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• The long-term care insurance program has been repealed.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/