The Top Health Policy Stories of 2012

Health and mental health policy stories dominated 2012.  From how the Affordable Care Act framed the health policy debate at the start of the year to how the Sandy Hook tragedy framed the mental health and public health debate at year’s end, 2012 will go down in history as the most significant year in health policy since the 1960s.

Here are summaries of a few of the biggest news stories.

The Supreme Court Decision on the Affordable Care Act.  Nothing quite compares to the drama of the day in June when the Supreme Court ruled the Affordable Care Act to be constitutional.  Few people guessed right in advance that the decision would come down to finding the “individual mandate” to be constitutional because it is a tax, but mandatory Medicaid expansion unconstitutional because it tied future federal funding for the existing state Medicaid programs to the Medicaid expansion.

People on both sides of the debate came away wanting more, and states reluctant to accept the decision waited months to see if the fall election would change the policy environment.  It didn’t.  So as the year drew to a close was whether they, or the federal government, would implement the insurance exchanges.

The Debate over the Future of Medicare.  In the campaign, we all learned more about the two major parties’ competing visions about the future of Medicare.  The Democrats want the current structure of the program preserved; the Republicans would like to make the current Medicare program just one option available to seniors among a variety of private health insurance plan choices.

When the dust settled, the Democratic vision had carried the day.  Nevertheless, Mitt Romney’s supporters argued afterwards that he actually “won” the Medicare debate when he took a majority of the vote of senior citizens.  But even that “victory” may have resulted from the fact that he opposed the $716 billion cut.

Meanwhile, a little compromise is all we really need to preserve Medicare – but not the increase in the age of eligibility policymakers have recently pushed. 

The Medicaid Expansion.  The governors of seven southern states declared in the summer that with Medicaid expansion now an option, they weren’t planning to implement it.  They cited the significant cost of doing so.  Florida, for example, said it would cost $351 million a year, and Texas trumped that with a $4.4 billion price tag. 

But by the end of the year those states were faced with the fact that it will be at least 9 times more expensive not to expand the program.  Not embracing the expansion would cost Florida at least $3.2 billion and Texas $39.6 billion in annual lost federal revenue. 

That’s a lot of money to turn down – especially when the alternative is asking state taxpayers to foot the bill.

The Cuts to State Mental Health Services.  As of 2012, the tally of state budget cuts to mental health services grew to $4.6 billion over the past four years, with no end of cutting in sight.  I wrote about the real-time effects of these cuts in Anna Brown’s Death, California Screaming, the Mental Health Policy Mistakes We Make and the Sons and Daughters Who Pay for Them, and, focusing on veterans, in Iraq and Back and Answering the Call. 

There’s a depressing bottom line to all these stories: people with mental illness got lip service or worse. 

Athletes – and Others – Dying Young.  When Pro Football all-star Junior Seau died in the spring, it revived talk of the Curse of the 1994 San Diego Chargers. He was the 8^th member of that team to die before turning 45.  Were these deaths the cumulative effect of concussions? Or related to long-term side effects of performance-enhancing drugs that ruined the legacy of Lance Armstrong and a host of steroid-era baseball superstars, like Mark McGuire, Barry Bonds, Sammy Sosa, and Roger Clemens?

Not exactly.  At least in the case of the ’94 Chargers, former professional athletes weren’t dying young from concussions or performance-enhancing drugs, but for many of the same reasons – accidents, obesity, heart conditions, and complications from diabetes – non-athletes die young, too.  It’s avoidable, but not when we cut $5 billion from public health as we did this year.

Sandy Hook.  We need to say it again. Violence is a public health problem, not a mental health problem.  If we learn nothing else from tragedy, I hope it will be these three things: anyone of us could be a victim of violence; we can prevent much of it by treating it as a public health problem; and blaming people with mental illness for the increase in violence in America will only lead us down a dark path.

I wish you all a safe, peaceful, and Happy New Year. 

The Tragedy of Sandy Hook

The entire world is in mourning over the senseless and horrifying massacre of innocent children and adults in Sandy Hook, Connecticut. 

This hit so close to home for me, about forty miles from where I grew up.  So many of my former legislative colleagues are among those trying to help the state through it. 

I can’t even pretend to imagine what this must be like for the families of Sandy Hook. 

On the first day of the tragedy, too many politicians trotted out their tired old line that “today is not the day to have the debate” about gun control.  Thank God their tone-deaf voices were silenced by the outcry of reasonable people.

Connecticut Congressman John Larson (D-1) said that “Congress should be prepared to vote on requiring background checks for all gun sales, closing the terrorist watch list loopholes, and banning assault weapons and high capacity clips. Those measures don’t solve all our problems, but they’re a start.”

Senator Joseph Lieberman (I-CT) and Senator Richard Blumenthal (D-CT) also called for an assault weapons ban.  

But does our nation have the will to do this and more?

I hope so, because if the images of six and seven year olds staring down the barrel of an assault weapon in their last split seconds of life do not motivate us, then nothing will.

And there are two big things that it is past time to do. 

This first is to get lethal firearms out of the hands of people who are not defending us.  The second is to reverse the damage we’ve caused by neglecting and discriminating against people with mental illness because we mistakenly think that they are the cause of all the violence.

According to data reported in July by the Manchester Guardian, we are by far the most gun-toting of all of the most civilized nations in the world.  If the population of Newtown, Connecticut, is just average, then among them they already own 24,513 firearms. 

Adam Lanza’s mother owned the three of them used in the Sandy Hook massacre.  A self-described gun enthusiast, she was reported to feel she needed all this weaponry for safety and self-defense.  In the moment before her life was taken, did she feel safer, or better defended?

A member of Congress from Texas, Rep. Louie Gohmert (R-1), thinks we need even more. Does he really believe that the other 24,510 Newtown firearms made the children of Sandy Hook any safer that day?

Perhaps the horror of this massacre might open our eyes to something else – every day, an equal number of our sons and daughters die in our towns and cities because someone shoots them to death.

In 2007 alone, over 9,000 people in our country died because of gun violence, far more than the 6,656 Americans who have died in both the Iraq and Afghanistan wars since their beginning. 

We can do much better than this.  And, as President Obama declared in Newtown, “we will have to change.”

But making real change is not just finding someone to blame.

After tragedies, we often find at least hints of mental illness in the people using the guns.  But when we do, we miss the point. Violence is not a mental health problem, it is a public health problem.

Today, we are too quick to equate violence with mental illness, too quick to send people with serious mental illnesses to jail, and too quick to balance our state budgets by neglecting the people with the greatest service needs.

Connecticut’s Governor, Dannel Malloy, has shown leadership in his response to the massacre.  But another test of that leadership will come soon.  He recently ordered the rescission of up to $9.5 million in mental health services funding in Connecticut.  This funding is desperately needed to prevent and mitigate mental illnesses.  Governor Malloy is not alone in this regard – in all fifty states $4.6 billion has been cut from state mental health services during the last four years. 

Will Governor Malloy rescind that rescission now, and call on his colleagues around the country to do the same, so we can re-build our nation’s mental health services infrastructure, and better detect and treat mental illnesses early?  Will he help de-stigmatize those with mental illness, who are more often the victims of violence than its perpetrators?

Will the nation have the will to raise the money we need for prevention?

Because only if we do will we be able to say that protecting all of our children from harm is our highest priority.

Addendum:  There are news reports that Adam Lanza’s mother may have, for behavioral reasons, removed him from school at some point for home schooling.  I believe that voluntary or involuntary removal from school is often one step in a years-long chain of events that leads to bad outcomes. 

This time might therefore become a critical intervention point to change a bad trajectory and prevent future tragedies of all sorts – if we were to change our special education policy as follows:

Whenever a parent or a school believes that a special education student needs to be removed from his school for behavioral reasons, either via suspension, expulsion, or voluntary removal, for at least five consecutive days or for at least ten days in the course of a school year, there must be a mediation scheduled within 10 days with the school district, the parents, and the state education department as a mandatory third party.  The purpose would be to develop a new IEP with additional services.  The new IEP must have the input of a child’s regular health and mental health providers, if there are any.  If not, health and behavioral evaluations should be done to inform the mediation, with the state picking up the cost.  If any two parties agree to the additional services, then the services must become an immediate part of the IEP, with the state picking up the additional cost.  If the parents are not one of the parties in agreement, they still reserve their right to go to due process.  If the student is not yet admitted to special education, then the same event should trigger an immediate outside evaluation for eligibility for special education services.

Let’s assume that all parties would act in good faith.  But just in case one were concerned that a local district would low-ball a set of services from the start to shift more costs to the state, then a district could be made responsible for the costs of either its existing plan or the average cost of plans for comparable students in other districts, whichever is greater.

We’re all searching for answers.  This is just one suggestion.

Note: This column was published early this week because of the timeliness of the issue.  My prayers are with the people of Newtown.  Our Health Policy Matters will be return to its regular publication on December 26 and January 2.

Secession Fever

There’s a new disease this year along with the winter flu.  It is called Secession Fever. 

Secession Fever has reached epidemic stage across the south.  As of Monday, there were more than 25,000 cases in each of eight southern states – North Carolina, South Carolina, Georgia, Florida, Alabama, Tennessee, Louisiana, and Texas.  A ninth, Arkansas, had over 23,500.  Collectively, these states had almost 402,000 cases, and the number was still growing.

Secession Fever is a self-reportable disease.  People who have it signed a petition on the White House website.  Secession Fever is characterized by the irrational belief that the federal government does more harm than good, and that states would be better off if they seceded from the Union.

So what if these nine states did secede and form a new Southern Confederacy?  Would their citizens be better off?  Some data from the Kaiser Family Foundation and the Central Intelligence Agency suggest not.

In forming the Southern Confederacy, approximately 86 million people would find themselves living in the 14^th most populous country in the world, just behind Vietnam.  (The rest of the United States would drop from 3^rd to 4^th in population, trading places with Indonesia.)

They would find themselves worse off than they think they are.

The percentage of people living in poverty in the Southern Confederacy would be 17 percent, comparable to that in Trinidad and Tobago, Jamaica, and Turkey.  Meanwhile, the percentage living in poverty in the remaining United States would drop to 14 percent, comparable to the rate in the United Kingdom.

Life expectancy in the Southern Confederacy would also take a hit.  It would decline immediately to 77.7 years, 61^st in the world and comparable to life expectancy in Libya.  In the remaining United States, it would be almost 79 years.

That’s not all.  The health status of Southern Confederacy citizens would decline, too.

One in five residents in the Southern Confederacy would be uninsured, versus only 14 percent in the remaining United States. 

Even that high percentage would grow dramatically without the federal Medicaid and Medicare programs.  Without the federal share of Medicaid dollars, the percentage of uninsured in the Southern Confederacy would grow by at least 9 percent more, to close to 30 percent.  And without Medicare providing insurance for 16 percent of its population, the Southern Confederacy’s uninsured rate would approach 50 percent, killing off nearly every hospital and long term care provider.

Infant mortality would go up, too. 

For every one million births, 1100 more babies would die in the Southern Confederacy than in the remaining United States.  The infant mortality rate in the Southern Confederacy would be 7.5 per thousand – comparable to that found in Chile.

Disease prevention would also take a hit. 

The percentage of overweight adults in the Southern Confederacy would be over 65 percent, pushing ever higher the prevalence of diseases like diabetes, hyperlipidemia, and hypertension.

Public health would suffer, too.  The AIDS rate would grow, and the proportion of people infected with HIV in the Southern Confederacy would be similar to that found in Somalia.

Mental health services would not be spared, either. 

Nationally, we currently spend around $120 per capita on mental health services.  But in the Southern Confederacy, state mental health spending would be half that – just $61 per year.

It isn’t that people in the Southern Confederacy have better mental health status and need fewer services.  Just over one-third report being in poor mental health, just as in the rest of the country.  They’re just more likely to be ignored, neglected, or maltreated.

If there were ever a compelling argument for why we need a strong federal government, life in the Southern Confederacy is it.

Aspiring to the health standards of Somalia, Chile, Libya, Trinidad and Tobago, Jamaica, and Turkey – all nations with much to offer, to be sure – is hardly the stuff of “American Exceptionalism.”  But these nations turn out to be the real role models for those with Secession Fever.

These harsh health conditions reflect the realities of life in these southern states today.  We can argue that we can do better than this, but not if we can’t accept this reality – people are worse off in these states than in the rest of the United States.

Those with Secession Fever – and the political leaders who have fanned the flames of anti-federal sentiment for years – must be living in an alternate universe.

If you would like to schedule Paul Gionfriddo to speak to your group or organization, please email gionfriddopaul@gmail.com.

The Rule of 9 and the ACA Medicaid Expansion

There’s a simple way to calculate just how much a state will save in the long term by expanding the Medicaid program under the Affordable Care Act.  Just multiply whatever it says it will cost by 9.

That’s because the federal government will contribute at least $9 worth of match for every dollar a state spends on Medicaid expansion.

By now, we’ve all heard just how big some of the match numbers will be.  Based just on the estimates provided by the state itself in its January 2012 Supreme Court brief, Florida, for example, would gain at least $3.2 billion annually.

But Florida’s Governor has openly fought the expansion until recent weeks, and has yet to say whether or not he will support it in any form. 

He’s not the only one.  A weekend article in the Washington Post reported that as many as thirteen states may be leaning against the expansion, versus 17 plus the District of Columbia that are pursuing it.

According to the analysis on which the article was apparently based, the governors of 8 of the 13 anti-expansion states have recently reiterated their opposition to the expansion.  These include six – Georgia, Louisiana, Mississippi, Texas, South Carolina, and Oklahoma – that have been in the “rejection” category since the summer, and two –Maine and Alabama – whose governors added their states to the rejecting list in mid-November.

These governors typically cite the cost of the expansion as the reason to reject it.

However, a report released last week by the Kaiser Family Foundation took a close look at these costs over the next ten years and came to a different conclusion.  During a decade when the federal match will range from 90% to 100% for newly covered populations, the first column in the table below represents the incremental cost of the expansion over ten years for each of the eight current rejecting states.  And the second column represents the increased federal revenues each state will receive if it changes its mind:

Alabama             $1.1 billion          $14.3 billion

Georgia               $2.5 billion          $33.7 billion

Louisiana             $1.2 billion          $15.8 billion

Mississippi          $1.0 billion          $14.5 billion

Texas                  $5.7 billion          $55.6 billion

South Carolina   $1.2 billion           $15.8 billion

Oklahoma           $689 million        $8.6 billion

Maine                 ($570 million)      $3.1 billion

That comes to over $160 billion in lost revenue to these eight states alone.

Those lost billions represent money that will reimburse hospitals, nursing homes, community health centers, doctors, nurses, and behavioral health providers for care they will have to provide anyway.   

It’s especially hard to imagine what the Governor of Maine could be thinking.  Its $3.1 billion in new federal Medicaid revenue would actually be accompanied by a reductionin state Medicaid spending over the next ten years. 

The same is true in Connecticut, Delaware, Massachusetts, New York, Hawaii, Maryland, Iowa, Vermont, and Wisconsin.  With the exception of Iowa and Wisconsin, the others are all – logically – working toward expansion.

By the rule of 9 alone, it would seem that Medicaid expansion would be as close to a policy no-brainer as a state could get.

But just as there is a reason beyond the headlines why some states are reluctant to embrace setting up state health insurance exchanges under ACA, there is a reason why they don’t want to expand Medicaid, too.

It is because – just as in the case of rejecting ACA health insurance exchanges – states that are thinking of rejecting the Medicaid expansion just don’t do a very good job of protecting the health and mental health of their population.

On average, the thirteen states embracing the Medicaid expansion rank just under 17^th in the Best States for Your Health ranking, while the eight current rejecting states rank 39^th– a huge difference despite the presence of Maine, ranked 8^thoverall, on the rejecting list.

And on average, the thirteen states embracing the Medicaid expansion currently average 20^th overall in spending on mental health services, while the rejecting states together average 36^th. 

Some state governors saying no to expansion claim that the reason is because they are worried that the federal government will someday cease to fulfill its end of the bargain to pay 90% of the costs. 

But what I think they are really communicating is something else.  They personally reflect the view that health and mental health are not priorities in their state.  And they still hope to elect more people like them to Congress in the coming years to kill the expansion.

It’s cynical to hope for this, and it won’t happen.

Better Off With a Federal Exchange

As the December 14^th and February 14^thdates draw near for states to say whether they will create Affordable Care Act health insurance exchanges and what they will look like, the world seems upside down.

Traditional “states’ rights” advocates such as South Carolina, Georgia, Alabama, Louisiana, and Texas all say they will let the federal government set up their exchange.  Historically “strong federal government” allies like Connecticut, Massachusetts, California, New York, and the District of Columbia are setting up their own exchanges.

In all, sixteen states so far have said they want the federal government to set up their exchange, while eighteen states and the District of Columbia have decided to run their own.  The rest are either undecided or looking to partner with the federal government.  No states are considering a multi-state exchange – so much for “selling insurance across state lines.”

The states that are deferring to the federal government cite a number of reasons.   Cost, uncertainty, and too-tight deadlines are the most common.

Politics is also a factor.  Of those sixteen states, only two – Missouri and New Hampshire – have Democratic governors.

But there’s another reason why people living in those states should be pleased that they are deferring to the federal government.  Historically, reluctant states don’t make the health and mental health of their citizens a governmental priority.

In this year’s list of the ten Best States for Your Health, five – Connecticut, Massachusetts, Minnesota, New York, and Vermont – are moving forward with state exchanges.  Three – New Jersey, Pennsylvania, and Utah, are still undecided.  Only two – New Hampshire and Maine – are opting for a federal exchange.

However, in this year’s list of the ten Worst States for Your Health, the results are subtly reversed.  Four – Texas, Alabama, Oklahoma, and Louisiana – are opting for the federal exchange.  Only three – New Mexico, Nevada, and Mississippi – are planning for state-run exchanges.

That may not seem like a big difference.  But when you look at all the states that have decided, those currently opting to run their own exchanges have an average ranking of just over 20^th in protecting the overall health of their citizens.  Meanwhile, states deferring to the federal government have an average ranking of over 29^th in protecting the overall health of their citizens – over nine places worse.

The difference is just as clear when it comes to spending to protect the mental health of their citizens. 

States opting to run their own exchanges also have an average ranking of just over 20^th when it comes to funding mental health services.  States deferring to the federal government have an average ranking of almost 30^th – nearly ten places worse.

Keep in mind that if all 50 states chose one or the other and divided equally, the best possible average ranking would be 13^thand the worst possible 38^th.

You can view all the states in two new tables here.

Where health and mental health are concerned, “states’ rights” often means state-sanctioned neglect.

There are individual exceptions, of course.  Maine and Alaska historically spend well on mental health, but are opting for a federal exchange.  Nevada and New Mexico do poorly on protecting the overall health of their citizens, but are embracing state-run exchanges.

The take-home lesson, however, is clear.  If your state doesn’t want to create its own exchange, then you are probably better off with the federal exchange.

And if your state is still undecided, be careful about what you wish for.  Floridians, for example, would probably be better off with a federal exchange.  The state ranks 33^rd in overall health and 49^th in mental health spending.

On the other hand, undecided Pennsylvania is 8^thin overall health and 4^th in mental health spending.  There’s a much better chance that a Pennsylvania exchange would be better for its citizens than any the federal government could offer.

The reason for worry in the reluctant states has to do with the flexibility all states will be granted in setting up exchanges. 

Last week, the federal government published a new set of proposed rules governing the “essential benefits package” – the key components of all health insurance plans to be offered through the exchanges beginning in 2014.  States running their own exchanges will be given a great deal of latitude in determining just how rich these benefits will be.

And as the clock ticks toward the Valentine’s Day deadline, it’s hard to imagine new love coming from the states that have rejected our health and mental health so many times before. 

If you would like to schedule Paul Gionfriddo to speak to your group or meeting, please email gionfriddopaul@gmail.com.

A Little Compromise Will Save Medicare

A person who was unhappy with the outcome of the election suggested that the voters gave President Obama a “Mulligan” on election day – a second chance to do things right.  That’s one way to look at it.

But if you belief that, then you also have to say the same thing about the divided Congress – it, too, was being given at least one more chance to get things right.

That means agreeing to the surprisingly little compromise on which the future of Medicare will depend.

It’s hard to understand how two sides looking at the same reality and sharing the same goals could be so far apart in coming to an agreement about what to do.  Nowhere is this more evident than in the Medicare program debate.

Both sides acknowledge that Medicare is as popular as any entitlement, is as well run as any health insurance program, and addresses a need that is only going to grow in the coming years.

They also agree on certain facts.  The first is that Medicare hasn’t yet contributed to our debt.  The second is that it won’t for at least another 12 years, because there are enough reserves in the Medicare Trust Fund to offset any program deficits for that long.  The third is that the size of the program deficit last year was $19 billion. 

They also agree that on its present course, Medicare will eventually become too expensive to maintain.

There are two down-the-road problems with the Medicare program. 

The first is related to Medicare and healthcare inflation.  On its current inflationary trajectory the cost of Medicare will grow as the cost of healthcare in general grows.  Medicare alone will consume 6% of our GDP by the time today’s young adults become Medicare-eligible, and up to 7% of our GDP by the time babies being born today become Medicare-eligible.

The second is related to the current $19 billion Medicare deficit.  If this deficit isn’t closed, then it will grow over time, wipe out the Trust Fund, and undermine the entire Medicare program.

We need Congressional action to address both of these problems.

Congress has already taken some actions to address the first problem – the long-term inflationary growth in the Medicare program.  

The $716 billion in rate cuts included in the Affordable Care Act reduced Medicare’s long-term projected share of GDP from 10% to 7%.  This is a significant difference, accomplished without cutting a single benefit because the time horizon is so long.

If that were all we needed, Congress could recess before it even convenes.

But $716 billion isn’t enough to prevent the Medicare share of GDP from growing from 4% today to 6% twenty-five years from now.  And one part of that cut – an immediate 30% reduction in some provider rates – will likely be “fixed” at least in part by the new Congress as it has every year since 2002.

So we need another strategy, one that involves compromise. 

And the beginning of that compromise could be in two small steps that Congress and the President might take to address the second problem – closing the $19 billion deficit today. 

One step involves taxes and the other step involves spending.

In 2011, according to the Medicare Trustees 2012 Annual Report, Medicare revenues were $530 billion and Medicare expenses were $549 billion. If that gap were closed moving forward, then the Medicare Trust Fund would remain solvent.  And the Medicare program would be secure no matter what Medicare's share of future GDP is.

Closing a $19 billion gap in a $549 billion program shouldn’t be an insurmountable problem for governmental leaders.  It shouldn’t demand much political posturing.  And it doesn’t require a “grand bargain.”

If it were to be done just through a Medicare tax increase, it would cost every Medicare taxpayer (typically under the age of 65) an average of less than $10 per month.

If it were to be done just through a reduction in Medicare benefits, it would cost each Medicare beneficiary (typically over the age of 65) just over $30 per month.

What if we all shared the burden together?  That might mean an average $7 per month tax increase and an average $10 per month benefit reduction.

The American people might well agree to such a Medicare bargain.  And be thankful for the compromise. 

Happy Thanksgiving!

President Obama and Governor Christie: A Model of Cooperation for Protecting Public Health

It took Super Storm Sandy to remind us how much we need our government. And how rarely we see government leaders truly cooperate.

Cooperation has been a dirty word in politics for close to two decades.  But in responding to the crisis caused by Sandy, President Obama and Governor Christie showed us that political adversaries are at their best when they work together to meet our needs.

It took an environmental holocaust for this to happen.  But as the pictures of destruction in state after state circulated throughout the media, no one talked about privatizing FEMA.  No one complained that the government was spending too many taxpayer dollars rescuing people from death. 

It was a fine way for the President to end his first term in office – one that may ultimately have won him his re-election.  And also won him a new opportunity to collaborate with the states.

In the storm’s aftermath, we understand that one of the prices of having the freedom to live where we desire – Queens or Greenwich, Staten Island or the New Jersey Shore, Hoboken or New Orleans, the West Virginia mountains or the central plains – is that we must protect our living environment.

We understand that no place is safe from sudden destruction.  So we need all levels of government – and they need our support – to build better flood berms, hire more first responders, and put in place pumps and sewers to get polluted water more rapidly out of streets, subways, and homes.

And to prevent such catastrophes in the future.

God only knows if Sandy itself was caused by preventable climate change.  And it’s not really worth arguing anymore with people who deny what they see with their own eyes – that our weather has changed dramatically over the past few years.

What no one can deny is that we have been lax in our preparation for catastrophe.  We have been lax in investing in the infrastructures needed to clean up and repair the devastation.  And we have been lax in investing in the infrastructures that can prevent such catastrophic damage in the future.

This time, the crisis was in the northeast.  In recent years, the central plains and gulf coast have experienced similarly horrifying environmental catastrophes. 

No one knows who will be next. But we all know someone will be next.

So we need to prepare.  And this means strengthening our public health infrastructure.  That infrastructure:

• Prepares for and organizes our response to natural disasters.
• Makes certain we have access to emergency services.
• Handles pollution control and abatement, decreasing our negative effect on our environment.
• Enforces our building codes.
• Prevents environmental and health disasters every day.

We have let this infrastructure go during the last few years, with deadly consequences.

• Local and state health departments have lost over 55 thousand workers to budget cuts.
• In New York and New Jersey alone, over half of local health departments lost jobs due to budget cuts in 2011.
• Almost one-quarter (23%) of local health departments nationwide have reduced or eliminated emergency preparedness functions. 

Robert Pestronk, Executive Director of the National Association of County and City Health Officers (NACCHO), predicted what would happen  almost a year ago, when he said “at this critical juncture of dwindling funding and difficult choices, health departments are now doing less with less.  Budget cuts and a declining public health workforce challenge their ability to protect the health and well-being of all people in their communities.”

How well the people of Staten Island and scores of other communities understand this now!

Despite the closeness of the election, Barack Obama has a mandate as he enters the next four years.  It is to continue the bi-partisanship that served us so well at the close of the campaign season.

And governors like Chris Christie have a new mandate, too – they need to rebuild public health infrastructures in partnership with the federal government, no matter what their Congressional representatives may say or do. 

As we continue to pray for our most recent victims, let us hope – for the good of all – that in the coming years our leaders heed these needs, and tackle together all the real crises that command our attention as a nation.

And let us hope that rebuilding the infrastructure that has been devastated as much by budget cuts as it was by Sandy will be at or near the top of the list.

If you would like to arrange for Paul Gionfriddo to speak to your group or organization, or have questions about this column, please send an email to gionfriddopaul@gmail.com.

President Obama's New Health Policy Road

Newly re-elected President Barack Obama may now have a new road to health policy-making after three years of defending the Affordable Care Act.  And even if the Congress does nothing to help in the months to come, his road may be a whole lot easier than it has been.

Even with the Affordable Care Act in place, our health policy debate has been dominated by the belief that health care Armageddon is just around the corner.

But some recent data suggest that Armageddon may still be down the road.

Just how far may well determine how our health policy debate shakes out over the next two years.

First, let's look at the Armageddon scenario.

The candidates accepted the scenario that health care costs are out of control when they made the future of Medicare and Medicaid a centerpiece of the campaign.  Governor Romney’s proposed solution was to clamp down on federal funding for these programs.  President Obama advocated managing state and local costs by expanding the federal role in both programs.

But neither strategy leads to lower projected Medicare and Medicaid spending in the near future.  Both will become trillion dollar programs in the next few years.  There’s no turning back; this is already written in stone as the baby boomers age.

The $716 billion Medicare rate cut in both the Affordable Care Act and the Ryan Budget will help.  But it won’t be enough to stop Medicare from growing to 6% of GDP over the next generation.  And at least part of that cut – the physician payment cut – is likely to be overturned by the new Congress. 

So if policy leaders want to save Medicare, they will have to do more.  But there is no consensus about what this should be.

Medicaid spending is even more contentious, because the program is so expensive for the states. 

Romney’s solution – to change it to a block grant – only addressed this problem on the surface.  This is because the increase in projected Medicaid costs represents the actual projected costs of the actual projected Medicaid-eligible people using today’s eligibility standards. 

To put this more simply, there will be a trillion dollar bill to pay, no matter what.  Block grants will only change who pays that bill. 

Obama’s choice – to have this burden shouldered equally by everyone through the federal government – will help states immensely, but won’t make the program any cheaper.

The cost of healthcare for returning veterans will also drive health care costs upward during the next few years. 

In 2010, the CBO estimated that this could mean another $30 billion in VA spending over what we are paying today.

In this Armageddon scenario, all the pressure on governmental health care spending pushes upward.  And we have no clear policy solutions.

Limiting the growth in Medicare spending to 5% per year, instead of 5.7% is something for which most of the members of both parties have voted during the last two years.  That is already in place through the Affordable Care Act, and one potentially bipartisan option. 

But we need to go much lower than this to reduce the GDP burden of health care, and more aggressive rate-setting and regulation may do irreparable harm to certain safety net providers.

So President Obama’s hands may be tied – unless our healthcare future is tied to the second scenario.

In this scenario, healthcare inflationary growth declines rapidly.  And the information from 2010 and 2011 suggests that this is exactly what is happening.

Health care inflation was under 4% per year for two straight years in 2010 and 2011 for the first time in fifty years.  This may well have been recession-related.  But if health inflation stays low for even a little while longer, this will change the trajectory of health spending projections for years to come.

That may be why President Obama and Vice-President Biden made this a centerpiece of their campaign message in the closing weeks of the campaign. 

Even if the new Congress does nothing, low inflation changes the health policy picture dramatically.

Low health care inflation will add years of life to Medicare, absorb the 2.8% projected increase in state Medicaid spending attributable to the Medicaid expansion, and eventually drive down the price of health insurance even as Affordable Care Act consumer protections remain in place.

That puts the President in a position of strength for the next two years.  President Obama just won a tightly contested re-election.  The next few months will decide with just how easily his health policy agenda moves forward now.

What We Need in the Next Four Years

I wrote a column in January entitled A Dime’s Worth of Difference in 2012.

The central premise of the column was that this year’s health policy debate would fall short of what we needed.  It would instead resonate with the words “Obamacare,” “Romneycare,” “government takeover,” and “individual mandate.”  That is exactly what we got – and then some.

But we needed something more.

We needed an honest debate about:

• the future of Medicare for our elders;
• the importance of Medicaid to people with chronic conditions;
• the growing mental health needs of our population – including our returning veterans;
• the essential role of public health in our lives, no matter what our socioeconomic status;
• the fact that health and social assistance providers are the real job creators in our 21^st century economy, and must play a key role in our recovery from recession.

What we experienced instead was a tsunami of concern for our more selfish instincts – that we should not have to pay anything at all for our own health and well-being, and that there is nothing of value in the lives of those less healthy or fortunate than ours.

We have just gone through a campaign with a blizzard of mostly negative advertising in a handful of swing states, but not a minute devoted to what more we might do in the next four years to help:

• children whose plunge into poverty compromises access to the food they need to grow and thrive;
• young men and women returning from war with PTSD;
• older Americans facing hundreds of thousands of dollars of long term care expenses that we fail to insure;
• communities around the country whose decaying infrastructures have proved inadequate in recent days, months, and years to hold off environmental devastation caused in part by the radical changes to our climate we created.

We have heard nothing about jobs and health care.  We have, however, heard much from demagogues around the country about the $716 billion cut to Medicare, as if that were going to determine the fate of a nation. 

Think about it.  A bipartisan, consensus item – essentially limiting the future growth in the Medicare to 5% per year instead of 5.7% - took on such a life in campaign commercials that one could conclude that no greater threat to America’s health could exist than to limit inflationary growth – while expanding benefits – in our most popular entitlement program. 

And the irony was that the proposed solution to save Medicare from this devastation was to eliminate the program as we know it.

When I was a legislator, the people of my district clearly understood that only a rare person who walked the tightrope through life could do so without a safety net beneath them. 

They didn’t blame people for falling off that tightrope from time to time, they just asked that we legislators work together to get them back up again as soon as they were able.

In the area of health, this meant that:

• we cleaned up our environmental messes with government support;
• we immunized our children with government funding;
• we built public and nonprofit hospitals and clinics and regulated the care they provided with government involvement;
• we developed long term care services financed with government dollars;
• we provided for the basic needs of people with physical and mental disabilities and diseases with government assistance.

And we didn’t think this was a bad thing, because we realized that our government was purely and simply a reflection of us.  And, by the way, the second-leading creator of jobs in our country.

Maybe some think that our uniquely American form of government no longer works for us.  I’ve heard those echoes, but I don’t see them as representing the majority view.

In the next four years, we need to insist that our governing leaders take us – and themselves – more seriously.  We need them to stand together, not fall apart, in tackling the health issues that confront us.

We need both progressives and conservatives to understand that health and social assistance providers – not small businesses in general or manufacturers – are the real job creators of the 21^st century, and drive a large share of our economy.

We need them to understand the meaning of compromise.  We do not live in an either/or, all-or-nothing-at-all world. 

And what we need most is for the pandering to end.  

When George McGovern Made Mental Health A Campaign Issue

When Senator George McGovern, who died this past weekend, decided to run for President, he did so as a World War II hero who opposed the Vietnam War. 

A respected South Dakota senator, he helped galvanize anti-war sentiment among young people and ride it to the Democratic Party’s nomination in the summer of 1972.

His election prospects that year were as remote as Senator Goldwater’s had been just eight years earlier.  From opposite ends of the philosophical spectrum, there was much to admire about both of them.  But they were also both too removed from the center of the political spectrum to be electable in the moderate America of those times.

As a vocal McGovern supporter back in 1972, I have long wondered how he felt about the one thing I admired least about his political career – the moment when he let fear about mental illness alter the course of our public policy history.

There is an excellent and recent brief story about this on the National Public Radio website, summarizing a book written by Joshua Glasser entitled The Eighteen Day Running Mate.

Despite growing opposition to the war, Senator McGovern’s path to the Democratic Presidential nomination was far from easy.  By the time he won his nomination, he was a polarizing figure who was behind in the national polls. 

President Nixon’s campaign machinery was also in full swing at the time, doing its damage just after the Watergate break-in.  Had people known at the time all there was to know about the Nixon Administration, any viable Democrat probably could have beaten him.

But it was still a full year before the full nature of that Presidency would come to light in the Watergate hearings.  It was more than a year before Spiro Agnew would resign the Vice-Presidency over corruption, and two years before Nixon would resign the Presidency in disgrace.

So the focus was on McGovern, who was on the defensive politically.  “A” list politicians wanted to stay off of the McGovern ticket.  At the last minute, McGovern finally settled on Senator Thomas Eagleton – a respected Senator from Missouri.  When McGovern asked him if he had any skeletons in his closet, Eagleton answered “no” and accepted the nomination for vice-president.

Within days, there were rumors that Eagleton had a “complicated” medical history.  People didn’t talk much about “complicated” medical histories in those days, but the story bled out over the next two weeks. 

Several years earlier, on three occasions, Eagleton had been treated – ultimately successfully – for depression.

That was the sum total of Eagleton’s “complicated” medical history.

McGovern initially responded by supporting Eagleton – I remember when he declared that he was behind him “1,000 percent.”  But within days, fears began to grow in the media and among the public about whether Eagleton, with a history of mental illness, could be trusted with his “finger on the button.”  Bowing to this fear and prejudice, McGovern backed away from Eagleton’s candidacy, and Eagleton gave up the nomination just eighteen days after accepting it.

How might the course of our public policy history have changed if McGovern had kept Eagleton on the ticket?

Certainly, the discourse of the 1972 campaign would have been different.  Eagleton’s continued presence on the ticket might have stripped away at least some of our prejudices.  We all would have been educated about the nature of treatable mental illness.

And it would have shown an entire nation that mental illnesses were not to be feared, and did not need to prevent people from lives of amazing accomplishment.

It might have changed the course of actual public policy, too. 

If Senator Eagleton were more than just a quiet footnote to Presidential campaign history, would the Community Mental Health Centers Act still have been repealed back in 1981 and replaced with a block grant?

Would fewer people with serious mental illness today be in jail – a percentage that is three times greater than the prevalence in the general population and also three times greater than the prevalence among those incarcerated at the time of the 1972 campaign – and more have access to treatment?

I don’t know the answer to these questions, but I do know this.  Senator McGovern – whom I otherwise admired until his death – had just a moment on the stage when as a candidate for President he could have permanently altered the way we think about illness and disease.

And he squandered that opportunity.  

If you have questions about this column or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

Pushing for Mental Health Parity

Former U.S. Congressman Patrick Kennedy was in South Florida last week pushing the radical idea that all people, including those with mental illness, are created equal.

What makes this idea radical in 2012 is that we continue to discriminate against the 6% of Americans who have serious mental illnesses.  Patrick Kennedy understands this, and is devoting his life after Congress to fighting on their behalf.

It is a fight that affects him personally, as it does the one-fifth of all children and the one-fourth of all adults with a diagnosable mental illness each year.

Discrimination against people with mental illness takes on many forms – arrests for loitering, incarceration instead of treatment, and perhaps most commonly in the unequal coverage by insurers for mental health conditions.

This last form of discrimination was supposed to have ended with the passage of the Mental Health Parity and Addiction Equity Act of 2008.  But the federal “rule” implementing this law has never been finalized.

At a field hearing hosted by Rep. Kennedy on October 9^th, a speaker from the American Psychiatric Association talked about the effect this has had.  In late 2011 Florida Blue (formerly Blue Cross Blue Shield of Florida) terminated its contracts with nearly every behavioral health provider in the state.  Providers had to sign new contracts for significantly less reimbursement.

Before that action, a psychologist was receiving just under $52 for a full counseling session, already far less than the average hourly rates paid to carpenters, plumbers, and electricians. 

After the action, the same psychologist received just $46 per hour.

The Florida insurance commissioner said that he had no jurisdiction over this. 

This isn’t just Florida’s problem.  I point out in testimony being presented today (October 17^th) at a public hearing on behavioral health parity hosted by the Connecticut Office of the Healthcare Advocate that actions like this affect every state.  Because there is no federal rule, a Connecticut insurer covering mental health care given in Florida also pays that pitiful amount – because the Florida insurer sets the reimbursement for others.

Insurance discrimination affects everyone.  But people with serious, chronic mental illnesses face worse today. 

As low income, single adults, they were all supposed to become eligible for Medicaid benefits in 2014 to cover mental health services.  But the U.S. Supreme Court said earlier this year that states could opt out of that Medicaid provision.  As homeless people, they often end up in jails and prisons because there are not enough places of care.  And as returning veterans – or “returning heroes,” as Rep. Kennedy prefers to call them – they often wait months to receive treatment through the VA.

There is still another way we deny people with mental illness fair treatment for their disease – ironically, by hiding behind their “civil rights.”  Local police officers and sheriffs known as mental health officers have become gatekeepers to emergency mental health services, and judges often make decisions about treatment.  A mental health officer once denied my son emergency care at a time of severe crisis because he didn’t think the crisis was severe enough to “deny his civil rights” by bringing him to a hospital for 24 hours.  So he didn’t get care that day. 

But he was jailed six times over the next three years. 

People with chronic mental illness, Kennedy noted at a reception my wife and I hosted at our home, don’t have a big political constituency. 

That’s why states have been able to cut $4.6 billion in mental health funding since 2009.

We can change this nightmarish reality if we want to. 

Here are just two examples of how.

In recent months my son has been involved with a behavioral health court in San Francisco.  Behavioral health courts take into account a person’s mental illness in devising treatment strategies to reduce recidivism.  There’s evidence that they work.

And instead of just playing catch-up long after a disease has ruined lives, we can begin with equal treatment – including parity in insurance coverage – for a set of chronic diseases that take as big a health toll each year as cancers.

Rep. Kennedy is optimistic that the tide will turn soon.  He believes that this time we will not repay war heroes with neglect, and that what we do for them will lift up everyone with mental illness.

I sure hope he’s right.

Because there are elections around the corner, and something has got to change. 

Ending the Medicare Debate

If you care about Medicare, then who lost last week’s Presidential debate?  Perhaps we all did.

That’s because both candidates favored some cuts in the Medicare program.  And cuts translate into a real impact on real people.

But no cuts could mean something even worse - unsustainable levels of spending in the Medicare program.

The question is what’s the lesser evil – a cut in payments to providers or a cut in benefits to individuals?  That’s the choice President Obama and Governor Romney gave us.

President Obama favored cuts in payments to providers.  Governor Romney favored cuts in benefits to individuals.  The difference in their positions became clear as Romney pressed his point about the $716 billion in “cuts” that Obama supported in the Affordable Care Act.

The “cuts” Obama favored actually fell into two categories that are built into the law – provider rate reductions and cuts to private insurers offering Medicare Advantage plans. 

The provider rate reductions arguably hit doctors the hardest, because ACA presumed that the so-called “doc fix” won’t happen anymore beginning next year.  The “doc fix” has had bipartisan support every year since 2002, because it corrects a provision in the Medicare reimbursement formula that would immediately reduce reimbursement by around 30%. 

The other provider cuts are realized by limiting the increase in future Medicare reimbursements to 5% per year – less than the 5.7% health care costs are expected to grow.

Romney was emphatic during the debate that as President he would restore not just these provider dollars, but the private insurers’ administrative dollars, too.

But Obama pointed out that these savings were used in part to finance the closing of the Medicare donut hole and new Medicare prevention benefits.

More significantly, they also change the trajectory of Medicare spending significantly over time.  According to the 2012 annual report of the Medicare Trust Fund trustees, even with the savings the overall cost of Medicare will grow from just under 4% of GDP today to just over 6% in around thirty years, and then grow a little higher through 2085 (those are the green lines in the chart). 

So Obama just cuts away at the increase.

Romney’s position is more extreme.  Because without the savings, the cost of Medicare will grow to 7% of GDP by 2040, and then skyrocket to over 10% (those are the red lines in the chart) by the time babies born today hit retirement age.

If we had to borrow to cover that, it could bankrupt America.

Romney obviously doesn't want to bankrupt America.  But he did say that he favored leaving Medicare alone for people age 60 and above. (Note: The Ryan plan says 55, but Romney said “60” in the debate.)

For everyone else, Romney wants to reduce the projected cost of Medicare by changing it to a voucher program. 

He would give a health insurance voucher to everyone when they turn 65, and let them use it to purchase either “traditional” Medicare or private insurance through a federal Medicare exchange. 

The value of the voucher will be tied to the second-cheapest plan available, and won’t keep up with health care inflation.  The Medicare recipient will have to pay the difference out of pocket, negotiate with a doctor to accept less, or ration their own care.

Romney made a good argument for at least doing the “doc fix” again by arguing that many doctors won’t be able to absorb a huge rate cut, and will drop out of Medicare if the rate reductions are put into place.  But Obama made an equally valid point that the vouchers could be even worse for recipients. 

If the arguments are left standing there, as they were in the debate, then something has got to give, and everyone's going to lose.

So why not give voters a different choice – one that could end the debate with everyone a winner?  Because there is another option that could save Medicare for our grandchildren without resorting either to borrowing or to huge provider cuts or to Medicare vouchers. 

We have all enjoyed a 2% payroll tax “holiday” for the last couple of years to help stimulate the economy.  When this holiday comes to an end, all we need to do is to dedicate 1.33% back to the Medicare Trust Fund.

If we did this, then Medicare would be solvent for the next seventy-five years.

That's a choice about taxes we all should be offered.  Maybe we’d vote no, but at least we’d be voting with our eyes open.

If you have questions about this column or wish to receive an email notifying you when new Our Health Policy Matters columns are published, contact gionfriddopaul@gmail.com.

Florida's Medicaid Expansion Rejection Will Cost Residents

There was a fascinating news report out of Arizona this past week that embracing the ACA Medicaid expansion will result in $8 billion in new federal dollars flowing into the state over four years – in return for an investment of $1.5 billion from the state.

That looks pretty good on the surface, and the 435,000 people who will become insured as a result are a nice bonus.

What many people don’t recall is that Arizona was the last state to enroll in the Medicaid program.  So a report such as this from a state whose embrace of Medicaid was a long time coming is especially noteworthy.

After seeing numbers like that, I can’t help but wonder what might happen if the state decides not to expand Medicaid.  Its residents could lose a lot of money in return.

This is what Florida is facing.

We can calculate just how much money every resident of Florida will lose by reviewing what Florida Attorney General Pam Bondi wrote to the Supreme Court this past January:

Florida estimates that, as a result of the ACA, its share of Medicaid spending will increase by $1 billion annually by the end of the decade. Florida anticipates spending approximately $351 million on its share of the cost for newly eligible program participants who are presently uninsured and $574 million on the currently eligible but unenrolled.

Setting aside for the moment the $574 million she attributed to currently eligible people – who will be entitled to Medicaid whether or not the expansion goes through – let’s accept her calculation that the expansion population will cost the state $351 million annually “by the end of the decade.”

This means that the federal government will be sending at least $3.2 billion to Florida annually in 2020 if Florida accepts the Medicaid expansion.

That comes to $168 Florida will forfeit per person per year if it rejects the expansion, which represents a 90% share of the cost of the expansion.  And the forfeit is even higher in the years before 2020.

These are dollars that Florida residents will have to pay out of pocket if the federal funds don’t flow.

Here’s why.  Estimated Medicaid expenditures represent just that – projected actual health care expenditures, not insurance premiums or some other indirect cost.

So the $3.5 billion will be spent, one way or the other.  In the absence of Medicaid expansion, it will be paid by state and local taxes, offset in part through charitable giving, or financed through private insurance premiums (with an additional 15% administrative overhead). 

In other words, the $3.5 billion won’t just disappear into the atmosphere somewhere.

When Mitt Romney, who along with Florida Governor Rick Scott opposes the Medicaid expansion, was asked for an alternative, he must have felt put on the spot.  Because he suggested that hospital emergency rooms could take up the slack, although he knows that hospital ERs are the last place a community wants to provide indigent care.  This is because the cost is so high. 

I’m not happy about having to cough up $1,244 over the next seven years so that my governor can make a point that he doesn’t like a federal law. 

I already get that, and understand that he and the six other governors who are thinking like him are probably a lost cause to my way of thinking.

But most of our state legislators are running for office this fall, and they may actually care what we think.  I think we can do a lot of good with $3.5 billion.  So I’ve got a question for them. 

Who’s got a better idea than expanding Medicaid for paying this $3.5 billion bill? 

ACA and the Collapse of Capitalism

Here is a question I’d love to see candidates answer before the election.

Source: NY Times

Does the continuing activity around the implementation of the Affordable Care Act signal the collapse of American capitalism – at least as it pertains to health and health care?

The myth of American capitalism is so powerful that I imagine they won’t touch this one with a ten foot pole – or even a ten-foot long poll!  In the politics of our $2.6 trillion healthcare economy, however, capitalism takes a back seat.

The recent activities of the Connecticut health exchange board explain why capitalism in health care is about as relevant as a Democratic voter in Utah. 

Connecticut is one of the dozen or so states embracing ACA, and is making an impressive effort to implement its health insurance exchange on time in 2014.  By contrast, more than half the states have yet to even declare their intentions, even though the deadline for doing so is mid-November.

According to a recent, well-written article in CT News Junkie, its health exchange board, tasked with the job of approving the “essential benefits package” for the state, did so last week.  The essential benefits package will become the standard in each state for what must be offered by insurers after the law takes effect.

The board voted to base Connecticut’s essential benefits package on one of its most popular health insurance plans.  The plan is offered by ConnectiCare, an HMO.  ConnectiCare has offered good health insurance packages for many years – I was insured by ConnectiCare for many years when I was a resident of Connecticut.

So far, so good.

But here’s the ironic twist that makes you wonder if capitalism can survive health care, and if health care can survive capitalism. 

The one member of the board voting against the package was the former CEO of ConnectiCare.  His reason was that the plan will provide to be too rich for many small businesses and individuals to afford.

He was quoted as saying that small businesses would have to drop insurance.  According to the report, here is how he put it:  The essential benefits were supposed to set a floor for insurers “but it’s like we’ve taken an elevator to the 12^th floor.”

Think about it.

If an insurance plan that provides fair coverage for emergency services, mental health services, prescription drugs, pediatric services, pregnancy services, and rehabilitation has become too rich for all the people who need those services the most to afford – even with thousands of dollars in tax credit subsidies – then what kind of an insurance market is that?

And if Connecticut’s comprehensive, but essential, benefits cost too much, then what’s your alternative?

As a Florida Congressman once got in political trouble for asking, “dying quickly?”

If the ACA essential benefits approach doesn’t work then there are really only two options left to consider.

The first is to regulate the price of healthcare as aggressively as you can. 

The second is to create a Medicare-for-all system with the leverage and muscle to decide how much it will pay for healthcare services no matter what a provider wants to charge.

Both require significant governmental intervention.  And neither is an endorsement of the kind of market-driven capitalism favored by some candidates this year.

So why can’t all this still be part of our national campaign dialogue about health care?  Is the myth of capitalism and “free” enterprise so strong that politicians can’t even talk about how important the role of the government is in subsidizing our care and regulating and managing the marketplace?

I’m just asking.