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/

A Long Road Back To Sanity - States Finally Reversing Cuts to Mental Health

All over the country, governors are finally beginning to propose new mental health services funding in the aftermath of last year’s mass shootings in Aurora and Sandy Hook.

Notes: OH funding is from existing OHT appropriation.
CT funding is bond money, some of which may
be used by non-MHSA providers.

There will be a long road back to policy sanity.  We have to dig ourselves out of the mess caused by $4.6 billion in state mental health cuts over the last few years.  But these governors give us hope that the funding-cut nightmare over which many of them have presided may be finally coming to an end. 

In recent weeks, both Republicans and Democrats have announced new community behavioral health funding initiatives, typically ranging between $5 million and $20 million.  

But support for community mental health services is not universal.  In states with the worst track records in funding mental health services, their governors continue to be sadly out of step with their colleagues across the nation.

In Idaho, which has recently dropped to the bottom of mental health services spending, Governor Butch Otter’s major mental health initiative in the aftermath of the Sandy Hook shooting is for $70 million to construct a 579-bed “secure mental health facility” on the grounds of the state’s prison south of Boise.  That would be considered progressive by late 19^th century standards.

At least Otter’s proposing to do something.

Florida has been at or near the bottom of mental health spending for years.  But Governor Rick Scott – whose administration just cut millions more away from community mental health services in October – seems to think that if he just ignores the problem it will go away.  He requested no new dollars for mental health services in his 2014 budget.

But in the rest of the country, the emerging news is much better.  In the last month or so:

According to the Lansing State Journal, MichiganGovernor Rick Snyder said he will seek $5 million in new funding for mental health services to identify young people with mental health needs.  Michigan has cut $124 million from community mental health programs since 2004.

In Missouri, where eighteen months ago Anna Brown’s death in a St. Louis jail after she was refused care in a hospital emergency room drew national attention, Governor Jay Nixon is proposing $10 million in new mental health funding, primarily for a hospital emergency room diversion program.

In Colorado, Governor John Hickenlooper, whose state suffered through the Aurora mass shooting last summer, has proposed spending $18.5 million in new funding, including over $10 million for five urgent care centers for people with mental illness and a statewide 24-hour hotline.

In Connecticut, the site of the Sandy Hook massacre, Governor Dan Malloy proposed $20 million in new bond funding to assist community behavioral health providers with infrastructure projects that providers say have either been set aside because of budget cuts or have been draining money needed for direct services.

Kansas Governor Sam Brownback, saying that he was committed to strengthening the state’s community mental health system, announced his support for an additional $10 million to increase funding to 27 community mental health centers and to establish a regional system of peer support, intensive case management, crisis intervention, and other evidence-based services.

Oklahoma Governor Mary Fallin announced that she will seek $16 million in new mental health services funding - $8 million for existing programs and $8 million for new programs, including early intervention programs for children and a new state-supported mental health crisis center.

And in Ohio, Governor John Kasich reported that he was authorizing the expenditure of $5 million from an Office of Health Transformation discretionary fund to support children’s crisis intervention services.

These represent just a handful of states taking action, but a cross-section as well. 

The reasons the governors made these proposals may vary.  Some governors may be avoiding gun control debates.  Others may still erroneously equate mental illness with violence. 

The mental health funding initiatives the governors are proposing, however, are needed. 

The governors are working to improve community mental health systems.  They are calling for early identification and treatment of mental illnesses in children, adding new crisis intervention services, and addressing other neglected priorities in their own states. 

And while the numbers may pale in comparison to the cuts made in recent years and won’t undo the damage overnight, they are steps in the right direction. 

These steps should be embraced by legislators in their states, and in states with less understanding governors.  

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

The Chain of Neglect: The Real Link Between Violence and Mental Illness

More than 11 million American adults with mental illnesses – 4.5 million of them with serious mental illnesses – are not receiving care today.  So it may not be unreasonable to conclude that the history of public mental health services over the last century can be summed up in a single brief sentence. 

We replaced the chains of institutions with a chain of neglect.

I have argued that this chain of neglect typically begins when children with mental health needs are still young, and continues throughout their lives.  And that it often has tragic consequences.

Why is it so important that we talk about breaking it now, the month after Sandy Hook and almost exactly two years since the mass shooting in Tucson?

It is because tragedies like those in Sandy Hook and Tucson remind us that it is wrong to balance budgets on the backs of children and young adults with mental illness and expect that there will be no consequences.

This is a sensitive, and even complicated, issue to discuss, because mental illness doesn’t cause violence.  Violence causes mental illness.

Violence and mental illness also share some of the same risk factors, such as trauma and abuse.

They have something else in common, too.  They often appear together in times of tragedy.  And this may be the result of conscious policy decisions we have made.  

It is hard to exaggerate the enormity of the problem that we have created by chopping away at mental health services. 

In 1970, according to a 2009 articleby Steven Sharfstein and Faith Dickerson in Health Affairs, there were 525,000 psychiatric beds in American hospitals.  Eighty percent were in public institutions.  By 2002, the number had dwindled to 212,000.  Only 27% (or approximately 57,000) were in public institutions. 

In the last ten years, things have gotten much worse.  Between 2002 and 2010, states cut even more beds, reducing the number of public hospital psychiatric beds from 57,000 to just over 43,000.  By 2009, according to SAMHSA Administrator Pamela Hyde, over 10 million people were reporting that they had unmet mental health needs.

What did states do after cutting inpatient beds?  They cut community services, too.  Since 2008, according to the National Association of State Mental Health Budget Directors, states have cut mental health budgets by $4.6 billion.

It doesn’t take a policy expert to conclude that when 4.5 million people with serious mental illness are receiving no mental health services, this is neglect.

And this neglect is the real link between mental illness and violence.  Because while mental illnesses may not lead to violence, neglecting them assuredly will.

We can fix this. 

After the Sandy Hook tragedy, the Hartford Courant invited me to make some suggestions about how. 

I offered three.  Because mental illnesses typically begin in childhood, the first is intervening early, by making mental health screening a part of regular well-child and, later, well-care exams.  The second is intervening in the schools, by adding new special education services – paid for by states, not local education authorities – as symptoms of mental illness begin to affect school performance.  The third is intervening when young adults need services, by re-directing dollars from jails and prisons to community mental health programs.

The resulting Op Edit, Breaking the Chain of Neglect, was published by the Courant on December 28^thand appeared in print on December 30^th.  I hoped that it would add to a Connecticut dialogue about improving mental health services – one that has been ongoing for at least thirty-five years, when I first served in the State Legislature.

But perhaps we can all hope for something more in the aftermath of so many potentially avoidable tragedies – thoughtful new policies, instead of neglect.

In the past week, the column has been reprinted by a dozen others, including the Arizona Daily Star, the Dallas Morning News, the Tulsa World, the Las Vegas Sun, the Milwaukee Journal Sentinel, the Lawrence Journal World, the Chattanooga Times Free Press, the Kansas City Star, and the Youngstown Vindicator.

If policymakers in just those areas were to decide to work together to improve mental health services for children and young adults, then the prevention, early intervention, and treatment improvements we need so badly might finally come.

And those policymakers could leave a lasting legacy for their own children – who, I can attest, may someday need the services themselves.  

Follow Paul Gionfriddo on Twitter @pgionfriddo.  Find Paul Gionfriddo on Facebook at http://www.facebook.com/paul.gionfriddo.  Email Paul Gionfriddo at gionfriddopaul@gmail.com.

The Top Health Policy Stories of 2012

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Tragedy of Sandy Hook

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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