Let's Treat Mental Illness Before It's Too Late

Why is mental illness the only chronic disease we don't begin to treat until Stage 4?

I posed that question in a presentation for over 400 attendees at last week’s winter meeting of the North Carolina Hospital Association.  For an audience that witnesses first-hand the crowding of patients with mental illnesses into general hospital beds and emergency rooms, the question resonated.

Stage 4 of a chronic disease is associated with the imminent threat of death – a widely metastasized cancer, for example, or kidney disease so advanced that only dialysis or a transplant keeps the person alive.

The odds of recovery are long.

It is the same with mental illness.  Either the patient's life or someone else's needs to be at stake before we guarantee access to treatment.  That's Stage 4.

Diagnosing and treating a disease at Stage 1, 2, or 3, always improves the odds of survival and recovery.

Why not apply that standard to mental illness, too?  In Stage 1, people show early signs of the disease – sleeplessness, anxiety, and fatigue, for example.  These are signs that can be readily identified using common mental health screening tools, and symptoms that can be managed through the use of medications, counseling, or even healthy living.

In Stage 2, the disease is more advanced and the symptoms more pronounced.  Depression may affect performance at school or work for example, or “command voices” (sometimes known as auditory hallucinations) may become louder and more pronounced.  This is a stage at which – if we act aggressively and provide the proper supports – we can help patients maintain an independent life, even though they may require an occasional hospitalization. 

People in Stage 3 are in need of ongoing treatment and support, which is often expensive – like chemotherapy in the case of cancer.  But with mental illness, people in Stage 3 are far more likely to be in jails than in treatment beds, and among the homeless population instead of the general population. 

While 6 percent of the general population has serious mental illness, that description applies to an estimated 15 percent of male prisoners, 31 percent of female prisoners, and one-quarter of all people who are homeless.

Intervening effectively during Stage 1, 2, or 3 can save lives and change the trajectories of those lives for literally millions of people.

But that isn’t what we usually do.  According to the National Institute of Mental Health, just over half of adults with serious mental illness receive any treatment at all.

That finally may be about to change. 

Last week, Florida’s Governor Rick Scott and the Federal Department of Health and Human Services came to a compromise.  HHS is going to permit Florida to transition nearly all Medicaid patients into private managed care plans, including for those needing long term care.  In return, the Governor dropped his opposition to Medicaid expansion.  If the Legislature agrees, Medicaid will be available for many more adults with chronic diseases – especially for people with mental illnesses.

And this will make a huge difference.  

If Florida implements Medicaid expansion, other states - like North Carolina - that are still on the fence are more likely to follow suit.  And its managed care program may also offer cost-saving lessons to states that have already braced expansion.  

Policymakers will have a new source of revenue to intervene more effectively to treat mental illness at every stage.

This means more screening and early intervention at Stage 1, more integration of behavioral health, education, and primary care services at Stage 2, and more emphasis on treatment as opposed to incarceration or neglect at Stage 3.

The best part is that states can pick and choose from a long menu those strategies that suit them the best. 

And this means that patients in general hospitals throughout the country – where mood disorders are the 5^th most common diagnosis – will finally get some relief.    

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

States Refusing to Set Up Health Exchanges are Helping Their Children - But Not in the Way They Think

The reasons that 25 states chose not to participate in creating a new health exchange aren’t exactly the ones they’ve been claiming – that Obamacare is too complicated, too anti-consumer, or too politically unpopular. 

The truth is that they have never done a very good job of protecting the health and well-being of their people – especially their children – and they were not ready to start now.

Now that all fifty states have decided whether or not they will at least participate in running their own health insurance exchanges as allowed by the Affordable Care Act (you can see the updated information about what each state decided on my state rankings page), a clear picture is emerging of what distinguished the states choosing to participate from those refusing to do so.

On the whole, when compared to one another, the 25 states that have chosen to participate in running their exchanges (17 by themselves, 8 in partnership with the federal government)do a much better job of taking care of their people than do the 25 states that have deferred to the federal government.

So, just as we imagined a few months ago, residents in the states that refused are likely to be much better off with the federal government running their exchanges.

In many cases, the differences between the states choosing to participate and those refusing to participate are significant.

Let me illustrate why by showing you some updated numbers.  But first, let me explain briefly how I get to them. 

If you rank the states from best to worst, and assign the ranking of 1 to the best and the 50 to the worst, then two “averages” result.  The average ranking of all the states will be 25.5.  And if you divide the states into two equal groups of 25, with all the top-ranked states in one group and all the bottom-ranked states in the other, then the average ranking of the top group will be 13, and the average ranking bottom group will be 38. 

So keep in mind that 13 is the best possible average ranking for any group of 25 states to have, and 38 is the worst possible.

Now here are some average health-related rankings of the group of 25 states choosing to participate in establishing their own exchanges:

• Overall health (OHPM 2012 rankings):  21.5
• 2012 Kids Count ranking: 21.2
• Percentage of uninsured: 21.7
• Percentage with employer-based insurance: 22.4
• Ranking in spending on mental health: 24.7

And here are the average rankings of the group of 25 states refusing to participate in establishing their own exchanges:

• Overall health (2012 OHPM rankings): 29.5    
• 2012 Kids Count ranking: 29.8
• Percentage of uninsured: 29.3
• Percentage with employer-based insurance: 28.6
• Ranking in spending on mental health: 26.3

In every instance, states choosing to participate in setting up their own exchanges have a much better track record than states refusing to participate.   In only the mental health spending ranking is it even close. 

Those of us living in one of the 25 states refusing to participate ought to be thankful that our state policymakers punted on the exchange, because it is more likely than not that we’ll be much healthier and better insured in the long run. 

Especially our children.  States choosing to participate rank an average of almost ten places better than the states refusing to participate.  Children may have literally won the health lottery when those states decided that the federal government could do a much better job of assuring access to health care in the future.

The differences among the states are not just political ones, either. 

Solid Republican states like Utah, Idaho, and Kentucky are all creating their own exchanges, and states like Arkansas, West Virginia, and South Dakota are partnering with the feds.  Meanwhile, Maine, Wisconsin, Ohio, and Pennsylvania are all letting the federal government create their exchanges.

And the decisions have turned the traditional north/south, “state’s rights” argument on its head.  States’ rights states, like Texas and Florida, are refusing to participate, while states like Connecticut, Massachusetts, and New York are choosing to do so.

States refusing to participate may have tried explaining their decision by claiming that the federal government created a program that was too complex, too controversial, or too anti-consumer.  But those clearly aren’t the reasons. 

No, the real reason is that they know that the federal government has already proven itself over time to be better equipped to protect our health than they are.

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

Failure to Expand Medicaid: Just Another Death Penalty?

For many, the fight over whether or not to expand Medicaid is just about the money.  But they overlook the fact that the lives of more than 36,000 people may hang in the balance. 

That’s the conclusion that can be drawn from a study published last summer in the New England Journal of Medicine.  The study was entitled Mortality and Access to Care Among Adults After State Medicaid Expansions.  In it, the authors calculated the numbers of lives saved as a result of an earlier Medicaid expansion in three states.

The three states were Arizona, New York, and Maine.  And while none of these expansion populations matched exactly the expansion population in the Affordable Care Act, they were similar enough to suggest that we might see the same results in the ACA Medicaid expansion population.

The authors concluded that Medicaid expansions could save 19.6 lives for every 100,000 people between the ages of 20 and 64. 

There are over 185 million Americans between the ages of 20 and 64.  That comes to 36,301 lives saved.

These lives are more important than the money. 

These people have families and friends who care about them.  And while some would like to think they should be able to make it on their own, the truth is that they need our help.

Most elected officials seem to get this.  I don’t see why it should even be newsworthy that six Republican governors have now said they support the expansion.   They understand reality.

For example, Governor Jan Brewer of Arizona favors the ACA expansion.  Expansion will save her state money, and it could also save an estimated 723 lives.  For a pro-life governor, what’s not to like about that?

Arizona was the last state to embrace the original Medicaid program.  Perhaps the people of Arizona learned from that experience something that the rest of us take for granted – Medicaid makes a big difference in the lives of people in the state as a whole.

In the four most populous states alone, the numbers of lives hanging in the balance is in the thousands. 

California and New York are already moving forward with the expansion.  That’s good news for an estimated 6700 people, 4421 in California and 2325 in New York.  One of those California lives saved could be my son’s.

But in Texas and Florida, two states at the epicenter of the anti-expansion universe, over 5000 lives still hang in the balance – 2925 in Texas and 2162 in Florida.  The decisions of those state legislatures will have a profound effect on the lives of many other fathers’ and mothers’ sons and daughters.

But expansion means lives saved in every state.  North Carolina can save 1126, Connecticut 422, and Utah 304. 

The table I’ve created with the calculations for all the states is here.

Every study has its limitations, and this one is no exception. 

However, the authors openly acknowledged the limitations of their study when they published it.  They noted that other analyses of the data led to similar results.  By one alternate analysis, they found that for every 176 new adults covered by Medicaid, one death was prevented.

That doesn’t seem like many at first.  However, the ACA Medicaid expansion, if fully implemented by every state, will cover an estimated 15.1 million new adults.  By that measure the expansion would save even more lives – a total of 85,568 nationwide.

What about the money?

In March of last year, the Congressional Budget Office calculated the cost of a full Medicaid and SCHIP expansion to be roughly $103 billion per year.  (More recent CBO Medicaid cost estimates are lower because CBO assumes not all states will expand.)  That comes to $2.8 million per life saved. 

The state share of that cost would be about $198,000.

I’m sure that some might argue that we can’t afford $2.8 million per life – unless of course, the life is their own or their child’s.

But more objective researchers with no political agenda to promote have actually taken the time to calculate the economic value of a life.  It comes to $7 million or more, making the paltry $198,000 one of the best investments a state could make.

So the questions become first, how much are our lives worth to our states?  And second, is the failure to expand Medicaid just another death penalty – one that targets the sick and innocent?

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

A Long Road Back To Sanity - States Finally Reversing Cuts to Mental Health

All over the country, governors are finally beginning to propose new mental health services funding in the aftermath of last year’s mass shootings in Aurora and Sandy Hook.

Notes: OH funding is from existing OHT appropriation.
CT funding is bond money, some of which may
be used by non-MHSA providers.

There will be a long road back to policy sanity.  We have to dig ourselves out of the mess caused by $4.6 billion in state mental health cuts over the last few years.  But these governors give us hope that the funding-cut nightmare over which many of them have presided may be finally coming to an end. 

In recent weeks, both Republicans and Democrats have announced new community behavioral health funding initiatives, typically ranging between $5 million and $20 million.  

But support for community mental health services is not universal.  In states with the worst track records in funding mental health services, their governors continue to be sadly out of step with their colleagues across the nation.

In Idaho, which has recently dropped to the bottom of mental health services spending, Governor Butch Otter’s major mental health initiative in the aftermath of the Sandy Hook shooting is for $70 million to construct a 579-bed “secure mental health facility” on the grounds of the state’s prison south of Boise.  That would be considered progressive by late 19^th century standards.

At least Otter’s proposing to do something.

Florida has been at or near the bottom of mental health spending for years.  But Governor Rick Scott – whose administration just cut millions more away from community mental health services in October – seems to think that if he just ignores the problem it will go away.  He requested no new dollars for mental health services in his 2014 budget.

But in the rest of the country, the emerging news is much better.  In the last month or so:

According to the Lansing State Journal, MichiganGovernor Rick Snyder said he will seek $5 million in new funding for mental health services to identify young people with mental health needs.  Michigan has cut $124 million from community mental health programs since 2004.

In Missouri, where eighteen months ago Anna Brown’s death in a St. Louis jail after she was refused care in a hospital emergency room drew national attention, Governor Jay Nixon is proposing $10 million in new mental health funding, primarily for a hospital emergency room diversion program.

In Colorado, Governor John Hickenlooper, whose state suffered through the Aurora mass shooting last summer, has proposed spending $18.5 million in new funding, including over $10 million for five urgent care centers for people with mental illness and a statewide 24-hour hotline.

In Connecticut, the site of the Sandy Hook massacre, Governor Dan Malloy proposed $20 million in new bond funding to assist community behavioral health providers with infrastructure projects that providers say have either been set aside because of budget cuts or have been draining money needed for direct services.

Kansas Governor Sam Brownback, saying that he was committed to strengthening the state’s community mental health system, announced his support for an additional $10 million to increase funding to 27 community mental health centers and to establish a regional system of peer support, intensive case management, crisis intervention, and other evidence-based services.

Oklahoma Governor Mary Fallin announced that she will seek $16 million in new mental health services funding - $8 million for existing programs and $8 million for new programs, including early intervention programs for children and a new state-supported mental health crisis center.

And in Ohio, Governor John Kasich reported that he was authorizing the expenditure of $5 million from an Office of Health Transformation discretionary fund to support children’s crisis intervention services.

These represent just a handful of states taking action, but a cross-section as well. 

The reasons the governors made these proposals may vary.  Some governors may be avoiding gun control debates.  Others may still erroneously equate mental illness with violence. 

The mental health funding initiatives the governors are proposing, however, are needed. 

The governors are working to improve community mental health systems.  They are calling for early identification and treatment of mental illnesses in children, adding new crisis intervention services, and addressing other neglected priorities in their own states. 

And while the numbers may pale in comparison to the cuts made in recent years and won’t undo the damage overnight, they are steps in the right direction. 

These steps should be embraced by legislators in their states, and in states with less understanding governors.  

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/