassadors ¹

of the princes of Babylon, who sent unto him
to inquire of the wonder that was done in the
land, God left him, to try him, that he might
know all that was in his heart.
¹ Hebrew interpreters.

31. who sent] Read rather, with LXX., who had been sent.

to inquire of the wonder] According to 2 Kings xx. 12; Isaiah

xxxix. 1, the ostensible reason of the embassy was to congratulate
Hezekiah on his recovery. The real object was to gain over Judah to
an alliance against Assyria, from which Babylon was constantly
seeking to revolt.

to try him, that he might know, etc.] The phrase is based on

Deuteronomy viii. 2.
 ³²Now the rest of the acts of Hezekiah, and his
good deeds, behold, they are written in the
vision of Isaiah the prophet the son of Amoz,
in the book of the kings of Judah and Israel.
32. his good deeds] Compare xxxv. 26 (of Josiah); Nehemiah xiii.
14 (of Nehemiah).

the vision of Isaiah ... in the book of the kings] The reference is
apparently to Isaiah xxxvi. 2‒xxxix. 8 = 2 Kings xviii. 17‒xx. 21.

³³And Hezekiah slept with his fathers, and they

buried him in the ascent of the sepulchres of
the sons of David: and all Judah and the
inhabitants of Jerusalem did him honour at his
death. And Manasseh his son reigned in his
stead.
33. in the ascent of the sepulchres of the sons of David] What is
implied by “the ascent of the sepulchres,” the phrase being found
only here? Some hold that it means a place outside the royal
burying-ground, and that, since exclusion from the royal sepulchres
was a mark of dishonour otherwise confined to the bodies of wicked
kings (xxi. 20, xxiv. 25, xxvi. 23, xxviii. 27) the statement could hardly
emanate from the Chronicler himself but must be derived from some
old and presumably trustworthy source: an unsatisfactory view.
Certainly the Chronicler cannot have understood the phrase to mean
anything derogatory to Hezekiah, and there is, in fact, no necessity
to interpret it as some place outside the royal sepulchres. On the
contrary, it is reasonable to suppose that it means a definite part of
this royal cemetery, the lower slopes (“ascent”) or possibly the higher
part.

did him honour] compare xvi. 14, xxi. 19.

 Chapter XXXIII.
1‒10 (compare 2 Kings xxi. 1‒16).
Manasseh’s Reign. His Apostasy.

¹Manasseh was twelve years old when he

began to reign; and he reigned fifty and five
years in Jerusalem. ²And he did that which
was evil in the sight of the Lord, after the
abominations of the heathen, whom the Lord
cast out before the children of Israel.
1. in Jerusalem] The Chronicler omits here the name of
Manasseh’s mother, Hephzi-bah.

³For he built again the high places which

Hezekiah his father had broken down; and he
reared up altars for the Baalim, and made
Asheroth, and worshipped all the host of
heaven, and served them.
3. the Baalim] i.e. the gods—of Canaan—Baalim being the plural
of the word Baal (Lord, i.e. God). See the notes on xvii. 3, and 1
Chronicles viii. 33.

Asheroth] compare xiv. 3 (note).

the host of heaven] See the note on xviii. 18. Compare 2 Kings
xvii. 16; Jeremiah viii. 2.
 ⁴And he built altars in the house of the Lord,
whereof the Lord said, In Jerusalem shall my
name be for ever.
4. shall my name be for ever] Compare vii. 16.

⁵And he built altars for all the host of heaven in

the two courts of the house of the Lord.
5. the two courts] Compare iv. 9 (note).

⁶He also made his children to pass through

the fire in the valley of the son of Hinnom: and
he practised augury, and used enchantments,
and practised sorcery, and dealt with them
that had familiar spirits, and with wizards: he
wrought much evil in the sight of the Lord, to
provoke him to anger.
6. He also made] In the Hebrew there is stress on the pronoun
“He” (that wicked one!).

to pass through the fire] Compare xxviii. 3 (note).

in the valley of the son of Hinnom] Compare Jeremiah vii. 31, 32.

practised augury] The precise meaning of the Hebrew word

(‘ōnēn) is quite uncertain, so that we cannot be sure what form of
divination is meant. “Augury” among the Romans consisted chiefly in
observing birds and interpreting the observations made, but auguries
were also taken from other natural phenomena.

practised sorcery] The Hebrew word (kishshēph) probably means

“to make a magic brew with shredded herbs.”
 with them that had familiar spirits] The Hebrew word (ōb)
probably means a necromancer who used ventriloquism in the
practice of his art. The witch of Endor (1 Samuel xxviii.) was such a
person. LXX. here has [ἐποίησεν] ἐνγαστριμύθους, i.e. “he appointed
ventriloquists.”

⁷And he set the graven image of the idol,

which he had made, in the house of God, of
which God said to David and to Solomon his
son, In this house, and in Jerusalem, which I
have chosen out of all the tribes of Israel, will I
put my name for ever: ⁸neither will I any more
remove the foot of Israel from off the land
which I have appointed for your fathers; if only
they will observe to do all that I have
commanded them, even all the law and the
statutes and the ordinances by the hand of
Moses.
7. the graven image of the idol] In 2 Kings xxi. 7, Revised Version
“the graven image of Asherah.” For Asherah compare xv. 16 (note).

⁹And Manasseh made Judah and the

inhabitants of Jerusalem to err, so that they
did evil more than did the nations, whom the
Lord destroyed before the children of Israel.
9. And Manasseh made Judah, etc.] Compare Jeremiah xv. 4,
where the captivity itself is referred back for its cause to the evil
deeds of Manasseh.
 ¹⁰And the Lord spake to Manasseh, and to
his people: but they gave no heed.
10. the Lord spake] i.e. by prophets; compare 2 Kings xxi. 10‒
15.

11‒13 (not in 2 Kings).

The Punishment of Manasseh, and his Repentance.

It has been urged that the tradition of Manasseh’s captivity in

Babylon, his restoration to the throne of Judah, and his attempt at
reformation—events related only by the Chronicler—ought not to be
regarded as historically true, but are simply inventions put forward as
a possible explanation of the (to the Chronicler) strange fact that the
wicked king Manasseh reigned for no less than fifty and five years.
The objections to the tradition are not slight—in view of the general
character of the Chronicler’s work. In particular, the story of
Manasseh’s penitence might easily be an assumption to justify the
fact of his long reign, and it is very difficult to correlate it with
Jeremiah xv. 4, where the captivity of the nation is expressly
declared to be due to Manasseh’s wickedness. The evidence is not
decisive, however; and a brief and perhaps half-hearted repentance
towards the close of his reign might well be forgotten or deemed
negligible. The evidence against the historicity of the tradition of the
captivity of Manasseh is much less strong, being chiefly the silence
of Kings. The facts mentioned in the following note indicate that
there is nothing inherently improbable in the tradition, and it is
therefore legitimate to accept it as very possibly correct, although we
are not yet able to confirm it from the Assyrian records.

¹¹Wherefore the Lord brought upon them the

captains of the host of the king of Assyria,
which took Manasseh in chains ¹, and bound
him with fetters, and carried him to Babylon.
¹²And when he was in distress, he besought
 the Lord his God, and humbled himself
greatly before the God of his fathers.
¹ Or, with hooks.

11. Assyria] Manasseh is mentioned in an Assyrian list of kings

tributary to Esar-haddon and Asshur-bani-pal, but no Assyrian
inscription at present known speaks of his captivity. We have,
however, monumental evidence that there was a great insurrection
against Asshur-bani-pal, the grandson of Sennacherib, in which
Western Asia (and perhaps Manasseh) was involved. The
subsequent restoration of Manasseh to his kingdom is not incredible,
for Neco I of Egypt was first put in fetters and afterwards sent back
to Egypt. (Driver in Hogarth, Authority and Archaeology, pp. 114‒
116.)

in chains] Rather, with hook (as margin); compare 2 Kings xix.

28 (= Isaiah xxxvii. 29). Assyrian kings sometimes thrust a hook or
ring into the nostrils of their captives and so led them about. The
practice is illustrated on many Assyrian reliefs in the British Museum
(see Handcock, Latest Light on Bible Lands, p. 159).

to Babylon] Nineveh, not Babylon, was the capital of Assyria, but

as Asshur-bani-pal at times resided in Babylon, there is nothing
improbable in any important prisoner of his being carried thither.

¹³And he prayed unto him; and he was

intreated of him, and heard his supplication,
and brought him again to Jerusalem into his
kingdom. Then Manasseh knew that the Lord
he was God.
13. he prayed unto him; and he was intreated of him] It is very
pleasing to notice that, for all the rigidity of the Chronicler’s theology,
he allows that even an heinous sinner may repent, and that, if he
does so, he will meet with Divine acceptance.

14‒17 (not in 2 Kings).

The Later Deeds of Manasseh.

¹⁴Now after this he built an outer wall to the

city of David, on the west side of Gihon, in the
valley, even to the entering in at the fish gate;
and he compassed about Ophel, and raised it
up a very great height: and he put valiant
captains ¹ in all the fenced cities of Judah.
¹ Or, captains of the army.

14. an outer wall ... fish gate] “This can only mean that outside
the existing rampart of the citadel, on the ridge above the present
Virgin’s Spring [i.e. St Mary’s Well, see note, xxxii. 3], Manasseh
constructed another line of fortification which he carried northwards
past the Temple Mount, and round its northern slope,” G. A. Smith,
Jerusalem, 1. 208. The fish-gate was in the northern wall, probably
corresponding to the modern Damascus Gate (Jerusalem 1. 202).

Ophel] compare xxvii. 3 (note).

¹⁵And he took away the strange gods, and the

idol out of the house of the Lord, and all the
altars that he had built in the mount of the
house of the Lord, and in Jerusalem, and
cast them out of the city.
15. he took away the strange gods] Compare verse 7.
 ¹⁶And he built up ¹ the altar of the Lord, and
offered thereon sacrifices of peace offerings
and of thanksgiving, and commanded Judah
to serve the Lord, the God of Israel.
¹ According to another reading, prepared.

16. he built up] or he rebuilt, compare xi. 5 (note).

peace offerings] compare 1 Chronicles xvi. 1 (note).

commanded Judah] compare verse 9; 2 Kings xxi. 11.

¹⁷Nevertheless the people did sacrifice still in

the high places, but only unto the Lord their
God.
17. but only, etc.] See note on xxxii. 12.

18‒20 (compare 2 Kings xxi. 17, 18).

The Epilogue to Manasseh’s Reign.

¹⁸Now the rest of the acts of Manasseh, and

his prayer unto his God, and the words of the
seers that spake to him in the name of the
Lord, the God of Israel, behold, they are
written among the acts of the kings of Israel.
18. his prayer] It was probably upon the ground of this remark
that the so-called Prayer of Manasses, which in the English editions
of the Apocrypha occurs just before 1 Maccabees, was composed.
The “prayer” referred to by the Chronicler is quite certainly not to be
associated even remotely with this apocryphal work, which by some
is thought to have been written originally in Greek, though it has also
been regarded as a Greek translation from some Hebrew midrashic
source. Its date is uncertain. It is given in a collection of hymns
appended to the Psalter in the Alexandrine MS. (A) of the LXX.
(Swete’s edition vol. iii. p. 824), and is also found in the Latin
Vulgate, though the translation is not by Jerome. See the edition by
Ryle in Charles’ Apocrypha, vol. 1.

the acts of the kings of Israel] See Introduction § 5, p. xxxii. Here,

since canonical Kings contains no mention whatever of Manasseh’s
prayer or the words of the seers to him, we see very plainly that this
source to which the Chronicler so often refers cannot be identical
with the canonical books of Kings.

¹⁹His prayer also, and how God was intreated

of him, and all his sin and his trespass, and
the places wherein he built high places, and
set up the Asherim and the graven images,
before he humbled himself: behold, they are
written in the history of Hozai ¹.
¹ Or, the seers So the Septuagint.

19. in the history of Hozai] Render, in the history of the seers;

compare margin and LXX., slightly emending the Hebrew text. To
take the Hebrew word (ḥōzai) as a proper name is unsuitable, since
the same word occurs as a common noun (“seers”) in the preceding
verse.

²⁰So Manasseh slept with his fathers, and they

buried him in his own house: and Amon his
son reigned in his stead.
 20. in his own house] i.e. as in 2 Kings “in the garden of his own
house.”

21‒25 (= 2 Kings xxi. 19‒26).

Amon’s short Reign. Josiah succeeds him.

²¹Amon was twenty and two years old when

he began to reign; and he reigned two years in
Jerusalem. ²²And he did that which was evil in
the sight of the Lord, as did Manasseh his
father: and Amon sacrificed unto all the
graven images which Manasseh his father had
made, and served them.
21. in Jerusalem] The Chronicler omits here the name of Amon’s
mother; compare verse 1.

²³And he humbled not himself before the

Lord, as Manasseh his father had humbled
himself; but this same Amon trespassed ¹ more
and more. ²⁴And his servants conspired
against him, and put him to death in his own
house.
¹ Or, became guilty.

23. And he humbled not himself] This verse is not in Kings.

trespassed] Render, became guilty (so margin); compare xix.

10, xxiv. 18, xxviii. 10, 13.
 ²⁵But the people of the land slew all them that
had conspired against king Amon; and the
people of the land made Josiah his son king in
his stead.
25. slew] Render, smote. The Hebrew word suggests that there
was a conflict between the people and the conspirators.
 Chapter XXXIV.
1, 2 (= 2 Kings xxii. 1, 2).
Josiah’s good Reign.

Of Josiah only good is recorded in Kings: “he did that which was
right in the eyes of the Lord, and walked in all the way of David his
father, and turned not aside to the right hand or to the left” (2 Kings
xxii. 2). In the eighteenth year of his reign he is said to have ordered
a repair of the Temple in the course of which a discovery was made
of a book of the Law. In consequence of its injunctions a thorough
reformation was carried out by Josiah, a solemn covenant with God
being entered into by the king and all the people, and attested first
by a crusade against all idolatrous images and symbols throughout
the land and then by a grand celebration of the Passover feast (2
Kings xxii. 3‒xxiii. 27). Obviously Josiah was a king after the
Chronicler’s own heart. He makes Josiah’s reforming energy begin
as early as his eighth year, causing some changes in the order of
events (see the note on verse 3). On the record of the Passover
feast the Chronicler has naturally fastened with special pleasure, and
he expands the brief allusions to it in Kings into a detailed account
occupying xxxv. 1‒19. His narrative of the death of Josiah differs
considerably from that in Kings. Several other minor variations are
pointed out in the notes below.

¹Josiah was eight years old when he began

to reign; and he reigned thirty and one years
in Jerusalem.
1. in Jerusalem] Here the Chronicler omits the name of Josiah’s
mother; compare xxxiii. 1, 21.
 ²And he did that which was right in the eyes of
the Lord, and walked in the ways of David his
father, and turned not aside to the right hand
or to the left.
2. turned not aside, etc.] A commendatory phrase applied to
Josiah alone of the kings.

3‒7 (compare verse 33; 2 Kings xxiii. 4‒20).

Josiah destroys the Symbols of Idolatry.

³For in the eighth year of his reign, while he

was yet young, he began to seek after the
God of David his father: and in the twelfth year
he began to purge Judah and Jerusalem from
the high places, and the Asherim, and the
graven images, and the molten images.
3. in the eighth year ... and in the twelfth] It should be noticed that
the order of the events of Josiah’s reign given in Chronicles varies
from that given in 2 Kings Thus we have in 2 Chronicles:

(1) Destruction of idolatrous symbols throughout Jerusalem,

Judah and Israel; xxxiv. 3‒7.

(2) Repair of the Temple and Finding of the Law; xxxiv. 8‒28.

(3) Renewal of the Covenant with Jehovah; xxxiv. 29‒33.

(4) Great Passover kept; xxxv. 1‒19.

(5) Death of Josiah; xxxv. 20‒27.

In 2 Kings on the other hand (2) and (3) precede (1), and the
reforming activity of the king is accordingly placed subsequent to the
finding of the Law in the eighteenth year of his reign. There can be
little doubt that the order in Kings is correct. The Chronicler thought it
desirable that the piety of the king should be displayed earlier, and
he has therefore dated its commencement from the eighth and
twelfth years. [This is preferable to the suggestion that “eighth”
(bishĕmōneh) and “twelfth” (bishtēym ‘esreh) may be due to a
transcriptional error of “eighteenth” (bishĕmōneh ‘esreh).]

while he was yet young] There is no clause corresponding to this

in 2 Kings, and the statement is probably due to the motive indicated
in the previous note. There is, of course, no reason to question the
piety of Josiah in his early years, for though in 2 Kings his
reformation is dated in the eighteenth year of his reign, i.e. when he
was 25 years of age (hardly “young” for a king), the favourable
judgement passed on him (2 Kings xxii. 2) is unqualified by any
suggestion that he was tardy in turning to Jehovah, and the
prophetic activity of Jeremiah is dated from the thirteenth year of
Josiah’s reign (Jeremiah xxv. 3).

in the twelfth year he began] The Chronicler spreads the

cleansing of the land over six years, i.e. from the twelfth to the
eighteenth; compare verse 8.

to purge] Josiah’s measures are more fully enumerated and

described in 2 Kings xxiii.; notice e.g. the removal of the Asherah
from the Temple (verse 6), the destruction of the houses of the
Ḳĕdēshim (compare Deuteronomy xxiii. 17, 18) which were in the
house of the Lord (verse 7), the deportation of priests from the cities
of Judah into Jerusalem (verses 8, 9), and the defiling of Topheth
and of Beth-el (verses 10, 15, 16). The Chronicler not unnaturally
prefers to avoid these details and employs the usual general terms
here, partly because he has already credited the penitent Manasseh
with a reform of this character (xxxiii. 15), partly also because he
may have been unwilling to suppose that such flagrant abuses in the
Temple as are mentioned in Kings had continued to this date.

the Asherim] compare xiv. 3 (note).

 ⁴And they brake down the altars of the Baalim
in his presence; and the sun-images, that
were on high above them, he hewed down;
and the Asherim, and the graven images, and
the molten images, he brake in pieces, and
made dust of them, and strowed it upon the
graves of them that had sacrificed unto them.
4. the Baalim] Compare xxxiii. 3 (note).

the sun-images] See note on xiv. 5; and compare 2 Kings xxiii.

11.

⁵And he burnt the bones of the priests upon

their altars, and purged Judah and Jerusalem.
5. he burnt the bones of the priests] Specially at Beth-el; 2 Kings
xxiii. 15, 16.

⁶And so did he in the cities of Manasseh and

Ephraim and Simeon, even unto Naphtali, in
their ruins ¹ round about. ⁷And he brake down
the altars, and beat the Asherim and the
graven images into powder, and hewed down
all the sun-images throughout all the land of
Israel, and returned to Jerusalem.
¹ Or, as otherwise read, with their axes. The text is probably
corrupt.

6. Simeon] Here as in xv. 9 Simeon is regarded as belonging to

the northern tribes, but its cities were in the south; compare the note
on xv. 9, and 1 Chronicles iv. 28 ff.

in their ruins] Remark the margin, “with their axes. The text is
probably corrupt.” The Versions afford no real help. A plausible
conjecture is given by Curtis, who would read, he laid waste their
houses.

8‒28 (= 2 Kings xxii. 3‒20).

Repair of the Temple. Discovery of the Book of the Law.

⁸Now in the eighteenth year of his reign,

when he had purged the land, and the house,
he sent Shaphan the son of Azaliah, and
Maaseiah the governor of the city, and Joah
the son of Joahaz the recorder ¹, to repair the
house of the Lord his God.
¹ Or, chronicler.

8. Shaphan] According to 2 Kings he was Scribe. See 1

Chronicles xviii. 16 (note).

the governor of the city] Render, a ruler of the city; compare

xxix. 20.

the recorder] margin the chronicler; compare 1 Chronicles xviii.

15 (note). Neither Maaseiah nor Joah is mentioned in 2 Kings.

to repair the house of the Lord] It may be conjectured that the

disrepair was not due solely to the abuses of Manasseh’s reign, but
was connected with the disaster recorded in xxxiii. 11, when an
Assyrian army carried off Manasseh to Babylon. Probably the
capture of the king was not achieved without the conquest of
Jerusalem, and the Temple may easily have suffered serious
damage at that time. Note that Kings (which does not record the
disaster mentioned in Chronicles) uses strong terms regarding the
condition of the Temple when Josiah’s work was put in hand—“to
repair the breaches of the house,” 2 Kings xxii. 5.

⁹And they came to Hilkiah the high priest, and

delivered the money that was brought into the
house of God, which the Levites, the keepers
of the door ¹, had gathered of the hand of
Manasseh and Ephraim, and of all the
remnant of Israel, and of all Judah and
Benjamin, and of the inhabitants of
Jerusalem ².
¹ Hebrew threshold.

² Another reading is, and they returned to Jerusalem.

9. And they came ... and delivered] The matter is differently

stated in 2 Kings according to which they are sent to Hilkiah with a
message to him to “sum,” i.e. to reckon, the total of the money
collected in the Temple. The Chronicler has in mind the idea which
he set forth in xxiv. 6 ff.—namely, that the money was gathered by a
body of Levites who went round the country collecting it.

the Levites, the keepers of the door] In 2 Kings xii. 9 the keepers
of the doors are called priests; compare 2 Kings xxv. 18.

of the hand of Manasseh, etc.] In 2 Kings simply “of the people”:

i.e. Kings thinks only of the Southern Kingdom; the Chronicler
includes the remnant of the northern tribes. But see also the note on
xv. 9.

and of the inhabitants of Jerusalem] So one reading of the

Hebrew (the Kethīb), in agreement with the LXX. The margin and
they returned to Jerusalem follows the other reading (the Ḳerī).

¹⁰And they delivered it into the hand of the

workmen that had the oversight of the house
of the Lord; and the workmen ¹ that wrought in
the house of the Lord gave it to amend and
repair the house;
¹ Or, they gave it to the workmen &c. See 2 Kings xxii. 5.

10. and the workmen that wrought in the house of the Lord gave
it] The “workmen” are distinguished from the “carpenters and
builders” (verse 11); overseers of some kind are meant. To oversee
the work and to do the work may be synonymous phrases here as in
1 Chronicles xxiii. 4 and 1 Chronicles xxiii. verse 24. On the other
hand 2 Kings xxii. 5 favours the rendering “And they (i.e. Shaphan,
etc., and Hilkiah, verses 8, 9) delivered it into the hand of the
workmen that had the oversight ... and they (i.e. these overseers)
gave it to the workmen that wrought....” (Compare the margin.)

¹¹even to the carpenters and to the builders

gave they it, to buy hewn stone, and timber for
couplings, and to make beams for the houses
which the kings of Judah had destroyed.
11. the houses] Compare 1 Chronicles xxviii. 11.

¹²And the men did the work faithfully: and the

overseers of them were Jahath and Obadiah,
the Levites, of the sons of Merari; and
Zechariah and Meshullam, of the sons of the
Kohathites, to set it forward ¹: and other of the
 Levites, all that could skill of instruments of
music. ¹³Also they were over the bearers of
burdens, and set forward all that did the work
in every manner of service: and of the Levites
there were scribes, and officers, and porters.
¹ Or, to preside over it.

12. the overseers] There is no parallel in 2 Kings for the rest of

this verse and for verse 13. The addition is characteristic of the
Chronicler, exemplifying (1) his habit of inserting proper names,
(2) his interest in the Levites, particularly the musical class.

to set it forward] The same Hebrew word is used in 1 Chronicles

xxiii. 4, and is there rendered “to oversee the work.” (Compare the
margin.)

could skill] “Skill” is used as a verb also in ii. 7, 8. Skill of

instruments = “play skilfully upon instruments.”

¹⁴And when they brought out the money that

was brought into the house of the Lord,
Hilkiah the priest found the book of the law of
the Lord given by ¹ Moses.
¹ Hebrew by the hand of.

14. This verse has no parallel in 2 Kings.

the book of the law] See the Additional Note at the end of the
chapter, pp. 337 ff.