In 2014, the Gap Will Widen between the Health and Mental Health "Haves" and "Have Nots"

Let’s open 2014 with four health policy predictions.  Here are the first three:

• Obamacare enrollments will top 5 million.
• Uninsured rates will come down.
• Health inflation will tick up.

Here’s why you can count on these.  

First, 1.1 million people have already enrolled in Obamacare.  The Administration hopes for 7 million by March.  That may be optimistic, but there will be another burst of enrollments in a couple of months.  And there will be another open enrollment period toward the end of the year. 

So at least 5 million enrollments seems reasonable.  And here is a bonus prediction.  If that many sign up, the politics of Obamacare in the half of the states that have embraced it will probably shift during the 2014 election cycle.  Their people will, too.

Second, the number of people who are uninsured will go down.  A 1 or 2 percent decline will be attributable to Obamacare.  The improving economy will also help.  And this means that the numbers will be better even in the states that did not embrace Obamacare.

Third, because more people will be insured and getting care, health inflation will go up again.  Both the Congressional Budget Office and the Administration have been predicting this for 2014 ever since the passage of Obamacare. 

In fact, if it doesn’t happen, this will probably be the health policy news story of the year.

But the fourth prediction may be most significant of all.  The gap will widen between the states with better health and mental health care and those with worse. 

And this has everything to do with Medicaid money.

As of December, the states were literally divided down the middle between those that decided to expand Medicaid in 2014 and those that did not.  If you compare the 26 states (including the District of Columbia) that decided to expand Medicaid to the 25 states that did not, the expanding states already have a decided advantage in supporting health and mental health care.

And with hundreds of billions more dollars flowing into those states over the next few years, that gap will probably widen.

Consider how these Medicaid dollars could widen the gap in just two areas – the number of nationally-ranked hospital specialty programs in a state and mental health spending. 

First, think about the high-quality hospital specialty services we all want and sometimes need.  Hospitals rely on Medicaid dollars for a significant portion of their revenue.

Medicaid-expanding states already have significantly more nationally-ranked hospitals and specialty programs, according to the U.S. News and World Report 2013-2014 rankings, than states that do not.

Seven of the ten states with the greatest numbers of nationally-ranked specialty programs decided to expand Medicaid.  And consider the advantage already enjoyed by California (ranked #1 in number of nationally-ranked specialty programs) and New York (#3) over the two most-populated states that decided not to expand Medicaid – Texas (#6 in number of nationally-ranked specialty programs) and Florida (#11).

California and New York, with 678 hospitals between them, are home to a total of 28 hospitals with at least one nationally-ranked specialty, with a total of 154 nationally-ranked specialties overall.

Texas and Florida, with 895 hospitals between them, are home to a total of 16 hospitals with at least one nationally-ranked specialty, with a total of 70 nationally-ranked specialties overall.

Texas and Florida are leaving as much as $100 billion on the table over the next ten years, much of which would have ended up on hospitals’ bottom lines.

The same point can be made regarding funding for care for people with mental illnesses – on whose behalf many of those Medicaid expansion dollars will be spent. 

The 26 states expanding Medicaid already spend much more on mental health services than those are not.  And the disparity is striking.  According to the Kaiser Family Foundation, the average state spends $120 per capita on mental health agency programs. 

But the states expanding Medicaid spend $139, on average, compared to $116 by states that refused.

And even these spending numbers look artificially close because of high per capita mental health spending in states like Alaska and Maine, which have small populations.  When population size is taken into consideration, as is clear from the pie chart above, the expanding states account for nearly twice as much of the nation’s per capita mental health spending as do the non-expanding states. 

And that gap – like the gap between the “haves” and “have nots” – will only widen in 2014.

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

The Top Health Policy Stories of 2013

It has been a busy health policy year.  Here are my choices for the top health policy stories.  They all may not have made big headlines, but all will reverberate for some time. 

The Slowing of Healthcare Inflation

This was on my watch list coming into this year, and I’ll lead with it today because it was the best health policy news of the year.  When healthcare inflation came in low this year, it did all sorts of good things.  It helped balance state budgets, extended the life of the Medicare Trust Fund, and dropped the price tag of the Affordable Care Act.  Inflation is supposed to jump up this year as millions more become insured, but we can at least hope that a more modest trendline continues.

Mental Health Parity

And for some more good news… It took five years and incessant lobbying from heroes like Patrick Kennedy, but the final rule implementing the Mental Health Parity Act of 2008 was finally released this year, coinciding roughly with the 50^th anniversary of President Kennedy’s signing of the Community Mental Health Centers Act of 1963.  This isn’t the end of the fight for fairness and equity for people with mental illnesses. It is just a new beginning. One that will test a new generation of policy leaders. Let us hope – and pray – that these leaders will rise to the occasion and make policy with justice for all.

And now for the not-so-good news….

The Lack of Action in the Aftermath of Sandy Hook

Didn’t you just assume that policymakers would give us much stronger gun laws and much more robust mental health screening and services in the aftermath of the Sandy Hook massacre?  But for most, once the wailing quieted down, so did their commitment to act – just as it did after Tucson, Aurora, Blacksburg, and D.C.  It is a year later now.  What has really changed to prevent such a tragedy from happening again in the future?

The Death of Itzcoatl Ocampo

Itzcoatl Ocampo may not be a household name, but when he died last month in a jail cell while awaiting trial for murder, it was a depressing denouement to the story which probably demonstrated most effectively how our social welfare policies have failed.  Ocampo was accused of killing four homeless men two years ago.  I wrote about this in a column entitled California Screaming. But those victims’ lives had value – to their families and society. And Ocampo was a decorated veteran.  His death was reported to be a suicide; his mental health needs may have been neglected.  I’ve known policymakers who would argue that this was one person gone bad, and no one could have foreseen the outcome.  But they are wrong.  This story is way too familiar, and ties together the way we too often neglect homeless people with chronic mental illness, veterans, and veterans who are both homeless and chronically mentally ill.

Magic Johnson Speaks Out – Again – about AIDS

It was twenty-two years ago when Magic Johnson announced that he was infected with HIV.  At the time, most people saw HIV infection as a death sentence.  But as he and others lived on with the AIDS virus because of advances in pharmaceutical medicine, two things happened.  We grew to understand that people could live with HIV infection.  And we became more complacent about preventing it.  As Johnson and others point out year after year, a quarter million U.S. residents are infected and don’t even know it.

The Tragedy of Allen Daniel Hicks, Sr.

When Allen Daniel Hicks died of a stroke in 2012, he died of an often-silent chronic disease that attacks African American men more frequently than other men and women.  And we know this.  What made Mr. Hick’s death so tragic, and what made it a story in 2013, were the circumstances under which he died.  After suffering his stroke while driving his car in Florida, he was initially brought to jail, instead of a hospital, for resisting an officer – apparently while incapacitated. A settlement was announced this year, making news headlines in Tampa. But the whole story reminded us that race does matter, in the ways diseases attack us, and sometimes in the way we respond to them.

The Obamacare Rollout

If it hadn’t been for the government shutdown and Duck Dynasty, the problems with the Obamacare rollout might have been the only news story of the last three months of the year. In fact, this was such a pervasive story (and, I think, a political winner for the Republicans), that it probably even prevented another budget crisis from happening.  (I bet you didn’t even remember that Congress had originally scheduled one for this month.) Thank goodness for small favors, but with over a million people already insured because of Obamacare the real story of the rollout will not be written until next year.

And so in the meantime, in the words of St. Nick, Happy Christmas to all!

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