Mental Health, America

اضغط هنا لمشاهد الفديو كامل 

I started writing Our Health Policy Matters three and a half years ago, right after the 2010 mid-term elections.

Since then, I have written about two policy areas about which I am passionate – public health and mental health.  As I explain below, I am about to change my professional focus.  And while I will be speaking about one more than the other in the future, for me these two areas are related. Let me explain why.

Mental health and public health are first and foremost about wellness.  They are about identifying risk factors for disease and eliminating or mitigating them.

Many of the same environmental risk factors contribute to poor health, especially poor mental health.  These include poverty, violence, abuse, and neglect.  When we address or mitigate these risk factors, we improve our nation’s health and mental health together.

We often place the burden of responsibility for maintaining one’s health squarely on the shoulders of individuals.  But this is a too-narrow approach.  We cannot prevent every physical illness by eating right and exercising, nor can we prevent every mental illness by simply willing it away.

What we forget sometimes is a simple, self-evident concept about wellness – the brain is a part of the body, and there is no health without mental health.

This leads to two unintended consequences.  The first is this.  In our effort to help people understand the linkage between mental illnesses and addictions, we use a term – behavioral health – that often implies to laypeople that these illnesses are bad behavior, and nothing more.  Mental illnesses therefore seem less serious than other chronic diseases – even though they shave twenty-five years or more from life expectancy.

The second is that we divide health care and mental health care into two non-integrated treatment systems.  We know the result.  Mental health care is poorly supported.  Our community support systems are inadequate.  People with serious mental illnesses are overrepresented in the homeless population.  Our jails and prisons have become our new state hospitals.

When we ignore the importance of promoting mental health and preventing mental illness and integrating care and treatment, we underestimate the power of recovery. 

Mental illnesses can be managed, just as any other chronic conditions can.  Recovery from cancer is possible – and even the norm for many – and so, too, should recovery be the norm for many mental illnesses.

When do not put resources into prevention, integrated care, and recovery, we make mistakes.  Because mental illness is often a childhood disease and there is a long lead time between the emergence of symptoms and the receipt of appropriate care, we make two mistakes in particular.  We overburden both our educational and primary care systems.

Our educators never expected to confront – as first-line responders – such needs in their classrooms.  Our primary care providers never expected to become experts in the early identification of mental illnesses.  Yet half of mental illnesses appear by age 14, and the vast majority of medications for mental illness are prescribed by primary care providers.

This system leads to failure.  I have explained why in other columns, and in an essay I wrote in 2012 for Health Affairs.  And I have written a book about the subject – Losing Tim – that will be published by Columbia University Press in the fall of this year.

But now I have been offered an extraordinary opportunity to do something more.

In a few weeks, I will become President and CEO of Mental Health America.

MHA is a Washington, D.C. area group that has advocated for mental health for over a century.  With 228 local affiliates scattered around the nation, MHA has an extraordinary history of leadership in the modern mental health movement in America – one that I hope to continue.

I am already part of an MHA family.  My wife Pam is, and will remain, CEO of the MHA Palm Beach County affiliate – the Mental Health Association of Palm Beach County.  And my daughter Lizzie works in direct services for the MHA affiliate in Connecticut, the Mental Health Association of Connecticut.

But my professional life is about to change.  For now, this will be my last Our Health Policy Matters column. 

I’ve appreciated the platform this column has given me, and hope that I have used it responsibly.  And I’m grateful to the thousands of readers who have come to this site each month.

I hope our paths will cross often in the future.  And I hope that when you think about Mental Health America, you will always think about mental health, America.  And about the work we still need to do to make mental health the norm for everyone.

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

The Climate Change in Insurance Exchanges

A different kind of climate change was in the news this week, as Gallup reported that the percentage of people who are uninsured declined rapidly from 17.1 percent to 15.9 percent in just three months.

That is a pretty substantial drop, and one that began when people started signing up for Obamacare.

According to Gallup and others, it translates into an additional 3 million people who now have health insurance, consistent with the numbers of people signing up for Affordable Care Act coverage.

That’s good news for Obamacare – perhaps. 

One of the more interesting – and sometimes frustrating – things about health policy is that like climate change it unfolds slowly over time, and so it is often difficult to see the change in climate while it is happening.

For one thing, there are always other variables.  For example, the unemployment rate has also gone down during this period, from 7.2 percent last October to 6.7 percent today. It is possible that some of these 3 million newly-insured people obtained insurance through employment, and would have gotten it anyway.

And there’s always the glass-half-empty view to consider.  Both the unemployment rate and the uninsured rate are just about back to where they were in 2008, right around the time that the economy was collapsing.  So most of the progress we’ve made so far amounts to dragging ourselves out of a deep hole.  We’re still just back to where we were before we fell in.

But if we look too closely at this, we miss the bigger picture.

In spite of all of the initial problems with Obamacare exchanges, and despite the unpopularity of the Act itself (54 percent still disapprove of the law, according to the Real Clear Politics average of recent polls), and despite those who believe that they may have lost their insurance because of Obamacare, the trend today is clearly in one direction.

More people are becoming insured.  And that means something in the long run. 

For one thing, it means that health and mental health providers who have been holding out from participating in insurance plans until they are sure that there will be patients there will need to start signing up.  There will be patients there, and they will be looking for providers who accept their insurance.

For another, it means that individuals who can afford insurance but have been choosing not to buy it – betting that the law will go away before they ever have to pay a penalty – are probably not going to win that bet.  As more people pay up to become insured, there will be increasing pressure on everyone else to pay their fair share, too.  Insurance is becoming more of an individual's responsibility.

People may not like their health insurance very much, but once they have it, they never want to lose it again.

So in all probability the fates of the Affordable Care Act and private health insurance are intertwined now and for the foreseeable future.  The structure of our health insurance system is changing before our eyes because of the Affordable Care Act.  But it isn’t going to undermine the idea of insurance – just the way we pay for it. 

Here is a parallel example to explain what I mean.  When IRAs were created, they were like today’s exchanges.  They were a small thing.  Defined benefit plans – or pensions – were the norm for employees (as employer-based insurance is still the norm today).  But IRAs, 401(k)s, and other tax-deferred savings offered a retirement savings option that took a savings burden off of employers and transferred it to workers.   This changed – in a single generation – the nature of how we will pay for our retirement years. 

The same thing could be happening now with health insurance.  The exchanges may seem like a small and controversial thing today – perhaps 5 million or so will be insured through them at the end of the 2014 sign-up period.  But this number is growing every day, and will grow a great deal more in the future. 

And as a result new small employers – the creators of so many new jobs in our society – may increasingly decide not to offer health insurance as workers find deals that are just as good on the open exchange markets. 

Shifting from employer-based insurance to individual insurance does reflect a change in climate.  As we argue over the details, who really knows how significant this change will be?

We've Grown Accustomed to Disgrace

It sometimes seems like policymakers go out of their way these days to pick on people with mental illness.

According to a report released last week by the American Mental Health Counselors Association, 3.7 million people with mental illness will remain uninsured because of the decisions of states not to expand Medicaid. 

And if you believe some earlier data from the Kaiser Family Foundation about the total number of people who will be left uninsured because of states' failures to expand Medicaid, then you can only conclude people with mental illnesses account for nearly 80 percent of all those who are being denied insurance coverage in non-expanding states.

This includes 652,000 in Texas and 535,000 in Florida, and around 200,000 each in Pennsylvania, Indiana, Georgia, North Carolina, South Carolina, Tennessee, and Louisiana.

The association characterizes this as “dashed hopes” and “broken promises.”

You might also call it a national disgrace.

For those of us who live in one of the non-expanding states, we’ve grown accustomed to disgrace.  Our states are often held up as examples of what not to do.  We have poorer health status, and usually spend less on mental health services.   We also have the life expectancies of Libyans.

Our policymakers often blame Washington for all of our troubles.  But Washington isn’t to blame for this one. Washington’s recent decisions on health policy did not contribute to our current staggering debt.  Fighting two interminable wars on a credit card at the same time our banking industry nearly collapsed took care of that. 

No, these decisions reflect a lack of understanding and empathy on the part of elected officials.   Their decisions have consequences, and cannot always be blamed on someone else.

Perhaps those who live in more progressive states are feeling a little superior right now.  But they should not be.  Legislators in those states also didn’t clamor to expand Medicaid for all these people with mental illness before the federal government stepped in and offered to pay for it. 

So we are really all in this together.

We are all pushing nearly 4 million people even farther out on the fringes of our health care delivery system. 

These are people living with at least one serious, often life-threatening, illness.  They are living near or below the poverty line.   They cannot afford to pay for health care.  And to top it off they are often subjected to stigma and discrimination. 

This is a group of people who are frequently homeless or incarcerated. 

And when they do need medical care, this is what we say to their providers.  Treat them for free.

We ask hospitals to care for them in their emergency rooms for free.  We ask community mental health centers to provide inpatient and outpatient services for nothing.  And we ask clinicians to donate their care.

The solution for this is simple and involves us all.  If we want to do so, we can bypass those non-expanding states entirely.

All we need to do is to ask Congress to amend the Affordable Care Act to allow people living below the poverty level the option of purchasing insurance on the exchanges at the same price as those living at the poverty level. 

Right now, they cannot.  The reason is that the price of insurance for someone living below the poverty level isn’t subsidized.  But it is for everyone between the poverty level and 400 percent of poverty – over $90,000 per year for a family of four. 

There are plenty of people who think we treat people below the poverty level like millionaires with our entitlement programs.  Ironically, in this one instance they happen to be right. 

If Congress were to make this change, the immediate result would be that 3.7 million people living with mental illness could get decent basic health insurance for little or no cost. 

Of course, it would cost the rest of us something.  But Medicaid expansion costs all of us something, too – even those of us living in non-expanding states. 

And the money would be put to good use. It would reimburse providers of necessary health care, stimulating the sector of the economy that accounts for one-sixth of our GDP (and a similar percentage of our jobs).

So everyone would win if we did this.

Who could object to that?

My guess?  Many of the same politicians who don’t favor Medicaid expansion.  Because when you get right down to it, where people with mental illness are concerned, some of these politicians may in fact be our biggest national disgrace.

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