Let's Treat Mental Illness Before It's Too Late

Why is mental illness the only chronic disease we don't begin to treat until Stage 4?

I posed that question in a presentation for over 400 attendees at last week’s winter meeting of the North Carolina Hospital Association.  For an audience that witnesses first-hand the crowding of patients with mental illnesses into general hospital beds and emergency rooms, the question resonated.

Stage 4 of a chronic disease is associated with the imminent threat of death – a widely metastasized cancer, for example, or kidney disease so advanced that only dialysis or a transplant keeps the person alive.

The odds of recovery are long.

It is the same with mental illness.  Either the patient's life or someone else's needs to be at stake before we guarantee access to treatment.  That's Stage 4.

Diagnosing and treating a disease at Stage 1, 2, or 3, always improves the odds of survival and recovery.

Why not apply that standard to mental illness, too?  In Stage 1, people show early signs of the disease – sleeplessness, anxiety, and fatigue, for example.  These are signs that can be readily identified using common mental health screening tools, and symptoms that can be managed through the use of medications, counseling, or even healthy living.

In Stage 2, the disease is more advanced and the symptoms more pronounced.  Depression may affect performance at school or work for example, or “command voices” (sometimes known as auditory hallucinations) may become louder and more pronounced.  This is a stage at which – if we act aggressively and provide the proper supports – we can help patients maintain an independent life, even though they may require an occasional hospitalization. 

People in Stage 3 are in need of ongoing treatment and support, which is often expensive – like chemotherapy in the case of cancer.  But with mental illness, people in Stage 3 are far more likely to be in jails than in treatment beds, and among the homeless population instead of the general population. 

While 6 percent of the general population has serious mental illness, that description applies to an estimated 15 percent of male prisoners, 31 percent of female prisoners, and one-quarter of all people who are homeless.

Intervening effectively during Stage 1, 2, or 3 can save lives and change the trajectories of those lives for literally millions of people.

But that isn’t what we usually do.  According to the National Institute of Mental Health, just over half of adults with serious mental illness receive any treatment at all.

That finally may be about to change. 

Last week, Florida’s Governor Rick Scott and the Federal Department of Health and Human Services came to a compromise.  HHS is going to permit Florida to transition nearly all Medicaid patients into private managed care plans, including for those needing long term care.  In return, the Governor dropped his opposition to Medicaid expansion.  If the Legislature agrees, Medicaid will be available for many more adults with chronic diseases – especially for people with mental illnesses.

And this will make a huge difference.  

If Florida implements Medicaid expansion, other states - like North Carolina - that are still on the fence are more likely to follow suit.  And its managed care program may also offer cost-saving lessons to states that have already braced expansion.  

Policymakers will have a new source of revenue to intervene more effectively to treat mental illness at every stage.

This means more screening and early intervention at Stage 1, more integration of behavioral health, education, and primary care services at Stage 2, and more emphasis on treatment as opposed to incarceration or neglect at Stage 3.

The best part is that states can pick and choose from a long menu those strategies that suit them the best. 

And this means that patients in general hospitals throughout the country – where mood disorders are the 5^th most common diagnosis – will finally get some relief.    

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

Florida's Shame is Connecticut's Gain

The next time Florida’s Governor tells you that the only way to create private sector jobs is to cut public sector health spending, don’t believe him. 

According to news reports, the Governor’s Office is already warning state health agencies to expect more budget cuts in 2012.  He wants the dollars to implement his 7-7-7 plan to create 700,000 jobs in 7 years.

source: US DOL data, 2011

How’s the plan working out for Florida so far? Dismally, by two different measures.  The first is the 2011 state unemployment claims data.  The second is the story of why Florida just lost another 7,500 jobs in health research.

The 2011 unemployment data show that Florida’s Governor has been more effective at killing jobs than creating them.  The week before Governor Scott took office, 14,139 Floridians lost their jobs and filed new unemployment claims.  In 36 of the 37 weeks since then, the number has been higher than that.  Another 15,713 Floridians filed new unemployment claims during the most recent September week for which data are available. 

To add insult to injury, there was a press conference a thousand miles away in Connecticut last week that explained why Florida’s job creation performance has been so dismal this year. 

 Jackson Laboratory, a Maine-based company, announced that it will build a new, $1.1 billion research lab on University of Connecticut Health Center property in Farmington, Connecticut.  The lab will produce over 661 new research jobs, support 842 construction jobs,  and create an estimated 6,200 spinoff and indirect jobs.

Jackson carries out cutting edge research in the genetics of Alzheimer’s disease, cancer, and diabetes prevention.  Landing the company was a huge victory for Connecticut.  A source close to Connecticut’s Governor reportedly proclaimed that it “will make Connecticut a world leader in the science of genomics.” 

This was all supposed to happen in Florida, as a part of that highly-touted 7-7-7 plan.   But in June, Jackson announced that it had “withdrawn” its request for $100 million from Florida to locate in Sarasota.  In its June release, its Executive Vice President was gracious, but clear, about why it went elsewhere.   “We respect that the state had to make difficult priority decisions in order to balance the budget this year,” he said.  But the lack of dollars “and the uncertainty of future funding made such a venture too speculative to undertake responsibly.”

In a story last week, the Hartford Courant, Connecticut’s newspaper of record, offered up a slightly different, and blunter, quotation from a company official.  It reported that a “Jackson source said ‘politicians in Florida took a dramatic, hard turn to the right, and funding dried up.’"  

One local Florida health leader recently said that “we used to just show ‘em a palm tree” to get people to relocate to Florida from the north.  Apparently, Florida can no longer sell itself to actual job creators on good looks alone.

As a result, the University of Connecticut – instead of the University of South Florida – will reap the benefits of a billion dollars of private investment in one of the most rapidly growing areas of health care.  In return for a $192 million loan and $99 million in support of research, Connecticut, instead of Florida, will get over 7,500 new jobs.

CT News Junkie, an online publication, rubbed it in with a headline article on September 30^thentitled “Florida’s Loss is Connecticut’s Gain.”  In the accompanying photo, Jackson Laboratory CEO Edison Liu is shown holding up a UCONN tee shirt as UConn’s President speaks, flanked by the Speaker of the Connecticut House and the Chairman of her Board of Trustees.

This was supposed to be Florida’s photo op.  But opportunity knocked, and no one answered. 

Florida has only its “hard turn to the right” to blame for the clouds over its horizon.  That’s why over 7,500 jobs will begin to fly north this winter.

Florida should be a leader in health research and treatment, especially research and treatment in diseases affecting an aging population.  But Florida can’t lead when its elected officials are running backwards. 

Florida’s Governor and Legislature have been slashing from health and mental health programs – including public health, Medicaid, and – as it turns out – even economic development spending.  And now the Governor, who should be ashamed by what happened with Jackson, wants to slash some more.   

The next time you visit Farmington, Connecticut, take a good look at where over 7,500 would-be Floridians will be buying their homes, paying their taxes, and spending their money for years to come.  You won’t see a single palm tree.

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

Uninsured Numbers a Compelling Case Against States' Rights

“States’ rights” is as popular a rallying cry as ever as we enter the early stages of the 2012 election campaign. 

To advocates of states’ rights, they are code words for state innovation and initiative, unhampered by the demands of a federal government.   In their minds, we are a United States of America. 

To skeptics, we are a United States of America, and states’ rights are the code words of political leaders who want to run their states as fiefdoms and answer to no higher authority. 

The new 2010 uninsured numbers released by the U.S. Census Bureau last week make a compelling case against the states’ rights position.

In the South, where the drum roll for states’ rights beats most loudly, 19% of all people were uninsured 2010 for the entire year.  This was more than in the West, where 18% were uninsured, the Midwest, where 13% were uninsured, and the Northeast, where only 12% were uninsured.

Place clearly matters where health insurance is concerned, and innovation and initiative in providing coverage for health care take a back seat in the Mecca of states’ rights.

Geography is an important factor in determining insurance status, but it isn’t the only one.  Others include:

·         Race and ethnicity – 31% of Hispanics were uninsured for the entire year, as were 21% of blacks;

·         Immigrant status – 34% of all foreign-born U.S. residents were uninsured, including 45% of those who are not citizens and 20% of those who are;

·         Income – 27% of people in households with less than $25,000 per year were uninsured.

But as bad as these numbers look, what’s behind them in the more detailed tables that accompanied the Census Bureau release is worth examining. 

It isn’t race, immigrant status, or income driving the health insurance numbers.  It’s geography.

Consider this fact.  The news headlines reported that 16.3% of the population of the United States as a whole was uninsured.  But when you remove people over the age of 65 – who are almost universally insured through the federal Medicare program – the percentage rises to 18.4%.

But in the two biggest southern states of Florida and Texas – where the new leaders of the states’ rights movement sit in Governor’s chairs – the numbers are far worse. 

In Florida, 24.6% of all people under the age of 65 were uninsured in 2010 for the entire year.

In Texas, 26.9% of all people under the age of 65 were uninsured in 2010 for the entire year.

Florida has earned its states’ rights badge through Governor Rick Scott’s attack on the Affordable Care Act.  His administration has refused to implement its consumer protections.  He has famously refused to accept public funding for many needed services because the funds were associated with the Act.  And he has turned down dollars to set up a health insurance exchange that would make more privately-funded insurance available in the state, too. 

Texas has earned its badge through Governor Rick Perry’s attack on Medicaid.  He has advocated repealing the Medicaid program in its entirety, making Medicaid a block grant so that Texas can do whatever it wants with it.  He once suggested seceding from the union if he didn’t get his way.

The one thing that neither Rick Perry nor Rick Scott can do is blame the federal government for the failures of their states to insure their populations properly.  Nor can they blame racial, ethnic, immigration, and income factors.

Mississippi, South Carolina, Maryland, and Georgia all have higher percentages of African Americans than Texas and Florida, but lower percentages of uninsured people.  New Mexico has a higher percentage of Hispanics than Texas, but a lower uninsured percentage.  And California has more undocumented immigrants than Texas and Florida combined, but a lower uninsured percentage, too.

Florida and Texas are also by no means the poorest states in the union. 

Florida and Texas have reached the bottom of the uninsured barrel through their own policy actions and despite their considerable assets.

When their governors talk about states’ rights in the area of healthcare, they seem to be arguing that every state should aspire to their level of failure.

Meanwhile, the one thing everyone seems to agree on is that more people in Texas and Florida will become insured when the Affordable Care Act is implemented by the federal government in a little over two years.

This has been characterized in recent Presidential debates as a federal takeover of health insurance.  But does anyone seriously believe that we would ever have needed an Affordable Care Act – or that it would have passed – if every state, including Texas and Florida, had taken care of its own problem like Massachusetts did?  

In Massachusetts, only 6% of the population was uninsured in 2010.

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

Florida's Medicaid Millionaires

Florida recently elected to turn down – again – over $2 million in Federal money to pay the administrative costs of expanding its Medicaid long term care program’s home and community based services.

In March 2011, Florida qualified for over $35 million to join most of the rest of the nation in participating in the Money Follows the Person program.  The program was created during the Bush Administration as a way of helping people move back out of nursing homes into the community. 

It became so popular in the 29 states (and District of Columbia) participating in it that it was expanded as part of health reform.  Thirteen additional states, including Florida, were invited to participate.  Former Governor Charlie Crist authorized Florida’s Agency for Health Care Administration (AHCA) to file Florida’s application.

Rejecting the program means that people who want to leave Florida nursing homes won’t be given control of the resources they need to do so. 

On the other hand, as a result of Florida’s 2011 Medicaid reform legislation, people who don’t want to leave Florida nursing homes may be forced out, and the money will go to managed care companies.

When Florida’s current Governor Rick Scott took office there was some question as to whether he would pursue the Money Follows the Person program.  After saying he would not implement anything in the Affordable Care Act, he changed his mind and said that he would accept the federal money for this program.  He sought approval from the Legislature to draw down the dollars. 

Then, he apparently changed his mind in May, and allowed the legislative session to pass without pushing for the action needed to allow AHCA to accept the money. 

After a strong reaction from the public against this decision, the Governor asked legislative leaders to revisit the issue in late June.  Key Senators cast a bipartisan vote to accept the money, but House members refused on a party line vote.

Though DHHS earlier said that it would leave the door open to Florida for the remainder of the year, this action may finally kill Florida’s participation in the program.

According to an Associated Press article, at least one of those who voted against it argued that Florida did not need to duplicate its existing programs.

But Florida spends only about half as many of its Medicaid dollars on home and community-based services as the national average.  In 2009, AARP put Florida’s percentage at 14%, while the national percentage was 27%.

This would suggest that at the very least, Florida does need to “duplicate” its existing programs.

Another House member correctly pointed out that although these dollars could have lessened the burden on state taxpayers, they were still federal taxpayer dollars.

This begs a bigger question.  Why would Florida’s elected officials not want tax dollars Floridians pay to Washington to come back to Florida to help meet our needs?  Because of this decision, Florida’s share of these federal home care tax dollars is going to be sent to, and used by, residents of 41 other states and the District of Columbia instead of Florida. 

It was a nice gesture for Florida’s state legislators to send $35.7 million to the people of Texas, Arkansas, North Carolina, Georgia, Louisiana, Mississippi, Kansas, Iowa, and Ohio, among others.  But they don’t represent these states. 

What they did to the Floridians they do represent was the equivalent of either imposing $35.7 million in additional taxes without adding new services, or cutting $35.7 million in services without reducing taxes.  Either way, Floridians lose.

These home and community-based dollars typically provide for the care of adults with disabilities.  About a third of program participants nationwide have physical disabilities, and about a third more have developmental disabilities.  Most of the people in Florida who would have benefited from the program are among the almost 900,000 Medicaid recipients between the ages of twenty and sixty-five. 

In nursing homes, many will become Medicaid Millionaires.  The lifetime cost of their nursing home care will probably exceed $1 million.  So long as they remain institutionalized, there is zero chance that they will ever be able to contribute independently to the cost of that care.

If they were to return home, that picture changes.  People with significant disabilities on the Money Follows the Person program are living and even working in the community again, spending – and sometimes even saving – a little money.  Early evaluation data from the Kaiser Family Foundation also suggest that the program is less costly per person than either nursing home care or other home and community-based programs, like Florida’s.

Nationwide, twelve thousand people had returned to homes and apartments because of the Money Follows the Person program as of the end of 2010.  It’s too bad at least some don’t get to call Florida their home today.  Perhaps they’ll retire here.

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

Cutting Health Care, Florida-style

When you’re headed in the wrong direction, running to the front of the crowd and yelling charge may not be the best strategy. 

On Monday, Governor Rick Scott of Florida did this when he proposed his new state budget. 

Like every state, Florida has struggled over the past few years as state revenues have declined.  The Center on Budget and Policy Priorities has documented just how tough that job has become – at least 21 states have already proposed budgets this year with inflation-adjusted spending below 2008 levels.  

In presenting his bare-bones $66 billion budget, Governor Scott promised to bring new business principles to state government.  The problem is that he forgot an old one.  If you don’t increase the supply of a product when demand goes up, you’re going to pay an increased price. 

He proposed $4 billion in cuts (over two years) from current Medicaid levels.  Medicaid is almost 30% of the state budget, and cutting it would help him close a budget gap caused by reducing taxes on corporations.

The problem is that Medicaid is a product in high demand.  Almost 3 million people in Florida were on the program as of the beginning of the year, an increase of a quarter of a million from one year ago.

Why is demand so high?  Three reasons stand out:

• because over 400,000 of Florida’s senior citizens can’t afford the cost of nursing care without it;
• because over 250,000 of Florida’s adults with disabilities like mental illness can’t work and otherwise survive on meager Supplemental Security Income;
• because over 1 million children under the age of 10 and another half million other poor children have no other health insurance. 

The only purpose of Medicaid is to give health care providers some modest reimbursement for the services they provide to these elders, people with disabilities, and low income children and their families.

There are two ways to cut from Medicaid today, and neither is in the public’s interest. 

The first is to pretend that providers are making a windfall off the program (they’re not) and to cut reimbursement rates to hospitals and nursing homes.  In 2009, Florida cut Medicaid rates to nursing homes by 10.5% percent, and in 2010, it cut Medicaid rates to hospitals and nursing homes by 7%.  Governor Scott wants to take another 5% this year.  When rates are cut, patients get less care, and providers get the blame. 

The second is to cut services from the program.  The Governor proposes to do this by making care more “consumer-directed.”  This sounds good until you imagine the 85 year old nursing home patient, the 8 year old child, and the 58 year old person with schizophrenia “directing” their own care.  It’s easy to see how this strategy might result in them receiving fewer services.   

A far better approach to reducing Medicaid costs is to invest in people’s health.  Healthier people don’t need as much medical care.  This is just common sense. 

If we don’t increase the supply of health programs soon, states are going to pay a big price.  Florida had 181,000 65-74 year olds on Medicaid last year.  This number grew by 10% to 199,000 this year.  It had 60,000 60-64 year olds on Medicaid last year, and this number increased to 67,000 this year. 

There are older, sicker, people headed for Medicaid in the future, and the only variable we can do anything about is the “sicker” one.

However, Florida’s governor thinks we should cut health programs a half billion dollars, and opposes implementing all of the provisions of health reform – even those designed to make our population healthier. 

As a result, he is sealing Florida’s fate.  Florida’s Medicaid program will continue to grow because of what Governor Scott is advocating today.  We need a better strategy than his.

Unfortunately, it’s hard to see one coming from the Legislature.  Florida’s version of March Madness is its annual 60-day legislative session.  Thinking long term is a luxury in that time frame, and legislative leaders are preparing their own short-term cut lists.

One of them would keep Medicaid in play for people with behavioral health problems, but reverse a small increase in the Governor's budget by eliminating every other state program serving them. 

 According to the Mental Health Association of Palm Beach County, Florida is meeting just over a quarter of the service needs of adults with substance abuse disorders, ranking 35^th in the nation in per capita spending for substance abuse services, and 49^th in spending for mental health services. 

Where the public interest is concerned, this strategy is scarily short-sighted.  Ten years ago, child welfare advocates were telling policy leaders that children whose parents abused drugs and alcohol were almost three times more likely to be abused, and we know that both substance abuse and child abuse are among the pre-conditions for violent behavior later on.

Actions have consequences.  Bad strategies lead to bad outcomes.

The Impact of Health Reform Repeal on Florida

Why should Floridians care if members of its House of Representatives delegation vote to repeal all the provisions of health reform this week?

Because even though the Senate and the President have said they will stop the measure dead in its tracks, a vote to repeal is a vote against the interests of Floridians.

If every provision of health reform were to be repealed, here are just some of the people of Florida who would be affected:

• 86,300 young adults who would lose insurance coverage through their parents’ health insurance plans;
• 182,672 Medicare recipients in the donut hole who would be charged at least $250 more for their prescription drugs in 2011 than they were in 2010;
• Early retirees of 190 Florida employers – including the University of Miami, Stetson University, Eckerd College, the PGA Tour, Inc., The Wackenhut Corporation, Tampa General Hospital, the Archdiocese of Miami, the Escambia County Sheriff’s Office, the Florida Firefighters Insurance Trust Fund, Duvall County Public Schools, the Cities of Orlando, Miami, Jacksonville, St. Petersburg, and Fort Lauderdale, and the town of Palm Beach – who have already applied to keep their retirees on their health insurance plans (full disclosure: I also get this benefit as an early retiree of the State of Connecticut);   
• 3.2 million Florida Medicare recipients, who would have to pay out-of-pocket for an annual check-up, mammograms, and colonoscopies;
• More than 8.7 million residents with private health insurance coverage who would lose consumer protections like the ban on insurers cancelling coverage because they become sick, and the ban on insurers using pre-existing conditions as an excuse not to insure people in the first place;
• Up to 290,000 small businesses in Florida now eligible for tax credits to cover the cost of health insurance for their employees.

People and businesses in every state would experience similar impacts if the reform law were repealed.



Members of the House who cast a vote for repeal are casting a vote against these constituents.  Is casting a vote against tax credits for small businesses, health and prescription coverage for Medicare recipients, and aid for employers and their early retirees really working on behalf of constituents? If not, then whose interests are they really serving?



What To Do About Health Reform?
source: AP-GfK Poll, January, 2011



According to a new AP-GfK poll, the public emphatically does not want Congress to repeal the reform law.  We’re still evenly divided about it, with 40% saying we support it and 41% saying we oppose it.  But when we’re asked what we want to do about it, only 26% want to repeal it completely and only 10% more want it to do less.  Four times as many – 43% -- want it to do more.

In the same poll, by the way, 59% opposed the mandate that individuals buy policies if they can afford them, but 59% supported the mandate that employers offer insurance to their employees.  This perhaps proves once and for all that as a nation we love mandates, provided they’re someone else's mandates!

The bottom line is that we want more health insurance coverage, not less, and we don’t want to lose the benefits we have. 

Does this matter to our elected officials?  If they’re representing our interests, it should.  But as Jim Saunders reported in Health News Florida last week, Florida Governor Rick Scott and 31 other Governors hold a different view.  Fearing they’re not up to the job of balancing their own state budgets without help from the federal government, they want permission to ignore Medicaid “maintenance of effort” provisions in the law.  These are the provisions that assure that states will do no harm to current Medicaid recipients, including seniors and children, over the next few years.

Scott wrote that “Florida should get to determine what program is the right fit for our state in terms of a Medicaid program,” even though he’s asking the Federal government to continue to pay more than half the cost.

What does this really mean?  Governor Scott and others want the Federal money they get for Medicaid, but they also want the power to dump as many mandated benefits from the program as they can, no matter how much harm this may do. 

Is this really the direction they think they were given by voters in 2010?