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/

Did We Turn the Corner on Mental Health in 2013?

At least thirty-six states increased funding for mental health services during 2013, according to a recent report by the National Alliance on Mental Illness.  And last week, Vice President Biden announced that the federal government was adding $100 million in new funding for mental health services.

So have we turned the corner on our nation’s mental health funding crisis, as many of the accompanying news headlines seemed to imply?  Or are these initiatives more a token gesture aimed at mollifying the mental health advocacy community in the aftermath of the Sandy Hook massacre, as others have suggested? 

I think that – with a couple of notable exceptions in Connecticut and Texas – the initiatives tend more toward tokenism than real change.

Consider the national initiative.  On the face of it, $100 million sounds like a lot of money.  But it still represents only around 3 percent of the Substance Abuse and Mental Health Services Administration (SAMHSA) budget, the agency which provides most of the direct federal funding to state and local mental health programs.

If the $100 million were distributed equally throughout the country through SAMHSA, it would provide for only a modest increase in community mental health budgets.  But this is not what the Administration has in mind. 

Instead, half of the money has been promised to community health centers through the Affordable Care Act to help them support the mental health services they have been required by law to provide for the past generation.  And the other half will be given to the Department of Agriculture (yes, Agriculture) to provide loans to rural community mental health centers and for telemedicine and other programs through the USDA community facilities direct loan program.

So the “$100 million for mental health” doesn’t look quite so impressive anymore.

But the truth is that funding mental health services has always been more the responsibility of the states than the federal government.  In fact, the total SAMHSA budget is still one-third less than the amount states cut from mental health services - $4.6 billion – between 2009 and 2013.   

So did the state increases this year actually restore the dollars that were cut?

Not exactly.

First of all, there are the fourteen states – including Florida (48th in spending coming into the year), which has developed an unflattering reputation in recent years for both vigilante violence and lack of compassion toward people with behavioral health needs – that either reduced mental health funding or held it level, in spite of overwhelming popular support for better mental health services.  And of the states that did increase funding, the increases were often modest ones. 

For example, Ohio cut $93 million over four years, and then added back only $50 million this year.  The $50 million made for a good headline, but Ohio’s funding is still far behind where it was five years ago.  And in Idaho – the lowest per capita spending state – Governor Butch Otter promised millions in new funding for mental health in early 2013.  But when the legislative dust settled, the increase was only 3.6 percent for community mental health services and 2.3 percent for psychiatric hospital services. There was no change in the funding for community psychiatric hospitalization. 

And looking forward, some lower-spending states are still not looking to do too much.  Utah, for example, has always put a premium on health, but does not spend highly on mental health. Utah’s Governor is recommending only a one-time, $1.5 million increase in FY2015 for mental health promotion and mental illness prevention.  This is better than nothing, but not enough to make a significant difference – especially if the commitment lasts for only one year.

And as NAMI noted in its report, when the issues became a little more controversial or complicated, fewer and fewer states took them on.

Only twenty-five states plus the District of Columbia decided to move forward with Medicaid expansion this year – an expansion that will help adults with mental illnesses in particular.  Only thirteen states made significant improvements to their mental health systems.  Just ten improved school-based mental health training and/or services.  And only five enacted legislation to improve early identification and childhood mental health screening. 

On the plus side, there are the two exceptions.  Connecticut – which felt most keenly the impact of the Sandy Hook shooting – led the way in passing comprehensive legislation to improve mental health service systems.  And Texas – which has long been near the bottom of states in funding mental health services – led the way in providing new funding for mental health services.

But we still have such a long way to go.  And for most of us around the country, we have not really made much progress in the past year.

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

Obamacare Crashes Again?

There are bad reviews and then there are bad reviews.  But it would be difficult to imagine some worse headlines than the ones Obamacare has received during the past month.

My favorite for over-the-top headline?  How about this gem from the National Journal: “Why Obamacare May Be Obama’s Katrina, Iraq.” That’s right.  An initiative to insure millions of Americans has been equated with the most frightening American natural and man-made disasters of the 21^st century. 

In a world in which we have come to expect tight plotlines, heroic successes, and quick and satisfying endings, I imagine that a blockbuster like Obamacare was never going appeal to critics.

The Obamacare story is being reported this month as if it were a classic disaster movie, with millions of people about to be left out in the cold to fend for themselves in a chaotic healthcare system as Obamacare exchanges crash and burn around them.

But that’s not close to reality.

This week’s announcement that the Obamacare website will work 90 percent of the time (which is another way of saying it still could be down over two hours per day) is hardly worth celebrating.  But the truth is that Obamacare itself is unfolding pretty much as expected.  The changes to the system that have been in place are for the most part popular and glitch-free.

And in another thirty days, people with pre-existing conditions will be guaranteed insurance at the same price as everyone else.  In roughly half the country, people with incomes below 138 percent of poverty will start to receive Medicaid benefits.  And nearly everyone with incomes up to 400 percent of poverty who purchase insurance through the exchanges will be given tax credits that make it more affordable.

But one big number – seven million – is already setting up Obamacare for a disaster sequel in the spring.

That’s the number of people who are supposed to get insurance through Obamacare exchanges by March.  And when the October and November numbers were slower than desired, another Obamacare disaster narrative began to take shape.

But no one ever thought that signing up seven million people would be effortless.

In fact, way back in March, Phil Galewicz wrote an insightful and prescient article for Kaiser Health News in collaboration with the Washington Post.  He quoted several people who are familiar with the challenges of enrolling people in health insurance programs.  He and they highlighted some of the issues that would confront the Obamacare exchanges.  The article’s conclusion?  People should be prepared for a “slow ramp up.”

In this context, some of the early numbers don’t look so bad after all.

Californians alone had completed over 360,000 insurance applications as of November 19.  Covered California - the state’s exchange – reported that 135,000 would qualify for the state Medicaid program and 80,000 others had already selected a health plan. 

And, according to the exchange, sufficient numbers of those people appeared to be young enough that the California program wouldn’t sink into the sea.

In New York, the reality was similar. As of November 24, according to its marketplace, NY State of Health, over 257,000 people had completed applications, and over 57,000 people were enrolled in insurance plans.

And in Kentucky, 60,000 people have already obtained either Medicaid or private insurance through its exchange.  And of those signing up for private insurance, 41 percent are in the 18-34 year old group.

CNN also reported in mid-November that the Washington and Connecticut exchanges were generating healthy enrollment numbers.  And the federal exchange numbers were not as bad as one might expect.  The November numbers included over 100,000 sign-ups despite the balky website, and according to HHS and CNN over 900,000 more people had completed applications. 

So how did CNN headine this good news?  “Obamacare success story sours.”

What will it mean if 4 or 5 million, not seven million, people enroll by next spring?  That will be enough to drop the uninsured percentage nationally from 15.4 percent to around 14 percent.

That might warrant some favorable reviews.

But if the reporting of the Obamacare story next spring is anything like it has been over the past month, the headline you will be reading may well be “Obamacare Crashes Again.”

So stay tuned.  And in the meantime, imagine what things would be like if the alternative to Obamacare had passed.  And believe it or not, there is one – from 2009.  In my next column, I’ll take a look at how it might be faring today.  You’ll be surprised.  

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

Mental Health Parity At Last

At long last, the Administration has released the final rule implementing the Mental Health Parity and Addiction Equity Act of 2008.

This will extend mental health insurance benefits on a par with medical/surgical benefits to at least 30 million more people. 

And, more importantly, we have finally ushered in a 21^stCentury response to a set of diseases for which we still often employ 19^thCentury treatments – locking the door and throwing away the key.

The Mental Health Parity Act (MHPA) was passed in 2008.  Its purpose was to end insurance discrimination against people with mental illness.  

For larger group health plans, it outlawed annual and lifetime limits on mental health or substance use disorder benefits when there are no annual or lifetime limits on medical/surgical benefits. And it required that co-insurance and co-payments be substantially the same for both mental health and regular medical/surgical procedures.

As it turned out, the MHPA needed the Affordable Care Act (ACA) for it to work most effectively.  And vice-versa.

ACA extended MHPA protections to the small group and individual markets, and made mental health and substance use disorder benefits “essential benefits” that all marketplace insurers (i.e., non-grandfathered plans) had to cover.

But ACA also relied on state benchmark plans to determine how the essential mental health benefits were defined.  This opened the door to the possibility that a state might use its own definition of parity – one less strict that the federal government’s – in defining those benefits, even though the MHPA set a standard federal approach.

For years, we have wondered how the final rule would reconcile the two laws.

Good news – the final rule makes the uniform, minimum parity standard come to life.

According to the final rule, states can require better parity coverage than is required by the federal law.   

But they cannot set minimum levels of coverage that are less than those demanded by the MHPA.  And if there is a dispute about this, the rule’s preamble clearly spells out how such a dispute should be resolved: “An insurer subject to MHPAEA may be required to provide mental health or substance use disorder benefits beyond the state law minimum in order to comply with MHPAEA.” (p. 46)

Still, there are limitations to the law and the rule.

For one thing, the MHPA does not by itself mandate that all insurance products include behavioral health coverage – we need ACA for this. As the rule notes, while treatment limitations are not permitted under the MHPA, “a permanent exclusion of all benefits for a particular condition or disorder… is not a treatment limitation for purposes of this definition.”  (Sec. 54-9812-1, p.103)  

Also, it does not establish uniform co-pays for providers.  The co-pay for a behavioral health provider’s service may still be different from, say, the co-pay for a primary care provider’s service.  Instead, the co-pays are calculated based on the co-pays set for all similar medical/surgical services covered in the plan.

And in high-deductible plans certain prevention services, such as screening, may be covered at no cost, while other mental health services may either have a cost or not be covered at all (see the preamble, p. 18-19).

Finally, the rule does not entirely resolve the question of provider rate-setting – a post-MHPA issue that arose in Florida when one insurer singled out mental health providers and reduced their rates in late 2011: “Plans and issuers may consider a wide array of factors in determining provider reimbursement rates for both medical/surgical services and mental health and substance use disorder services.… The NQTL provisions require that these or other factors be applied comparably to and no more stringently than those applied with respect to medical/surgical procedures…. The Departments may provide additional guidance if questions persist with respect to provider reimbursement rates.” (p. 24)

But all in all, this is a good rule.

It extends the parity provisions that have covered most of the 130 million people in large groups under the interim rule to an additional 30 million people (p. 64), and does so at an affordable price.

This expanded coverage will cost an estimated $10.55 per person initially, and up to $1.13 billion over five years (p. 78).  It will result in an insurance premium increase of less than 1 percent in both the individual and small group markets.

The new rule will cover all plans issued, or renewed, after July 1, 2014.  That will be a good day for fairness and equity.

Note:  I started writing Our Health Policy Matters exactly three years ago, in November, 2010.  Since then, I've published at least one new column per week, without a break.  So, for the first time, I'll be taking a couple of weeks off.  I will not publish next Wednesday or the week after, but will return with new columns after Thanksgiving.  If there is breaking news between now and then (and no, I don't consider the low Obamacare enrollment numbers to be newsworthy right now, but about what should have been expected based on the enrollment numbers for the now-put-to-bed PCIP program!), I may publish something off-schedule, and catch you up after vacation if you don't visit the site between now and then.  In the meantime, if you enjoy OHPM, I encourage you to take a look at some of the older columns you might not have had time to read in the past.  And feel free to contact me directly with ideas you may have for future columns! And thanks for reading - I've been averaging 13,000 readers per month lately.  Not huge by some Web standards, but not too bad either for a once-a-week health policy effort.  I thank you, and wish you a very Happy Thanksgiving!

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

The Lost War on Drugs

I admit it.  I have Obamacare fatigue.

I’m tired of endless stories about website glitches and the small numbers of people who rushed to buy health insurance three months before it would even go into effect.  But I am most fatigued by the newest invented controversy about the so-called “health-insurance-you-like” policies that have been outlawed because they do not meet even the bare minimum standards established by the law.  That’s right – the American people just love lousy health insurance!

Source: NSDUH, 2013

So I thought I would write about something less controversial – drugs.  Because some new facts suggest that if we really want to change a useless federal policy, we will end – as quickly as we can – our failed War on Drugs.

President Richard M. Nixon declared “War on Drugs” in June of 1971.  We have been fighting this war for forty-two years now, long enough to determine if it has made any difference in our lives.  It has. 

The War on Drugs has loaded up our jails and prisons, but has resulted in no discernible impact on illicit drug use among children or adults – except, maybe, to increase it.

Please don’t take my word for this.  Just take a look at the data.

According to the 2012 National Survey on Drug Use and Health, released a little over a month ago, only 19 percent of people over the age of 65 have ever used illicit drugs during their lifetime.  This was the last group that entered adulthood before the War on Drugs was declared.

But 47 percent of those born between 1948 and 1952 say they have used illicit drugs.  This was the group entering adulthood when the War on Drugs was declared. 

And for everyone entering adulthood after the declaration of war, lifetime illicit drug use is now greater than 50 percent.

So drug use may be up a little over the last forty years.  Is that enough to declare that the war is a failure? 

Maybe not, but here are some facts that are.  According to the NSDUH:

• An 18 year old (for whom drinking is illegal) is 10 percent more likely to drink than a 65 year old;
• A 16 year old (for whom smoking is illegal) is 36 percent more likely to smoke than a 65 year old;
• A 12 year old is three times more likely to use illicit drugs than a 65 year old.

So we’re losing our children to this war.  And not just compared to that older, pre-drug war generation.  In fact:

• A 15 year old is more likely to use illicit drugs than someone over the age of 40.
• An 18 year old is more likely to drive under the influence of alcohol than someone over the age of 45.
• And more than half of those who start to smoke still do so by age 18 – even though the number of people who first started to smoke after the age of 18 nearly doubled between 2002 and 2012.

When drug use leads to drug problems, it leads to jail and prison, but not to comprehensive drug treatment.

Thank goodness for peer support services, about which I have just written for Health Affairs.

Among the 4 million persons who received treatment for alcohol or illicit drug use last year, more than half – or 2.1 million – received that treatment from a self-help group. 

And despite the fact that prison populations have more than quadrupled since 1978 and that up to 75 percent of prisonershave been found to be dependent on alcohol or drugs at some point in their lives, year only 388,000 – a number equal to just 18 percent of the combined prison and jail population – received alcohol or drug treatment while in prison.

As pitiful as that percentage is, it is still better than what we offer in communities. 

Inadequate funding for drug treatment has meant that for the 1 million youths between the ages of 12 and 17 who needed treated for illicit drug use in 2012, only 121,000 – or 11.6 percent – received treatment in a treatment facility.  And of the almost 900,000 more who needed treatment for alcohol dependency, only 76,000 – or 8.9 percent – were treated in a facility.

And for everyone over the age of 12, 65 percent of those who needed treatment did not get it either because they had no coverage for it or no access to it.  

So you tell me - is this a war we won?

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

Obamacare Has Been Compromised Enough

I have never been the biggest fan of the Affordable Care Act. 

I believe that since the government is already paying over 70% of our nation’s health care bill and we’re paying another 12% out of pocket, this colossal effort to preserve the small share financed by privately-funded private insurance without bankrupting the nation may not have been worth the effort.  Medicare-for-all would have been a much better approach.

But now that an emerging group of at-risk Democratic senators have joined the Republican chorus to delay the individual mandate, I want to offer an opposing view to theirs. 

Obamacare has been compromised enough.

Since it was enacted in 2010, Obamacare has undergone the following significant changes:

• The minimum medical loss ratio requirements were delayed in several states.
• The long-term care insurance program has been repealed.
• The prevention fund has been raided.
• The reductions in payments to providers have been put off.
• The mandatory Medicaid expansion has been made optional.
• The employer mandate has been delayed.

These have all occurred before the program was fully implemented.  And this has had more to do with public pressure than public policy.

Now there are at least three more changes gathering steam – a delay in the individual mandate (favored by conservatives), a delay in the reinsurance pool tax (favored by liberals), and a delay in the 2.3% excise tax on medical equipment (favored by both).

The irony is that members of Congress think these changes will make them more popular with their constituents.  But that isn’t going to happen.  The popularity of Congress is at an all-time low.  Obamacare is at least four to five times more popular than Congress.

So enough already.  How about trying leadership for a change?

Democrats reversing course on the Affordable Care Act’s individual mandate is only today’s news.  Even though they now count on short memories, the Republicans and their conservative allies, who for the most part laid the philosophical foundation of the Affordable Care Act, including its individual mandate in the first place, also used to favor the individual mandate.  They reversed their position on it around the time President Obama embraced it.

So here is the question.  Are any of these people capable of staking out a position on this law as a matter of policy and then actually sticking by it – at least until the law is implemented?

When John Kerry said in the 2004 Presidential campaign that he voted for an appropriation for the Iraq War before he voted against it, it became a national joke and added “flip-flopping” to the political lexicon. 

A decade later, flip-flopping on the Affordable Care Act seems to have replaced leadership as a requirement of public office.

And here’s why a little leadership today could go a long way: because most of what is being argued about doesn’t really affect anyone anyway.

All the news this month about both the non-working federal exchange and the individual mandate affects about seven million people this year.  They are all either uninsured or have really lousy employer-based insurance.  That’s a little over 2 percent of the population.

For the rest of us who are not yet eligible for Medicare, the Obamacare consumer protections are what matter – no lifetime caps on benefits, no denial of coverage based on pre-existing conditions, no cancelling of coverage when people get sick, and mandated minimum medical loss ratios.  And these have all been in place, for the most part, for the last couple of years.

And for Medicare beneficiaries, the closing of the donut hole and the new prevention benefits are pretty much all they need to be concerned about, and they, too, have been in place for a couple of years.

No one objects to these.  And so far as I can tell no one is begging the members of Congress to change them.

So why don’t we just wait and see how the other 2 percent make out?  They have until March 31^stto sign up for insurance through the exchange.   And if in February they cannot because of technical problems, there will still be plenty of time to help them out by delaying the March 31^st “individual mandate” deadline.

In the meantime, let’s stop pretending that members of Congress have our interests in mind when they advocate delaying the individual mandate.  Or that they’re showing any leadership at all.

Because pandering and leadership are not the same thing.

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

President Kennedy's Unrealized Promise

Exactly a half century ago, in October, 1963, President John F. Kennedy signed the Community Mental Health Centers Act into law.  It affected two very different classes of people - people with mental illness and people with developmental disabilities.

In many ways, it was a civil rights act, promising to replace large, segregated institutions with integrated, community-based services.

It made a huge difference for people with developmental disabilities. 

But for people with mental illnesses, its promise is unfulfilled and the dream sometimes feels like it is dying.

When President Kennedy signed the Mental Retardation Facilities and Community Mental Health Centers Construction Acton October 31st, he did so with optimism. The law specified that the new community mental health centers would offer four services – prevention, diagnosis, treatment, and rehabilitation or recovery – to people with mental illness.  And the result would be that all people, no matter what their disability, would live freely and comfortably in their home communities.

Had he lived to today – into his late 90s – President Kennedy would be appalled at what became of this vision.

He would have witnessed in 1981 the replacement of direct federal funding for community mental health services with an inadequately-funded mental health block grant to the states.  And he would have seen the result.  Chronic homelessness grew, and jails and prisons became the new warehouses for adults with mental illness.  Here is a statistic that would have stunned President Kennedy – women in prison today are twice as likely to have serious mental illnesses as are men.

President Kennedy would also be dismayed that his vision for community-based special education for children with emotional disturbances became so clouded, and with such tragic consequences.  The Act provided for demonstration grants to improve special education services.  He never could have imagined that fifty years later, only 389,000 children would be receiving special education services because of emotional disturbances.  And if one in five school-aged childrenactually has a mental disorder, then this means that we are identifying only one in every 28 for special education services.

And, notwithstanding the promise of the Affordable Care Act, President Kennedy would also be far from satisfied with some recent federal foot-dragging.  In 2008, the Mental Health Parity and Addiction Equity Act passed with the help of his brother and nephew.  It guaranteed equitable insurance coverage for mental health and health conditions.  But it has taken five years for a final rule to implement that law (a rule now promised within days or weeks).  And at the same time funding for SAMHSA – through which federal block grant dollars flow – has declined.

He would have seen states do no better.

I was in the Connecticut State Legislature when we received our first block grants in the early 1980s.  There was zero interest in using state funds to continue building the community mental health center program. 

That was long ago.  So let’s look at today. 

In the five years between 2008 and 2013, states cut $4.6 billion from mental health services, often citing an unwillingness to burden state taxpayers with these services. 

But even when states were offered a free ride, many still refused to authorize additional spending on mental health services.  This year, twenty-two states refused to expand their Medicaid programs, even though the federal government agreed to pay 100 percent of the cost for three years and told states that they could contract the programs again as the federal share went down.  No surprise – many of the 5 million left behind will be people with mental illnesses.

If we wanted to realize the vision of President Kennedy, it would not be hard.

We could offer all children mental health screening as part of well-child exams, and admit more children with mental illnesses to special education services.

We could provide insurance coverage to more people with mental illness, and appropriate more funding to community mental health services. 

And we could opt not to send adults with mental illness to prison, at least until we have guaranteed them access to care and worked with them to develop a meaningful recovery plan that might help them avoid hospitalizations, homelessness, and imprisonment in the future.

If we did these five things, we could give vigor to the dream and honor the promise President Kennedy made when he signed the Community Mental Health Centers Act into law:

“It was said in an earlier age that the mind of a man is a far country which can neither be approached nor explored.  But today… it will be possible for a nation as rich in human and material resources as ours to make the remote regions of the mind accessible.  [People with mental illness]… need no longer be alien to our affections nor beyond the help of our communities.”   

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

Myth and Miriam Carey

This is Mental Illness Awareness Week. But the sad tragedy of Miriam Carey is another reminder of how deeply unaware we are about mental illness in general and its relationship to violent behavior in particular.

And how much we rely on myths to fill in the gaps in our knowledge.

We all heard the news about Ms. Carey last week.  But we were not exactly informed by it. 

Ms. Carey drove her car onto a White House driveway, hit some temporary fencing, backed up, and then pulled away. She was pursued toward the Capitol by law enforcement officers in what became a high-speed chase.  Ms. Carey was eventually cornered near Garfield Circle.  Six officers, with guns pulled, approached her car there.  She apparently panicked, scattering the officers as she drove away.  At least nine shots were fired at her as the chase began again.  She eventually got stuck on a median near a Capitol guard station, where she was shot to death by an officer.

As I watched the unfolding news that afternoon, the story was embellished, to say the least.  There were reports of a possible terrorist attack on the White House and the breaching of a White House barrier.  And gunfire had been “exchanged” in an apparent attack on the grounds of the U.S. Capitol, as Senators cowered in their offices.

But then the real story began to emerge.

Ms. Carey hadn’t breached a White House barrier; she had hit a fence or a gate.  No gunfire was exchanged, because Ms. Carey was unarmed.  And Ms. Carey wasn’t attacking the Capitol; she had fled in her car in that direction.

So the narrative changed.  Now Ms. Carey – suffering from mental illness – had “rammed” a barrier at the White House.  She was “obsessed” with President Obama.  She used her car as a 1300 pound “weapon” to mow down law enforcement personnel as she continued on her “rampage.”

And she “chose” to ignore officers who tried to subdue and pursue her.

Words themselves are powerful weapons.  And these new words helped paint the mythical picture of the seriously mentally ill person who stalks, snaps, and kills without warning. 

But this narrative proved to be wrong, too.

We later learned that Ms. Carey apparently drove all the way from Connecticut to Washington with her one year old baby in the car.  So she didn’t “snap.”  And there was no evidence in her home that she had been plotting against the President with whom she was “obsessed.”  And she wasn’t on a “rampage.” Not only was she unarmed, but she apparently managed to avoid pedestrians and other motor vehicles as she raced down Pennsylvania Avenue at speeds up to 80 miles per hour.

But because she is dead the pieces missing from her story – like what she was actually thinking at the time – will probably remain missing. 

And the myth-makers will have another field day at the expense of people with mental illnesses.  Because the facts about mental illnesses don’t fit the narrative.

These are the facts.

People do not acquire mental illnesses by choice.  They can’t turn them off like a faucet.  The people who knew her best said Miriam Carey was not out to harm anyone last week, and that her mental illness was being treated successfully.  But if she was suffering from a mental illness-induced panic in the final minutes of her life as she was chased and under fire, she would have been no more able to turn that off when the police yelled stop than to will herself to stop bleeding from her gunshot wound. 

All mental illnesses are not the same, but none is a very strong predictor of violence.  Postpartum depression – for which she had been treated – is not the same as schizophrenia or bipolar disorder.  But if you believe the myth that any of these conditions by themselves leads to violence, then take a look at the chart accompanying this column about the low lifetime prevalence of violence among people with serious mental illnesses, from an article published almost a decade ago in the New England Journal of Medicine.

And people with mental illness do not “snap” without warning.  There are often years of warnings that go unheeded by payers looking to save a dollar.  And by public officials who cut mental health budgets and deem mental health agencies and services as “non-essential.” And then cower in their offices at the first sign of trouble – the one part of the initial reporting that was, apparently, accurate.

Let’s deal with facts, not myths.  After all, this is Mental Illness Awareness Week.

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

Malice in Wonderland

As we gaze this week at the wonderland we call Congress, it might amaze us that Congress actually shut down the federal government over the implementation of the Affordable Care Act.

Rep. John Culberson of Texas grinned like a Cheshire Cat as he explained it this way in an outlandish interview on CNN, “we do not want the federal government socializing health care as they have in England and in France.”

This is socialized medicine?  Really?

He wasn’t content to leave it there, adding a new “sacred” right to the Constitution to explain further his position.

“The right to be left alone as Americans is probably our most important right.”

As the Mad Hatter would say, “Why, you might just as well say that ‘I see what I eat is the same as I eat what I see.’” 

But Representative Culberson was on a roll.  Literally.  This was two days after he was reported to have shouted “let’s roll!” as House Republicans concluded a caucus in which they re-affirmed their intent to shut down the government if Obamacare weren’t defunded. 

He explained that he was invoking the memory of the 9/11 heroes who brought down the airplane in Pennsylvania that was headed to Washington.  Was the irony lost on Representative Culberson?  That plane was in all probability heading toward the Capitol, and the heroes who brought it down may not only have kept our government open that day, they may have saved Representative Culberson’s life, and the lives of many of his colleagues.

Meanwhile, as Representative Culberson – a House member since 2000 – was giving his interview, some really bad things were happening to Americans hoping for an end to the economic quagmire he helped to create.

The Dow was shedding 129 points in anticipation of the shutdown.  In the last week, U.S. companies lost about $200 billion in value – more than the combined value of every company in Poland.

And we have had to suffer through all this because giving a $6000 tax credit to families earning $50,000 per year who purchase their own private health insurance is too “socialist” for Culberson.

I believe in our government.  I believe it is there to protect our actual rights (not ones Representative Culberson invents) and to work toward the common good.

And I am bothered because there is no charity in Representative Culberson’s view, only malice.

Toward the people who are helped most by Obamamcare – people with serious mental illnesses and other chronic conditions, lower-income workers, and uninsured people, for sure.

And toward the President on a disturbingly personal level, too – because this shutdown is not really about debt or deficit either.

Does anyone really think that if Ronald Reagan – not Barack Obama – were to be magically transported down a rabbit hole to the presidency today, then Representative Culberson would be saying the same things?

Five years into Reagan’s presidency, our national debt, which would triple during his term, was up over 100 percent – more than it has grown during Obama’s presidency.  Our federal deficit had grown from $74 billion to over $212 billion.

Medicaid was being transformed from a mostly long term care program for elders to a safety net health insurance program for families.  By 1988, eligibility was increased to 185% of poverty for pregnant women and children and even more for some through the Katie Beckett waiver.  These are far more generous than the 138% of poverty level Obamacare established for adults with chronic conditions.

Before he left office, piled on top of all that debt, Reagan even proposed the bare outlines of much of what became the Affordable Care Act.

He asked Congress to include catastrophic insurance, limiting out-of-pocket costs to $2,000, for every American covered by Medicare – along with a $60 a year increase in premium to pay for it.  He proposed a federal/state partnership to promote the formation of state-based risk pools to provide insurance for those who could not obtain it.  He called on states to mandate enhanced employer-based health insurance coverage.  And in his February 1987 radio address calling for all of these things, he said that the federal government should work with the private sector to promote public education about the choices and options available.

Representative Culberson was serving his first term in the Texas House of Representatives in 1987.  Do you imagine he – one of only two sponsors of legislation to put Ronald Reagan’s image on the $10 bill- favored a government shutdown to prevent Reagan’s “socialized health care?”

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

On the Brink of a Government Shutdown over Obamacare

It is hard to imagine a political strategy less likely to achieve its intended outcome while simultaneously harming the economy than shutting down the government to prevent the implementation of Obamacare.

But that probably won’t stop Senator Ted Cruz from trying.  And unless cooler Congressional heads prevail this week, while he will do no real harm to Obamacare, he may well do harm to the economy.

Obamacare is the law, shutdown or not.  And no matter what, on Tuesday you will still be able to go to any hospital in the country and get treated, your doctor’s office will still be open, and your insurance company will still expect you to pay your premium.

But when the government is shut down, the stock market suffers. 

And a few points on the downside in our stock market that are attributable to a single event may be more significant than you think.

Let’s go back to 1995.  The Newt Gingrich-led House shut down the government twice – on November 14, 1995 for a week and on December 16, 1995 for three weeks.

Until then, 1995 had been a boom year for the U.S. economy.  The S&P Index rose 34 percent for the year.  But on the day of the first shutdown, the S&P was down 3 points, or one-half of one percent.  And on the next trading day after the second shutdown, it crashed 9 points, or 1.5 percent.

What is a one-half of one percent drop in the markets worth today?   

We can do the math for Senator Cruz.

At the end of 2012, the total market value of every company listed on our U.S. stock markets was $18.6 trillion.  The markets are even higher now, so we can estimate that today all those companies combined are worth around $20 trillion.

So one half of one percent – or about 9 points on today’s S&P – would subtract around $100 billion from the value of those companies.  That is roughly equivalent to the annual cost of Obamacare!

So isn’t it ironic?  A shutdown won’t shut down Obamacare, but it could hit businesses harder in one day than Obamacare would in an entire year.  And that’s on the conservative side.

People like Senator Cruz don’t want to think about this, so they might look at it another way.

They will tell you that we spend around $3 trillion annually on health and healthcare in the United States.  That is about 15 percent of the market value of all of the companies that are publicly traded on our stock exchanges.  They will argue that this is way too high.

I agree. We can probably do it much less expensively if we put more resources into prevention and public health, like other countries do.

Of those $3 trillion, federal state, and local governments directly or indirectly pay about 71 percent of the bill.  We pay another 12 percent out of pocket.  The remainder is paid by privately funded private health insurance.

So can Senator Cruz assume that if we repeal Obamacare, we won’t have to pay that 71 percent?  The answer is no, because these are pre-Obamacare percentages.

And what effect will this government takeover of healthcare formerly known as Obamacare have on these percentages?

Thegovernment’s share might go up 2 or 3 percent, private insurers might pay 1 percent less, and our out-of-pocket share will go down a couple of percentage points.

It is hardly seems worth working up a Congressional lather over this.

But consider something to which all members of Congress ought to be paying attention. 

If our stock market were to go down just 1.5 percent because of a shutdown, as it did after the last shutdown, then $300 billion will be lost to publicly-traded American companies.  That is equal to the total market value of every publicly traded company in Belgium, Turkey, or Chile.  It is twice the market value of every publicly-traded company combined in Israel, and three times the market value of all the publicly-traded companies in Ireland, Austria, or Kuwait.

Remember the years-long effect that the collapse of the Greek economy has had on the European and world economy?  $300 billion is approximately four times the total value of every publicly-traded company in Greece before the meltdown.

That’s something to think about on the brink of a shutdown.

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

Hypocrisy In Motion

The latest Obamacare navigator “compromise” may calm one small battle in Florida.  But it won’t end the war on Obamacare being waged by hypocritical public officials around the country.

A couple of weeks ago, I wrote about the Congressional effort to undermine the Obamacare navigation program in its entirety.  A House Committee has ordered nonprofits winning navigation grants to produce reams of material, and promises to punish those that have failed to comply. 

Source: US Census Bureau

Navigators will assist people in applying for public or private insurance to pay for their health care.  

Navigators are not a new concept, created by Obamacare.  They are as old as Marco Rubio, and Obamacare is not the first federal initiative ever to fund them.  In fact, I implemented the policy of the Nixon Administration as a VISTA paralegal 35 years ago, navigating underinsured elders to the Medicaid program.

So we know that navigators can be trusted to do their jobs.

But that hasn’t stopped some public officials from sudden “worries” that navigators hired by nonprofit agencies will disclose private information that clients voluntarily give to them.

Three weeks ago, Governor Rick Scott of Florida – apparently trying to re-establish his credentials as the nation’s leading gubernatorial opponent of Obamacare after openly flirting with it during the 2013 legislative session – joined this chorus, wondering “how the federal government will prevent personal information from being stolen” by these nonprofits.

This was quite a contrast to enrollment efforts already well underway in states like Connecticut that actually want to help people get insured.

Then Governor Scott raised the stakes last week.  He ordered that no navigators be allowed in any state health department offices.  The reason this mattered is because in Florida, county health departments are actually arms of the state government, and their employees are state, not county, employees. 

So in banning the navigators from state offices, he was in effect banning outside navigators from enrolling people in county safety net clinics, federally-qualified community health centers, and a host of other facilities staffed by state employees.

He came under immediate fire from shocked public health officials, one of whom called the edict “cruel and irresponsible,” and said that it would compromise access to healthcare for “a multitude of needy Floridians.” Florida has the second highest percentage of uninsured people in the nation – two and a half times the rate of Connecticut.

A day later, state officials backed away after having an Emily Litella moment.  They realized that the counties actually own and control the properties in which the health department clinics operate.  The state employees, like the navigators, are just outside guests in these county buildings.   

A compromise of sorts was struck.  The state acknowledged that it had no authority to keep navigators out of the county buildings so long as the counties had them work outside of the actual clinic space.

Now most thoughtful people with any knowledge of history would probably use a colorful term here to characterize the state’s position.  I’ll just call it hogwash.

Public officials like Rick Scott are not the least bit worried about navigators being able to protect the privacy of individuals. How do we know this? 

Because Rick Scott was CEO of Columbia/HCA until 1997.  Like every hospital chain in the country, HCA hospitals have worked with navigators for years to capture Medicare, Medicaid, and insurance reimbursements for uninsured patients.  The navigators are often employees of outside entities working under contract.  Many even take a percentage of the billings for every person they enroll.

I know this because I competed with these companies when I was overseeing navigation programs for community nonprofits in Texas and Florida in the 2000s.  And these outside companies had access to all the private information about which Governor Scott professes to be worried today.

But there is more. 

In Florida, my nonprofit placed navigators in state health department clinics almost a decade ago and helped capture reimbursements for the state, relieving taxpayers of the bill.  No one accused us of breaching confidentiality.  But Jeb Bush – who had some common sense – was Governor then, and George Bush was President.

Hypocrisy is always in motion, and tough to pin down.  But in this instance, certain public officials made it too easy for us to see the real reason they want to prevent uninsured people from getting help paying the bills that clinics and hospitals must, by law, present to them.

They know for a fact that this part of Obamacare will work, and they desperately don’t want that to happen.

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

Suicide and Obamacare

In 2009, there were 36,891 suicides in the United States, according to the CDC.  This translates to a rate of 11.9 for every 100,000 people.

And rates among certain groups were even higher.  For example, the suicide rate among veterans, according to the Veterans Administration, was three times higher – or 35.9 per 100,000 veterans.

Suicide is a problem that ought to command our attention.

And it does.  For many years we have used suicide data as surrogates for documenting the consequences of serious mental illness.  We all know that the “danger to self” standard we use for determining when people with mental illness qualify for emergency care is, in effect, a “suicide may be imminent” standard.

As a result, for many years community mental health organizations have also been asked to track suicides as a measure of the effectiveness of their programming. 

But there are reasons why focusing on suicide rates too closely leads to inadequate public policy.

Suicides are just the tip of the iceberg.

Many more people consider or attempt suicide than die from it.  If you really want to be staggered by a national statistic, CDC reported that in 2011 7.8 percent of the teenage population had attempted suicide.  That is one thousand times as many as had died from it.

Also, the overwhelming majority of people with serious mental illness who die early do so not because of suicide, but because they are undertreated for other chronic conditions (such nicotine addiction, diabetes, and cardiovascular problems).  Some of these are linked to treatments they receive for their mental illnesses.

Finally, at the community level the number of suicides is usually so small that it is nearly impossible for any single organization to affect the rate more than anecdotally.  The agency may be able to point to individual cases where its intervention made a difference, but it will probably never be able to move the rate on its own.

And when the suicide rates don’t move, policy makers use this to justify decisions to reduce or eliminate program funding. 

So what does Obamacare have to do with suicide?

Many other provisions of the law have been lost in the din surrounding the most visible parts of the Affordable Care Act.

One of these was a mandate that the Department of Health and Human Services focus on the quality of our health care.  Since 2012, it has been doing this, along with a number of agencies in the Department, including the Substance Abuse and Mental Health Services Administration (SAMHSA). 

SAMHSA has just invested over two years in developing a National Behavioral Health Quality Framework (NBHQF). 

When the NBHQF is finalized, it will open the door to the use of new standard outcome indicators in determining the effectiveness of health and behavioral healthcare in our communities. 

We will be able to add these indicators to suicide rates, giving state and local officials much more powerful tools in judging the effectiveness of community mental health programs.

For example, suicide risk assessments (NQF #0104) will become a standard diagnostic tool in provider settings.  Providers will also be expected to use depression screening tools such as the PHQ-9 at six and twelve month intervals to monitor patients consistently over time (NQF #0710-0712).  And risky behavior assessment and counseling for children under the age of 13 will become a standard of practice (NQF #1406), as will diagnostic evaluation of children with major depressive disorder (NQF #1364-1365).

These all focus our attention on the 999 in every 1000 who consider and attempt suicide in addition to the one who tragically commits it.

We can also expect the integration of health and behavioral healthcare to become more systematic. 

Cardiovascular and diabetes monitoring of people who are prescribed antipsychotics (NQF #1933-1934) will become a standard of practice, as will management of ADHD in children in primary care settings (NQF #0107-0108). 

These indicators focus our attention on some of the other reasons people with mental illness die so young.

We all have an opportunity to say how we feel about these indicators. 

SAMHSA has released the NBHQFin draft form, and is accepting public comments on it until September 17, 2013.  Comments can be submitted using an online form, and don’t have to be formal or comprehensive.

The NBHQF will be finalized after the public comment period.  Then it will begin to guide the funding and delivery of mental health services. 

But for the next week, we all can say how we think the government should measure the quality of our behavioral healthcare services.

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

Members of Congress Scrutinize Navigators More Than a Run-up to Possible War

In the nervous run-up to a possible military strike in Syria, fifteen members of Congress last week took time from their busy vacations to sign a letter demanding more information from governmental contractors. 

But the targets of their attention were not the defense contractors who received $161 billion for their services.  They were universities, legal aid organizations, and small nonprofits who will share $67 million to help citizens apply for health insurance beginning in October.

The Congressional Gang of 15 included Fred Upton from Michigan, Pete Olson, Joe Barton and Michael Burgess from Texas, Tim Murphy and Joseph Pitts from Pennsylvania, Marsha Blackburn from Tennessee, Phil Gingrey from Georgia, Steve Scalise from Louisiana, Gregg Harper from Mississippi, Corey Gardner from Colorado, Morgan Griffith from Virginia, Bill Johnson from Ohio, Billy Long from Missouri, and Renee Ellmers from North Carolina.

They sprang into action after the grants were awarded in mid-August, demanding a response in writing within two weeks.

Here are some of their demands (thank you to Kaiser Health News for linking to the letter):

• “a written description of the work that will be performed,” including “a description of the number of employees, volunteers, or representatives that will be utilized and the pay and duties for each.”  
• A detailed budget for the program.
• “a written description of the training or education employees, volunteers, or representatives must complete,” plus educational requirements of the organization “beyond that required by any federal or state entity.”
• Supervisory processes and procedures.
• A description of how the organization will use the information obtained, including in follow-up communications with anyone with whom the organization speaks who might want to register to vote.
• Any communications with any health provider or any health insurance carrier to whom any individual might be referred for health care or coverage.
• All materials related to the grant application and award process.

Imagine being a 20 year old navigator in Florida just trying to help someone get insurance.  Do you really want some Congressman from Michigan “ACORNing” you if the person also asks you how to register to vote? 

Florida’s governor and do-nothing insurance commissioner aren’t going to help you.  They’ve already signaled their mistrust of navigators. 

You might think that any member of Congress who devotes so much vacation time to finding out whether sick people are getting help in finding a doctor would pay even more attention to matters that could soon drag our nation into another war.

And you might think that any member of the Congress taking time demanding this level of scrutiny about a program to help people get insured would apply a similar standard to other federal contractors. 

But you would be wrong.

When there’s more at stake, they sit back and wait.

Fred Upton, who has been on the job for twenty-five years and wrote the letter to the community agencies, hasn’t said a word in public about Syria.  He did, however, help a Vietnam veteran get his long-deserved service medals this month.  Pete Olson has no public position on military action, but said Congress should approve any.  Tim Murphy and Steve Scalise are among 140 members who want Congress “consulted” before the U.S. goes to war. And Billy Long went out on a limb when he asked the President to “tell his side of the story.”

If only they were as deferential about demanding the details about a paralegal contacting an insurer on behalf of a man with mental illness or a woman with cancer.

And take a look at the chart.  The value of the navigator contracts is so small compared to defense services contracts that you can’t even see it with the naked eye. 

As for the scrutiny they give to these other contracts that are worth 2499 times the value of the navigator contracts:

• They don’t demand educational credentials.  In the Snowden case, a 29 year old high school dropout was given access to “some of the most highly classified information in our government,” according to Sen. Susan Collins.
• They don’t t-cross and i-dot in advance. “According to the US Government Accountability Office in December 2012, there was a backlog of approximately 25,000 audits of DOD contractors as of the end of FY2011. “This backlog represents hundreds of billions of dollars,” GAO reported, and “has quadrupled over ten years.”
• And they don’t demand details about the numbers of employees, volunteers, or representatives, including their pay and duties.   Over 6500 contractors are working on $2 billion NSA expansion projects, according to a recent article.  As to who those contractors are, that information is simply described as “hush-hush.”

There is reason for outrage here.  You can decide over what.

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