What Polls Say About Our Attitude Toward Health Reform and Mental Illness

What did the politician say after bumping his head while walking along a sidewalk as he waved to his constituents?   “I never look at the poles.”

Whether political leaders admit to looking at the polls or not, when you look beyond the headlines some current polls are saying a lot about how people feel about health and mental health policy issues. 

In the spirit of post-State of the Union bipartisanship, let’s hope that President Obama and Congressional leaders use three recent polls to listen to us about health reform, and to educate us about mental illness.

First, this is what the President and members of Congress will hear if they listen to what people are telling pollsters about the health reform law.

• We like a number of the elements of health reform, and don’t want them repealed.
• We’re not afraid that health reform will affect our existing health coverage.
• We don’t think the current law went too far.

The headlines from three January polls suggest that we remain divided about the reform law, with slightly more opposing it than favoring it. 

A Rasmussen survey found that 53% of voters favor repealing the law and 43% do not.  In the most recent ABC News/Washington Post Poll, 50% said they opposed the health reform law versus 45% who favored it.  An AP-GfK poll found the public evenly split on the new law, with 41% saying they opposed it and 40% saying they favored it. 

But when we listen beyond the headlines, we hear a different voice. 

In the AP-GfK Poll, only 26% supported repealing the law in its entirety.  An earlier Rasmussen poll also found a minority for full repeal of the law – 39%. In the ABC News/Washington Post Poll, 18% said that they favored total repeal. 

Support for full repeal isn't very high, and the reason is that we like many parts of the new law.  In the AP-GfK poll, the public supported by 50%-34% the prohibition on insurers denying coverage based on pre-existing conditions (such as cancer, mental illness, diabetes, and heart disease), and by 59%-34% the prohibition on insurers cancelling coverage because someone becomes sick.

We're also not afraid that the law is going to have an adverse effect on insurance we have and like.  In the Rasmussen poll, only 34% said that they thought the law was likely to force them to change their existing coverage.  

There are also a lot of people who think that the law should go farther.  In the ABC Poll, one in four said that the reason they opposed the law was because it didn’t go far enough.  Over half of those who supported it agreed with them, also favoring a reform law that would go farther than the current one does. 

source: ABC News/Wash Post Poll 1/11

These are a lot of numbers to absorb all at once, but the bottom line is pretty straightforward, and paints a far different picture from the headline.  35% said the law went too far, 19% said it was just right, and a slight plurality – 38% - said it didn’t go far enough. 

Politicians who ignore this message do so at their own peril. 

Second, here is why the President and members of Congress need to provide leadership in educating us about mental illness in the aftermath of the Tucson tragedy.

• We believe erroneously that mental illness causes violence. 

Some people with mental illness commit violent acts, but mental illness is not usually the reason.  One quarter of our population has a diagnosable mental illness each year, and this group is no more likely to be violent than the other three quarters.  Substance abuse (but not substance abuse treatment), juvenile detention, physical abuse, and past history of violence are predictors of future violent behavior, but mental illness is not. 

We need leaders who are willing to speak that truth to us.    

As was noted by researchers at the University of Tulsa in 2008, media reporting on events like the Tucson shooting makes a difference in how people react to the event, contributes to misperceptions about people with mental illness, and deflects attention away from the actual context of violent acts.  

Leaders need to speak up before our responses to violence do more harm than good.

In the ABC News/Washington Post Poll, 83% said that they would support increasing federal funding to add people treated for mental illness to the federal gun registry in an effort to prevent them from buying guns, and 71% said that they would support this for people treated for substance abuse.

source: ABC News/Wash Post Poll 1/11

We are so scared of mental illness that 83% of us would waste precious tax dollars creating a registry that would violate the confidentiality of one quarter of our population while doing nothing to address the real causes of violence in our society.

That’s hard to understand, but I guess we all bump into polls sometimes and come up rubbing our heads.

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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?

Violence is a Public Health, Not a Mental Health, Problem

We were all understandably shocked by the horrifying shooting in Tucson AZ this past weekend.  A Congresswoman was critically injured, and six people, including a nine year old girl, were killed.

Media commentators have asked an important question – are public officials safe from violence anymore?  As a former public official who received threats of violence, that's a question about which I care personally.

There’s a consensus answer to it.  In our vitriolic political environment, hateful rhetoric sometimes pushes disturbed, paranoid people over the edge.  If we dial back the rhetoric and keep a closer eye on disturbed, paranoid people, we’ll all be okay.

But there’s a more important question we’re forgetting to ask that leads to a far different answer.

Who points a gun at an innocent nine year old and coldly pulls the trigger?

Tim and Mayor Paul Gionfriddo,
Middletown CT Sidewalk Sale
1990, c.Hartford Courant 

The answer to the question doesn’t fit easily into the narrative of this tragedy.   This is because shooters of nine year olds aren’t usually stoked by hateful rhetoric.  And shooters far more often target innocent nine year olds, who trust us to protect them, than they do equally innocent public officials.  

Think about this:

·        A nine year old was shot dead inside his Washington DC apartment in November, 2009, when a gunman fired through the front door. 

·        A nine year old boy was shot and injured in Brooklyn NY in June, 2010, in a dispute over a stolen bike.

·        A nine year old boy was shot and killed in an affluent gated community in Dade County FL in March, 2010.  A family member was the first identified as a "person of interest.”

·         A nine year old girl, playing on the sidewalk outside her aunt’s home in York PA, was shot in the back and killed in a drive-by shooting on Mother’s Day in May, 2010.

·         A nine year old girl was shot and killed while jumping rope in her grandmother’s front yard in Chicago IL in August, 2010.  Her seven year old sister was also shot. 

·         A nine year old Baton Rouge LA girl was shot six times as she got ready for school, and her mother was killed, in a home invasion in September, 2010.

·         A nine year old girl was shot and killed in October, 2010 while sitting in her family’s minivan in a parking lot in Davie FL.

·         A nine year old girl in Hercules CA was shot and hospitalized in critical condition when she opened her front door in December, 2010.

These are just some of the nine year olds who were recently shot in our country.  How big would the list grow if we added a longer time period, more ages, and additional weapons?  It’s not hard to imagine, because we have the data.  In 2002 alone, homicides took the lives of 250 children aged 4-11.

The reasons for these crimes – vigilantism, gang violence, family feuds, retribution, theft – are as varied as the lives of our neighbors.  These and other environmental demons are far, far more often the reasons why nine year olds get shot than are the illnesses of our brains. 

People with mental illness are more likely to be the victims of violence than its perpetrators.  A history of violence, juvenile detention, and physical abuse are stronger predictors of future violent behavior than is mental illness, but media stories linking mental illness and violence have created the mythical “paranoid, violent, mentally ill person” for people to fear – a myth the weekend shooter happened to fit.  

The poor link between mental illness and violence is not just my opinion.  You can read about it in the Federal Substance Abuse and Mental Health Services Administration Center (SAMHSA) fact sheet Violence and Mental Illness: The Facts.

Violence is a public health problem in our country.  It makes our living environment more dangerous, and shortens our lifespan.  When violence leads to sudden death, most victims can be called innocent bystanders. 

No one deserves to be shot or killed – not a Congresswoman or a child, not six people on a sunny Saturday in Arizona, not the eight children listed above, not the 250 4-11 year olds killed in 2002, and not the 4,090 children and adults killed in 2008 alone in the sixteen states participating in the CDC National Violent Death Reporting System.

Our understanding of violence as a public health problem dates back only about thirty years.  Today, we need to understand that the threat of violence is much bigger than the threat posed by one gunman in a single time and place.

Until we appreciate that we have put nine year olds in harm’s way no matter where they live, learn, and play, we will fail to learn the real lesson from the weekend’s tragedy.  We are all responsible for this environment of violence, and we had better start working together to clean up our mess before more children die.

A Grown-up Health Policy Agenda for 2011

House Speaker John Boehner said recently that Congressional Republicans will have to face raising the debt ceiling as “adults,” echoing his March, 2010 comment that they needed to behave like “grown-ups” when health reform passed. 

The passage of health insurance reform in 2010 did not solve all of our health policy problems, but passing a meaningless repeal measure in the House in January isn’t the best way for members of Congress to start putting their grown-up pants on. 

What might an actual adult health policy agenda look like in 2011?

First, federal and state officials would put more resources into public health.  Like computer anti-virus programs, public health programs work in the background, taking care of us even when we fail to take care of ourselves.  They make sure our water is pure, our neighborhoods clean, our hazardous wastes are disposed of properly, and our children are immunized.  People can argue over whether various prevention initiatives cost more or less than treatment but no grown-up can deny their effectiveness. 

Except, perhaps, some public officials.  Florida’s new governor is proposing to reduce the state’s commitment to public health by folding the State Health Department into the agency that manages the health care system.  “Potato salad,” is what an AFSCME representative called this approach.  More like mystery meat, I think.    

Second, everyone should get a $100 tax credit for athletic equipment.  If we’re going to stimulate the economy with tax cuts, why not stimulate a culture of wellness?  Taking $30 billion of the trillion dollars we’ll spend on health care reform in the coming decade and giving $100 to every citizen for a new pair of athletic shoes, a down payment on a bike or treadmill, a first baseball glove, or other athletic equipment adapted to their needs, would make a meaningful, adult policy statement about the importance of fitness in all our lives.

Third, legislators should require periodic mental health screening as part of the well-care exams of children and young adults.  Serious mental illnesses hit young people disproportionately, and hit them as aggressively as cancers, taking 25 years or more off their lives.  (See the accompanying chart and the bottom of my Health Facts and Sources page for explanations about the comparison.)

We can treat most mental illnesses effectively if we treat them early and aggressively, but we often wait until it’s too late.  One 20 minute mental health screening every five years from age five through age 30 is all it would take to get started, and we’d be on the road to a healthier nation.     

Fourth, mental illnesses should be treated like other chronic diseases, not hidden away in jails.  Would anyone support sending people with uncontrolled diabetes to jail when they go into a diabetic coma because they are being a danger to themselves?  It sounds absurd, but that’s how we treat a significant percentage of the over 25% of us diagnosed with a mental illness every year.  In 2007, Time magazine reported that the country’s largest psychiatric institution was a prison.  Others have estimated that the majority of the people in our jails have mental illnesses.  While almost any alternative would be preferable, the simplest solution is to de-criminalize mental illness, adding more community mental health services and centers and funding them adequately.

Fifth, state and federal policymakers should pass laws de-criminalizing casual drug use and drug addiction.  Pat Robertson suggested this on his show on December 16, 2010, joining a growing chorus of others, including the Justice Policy Institute, who argue that drug treatment is far better and less expensive than incarceration.  We’re still fighting and losing Richard Nixon’s War on Drugs, yet those who were born the year he declared it are turning 40 this year.   It’s time for a change.  Controlling the use of other drugs, like marijuana, the way we control prescription drugs, alcohol, or nicotine is not the same as being “for drugs,” and it’s a far more mature response to the situation we're in than hiding our heads and wishing the drug monsters away.

Sixth, Federal officials should expand the Medicare program to give everyone a medical home and pay for their free annual physical.  Wouldn’t this be a great birthday present for policymakers to give to every citizen – a partnership for health?  Congress went part way there in 2010 by including a free annual physical in the Medicare program, but this should be available to everyone, whether or not they’re privately insured.  If it’s too scary and “big brothery” for some public officials to take this one on, then at least they should provide a tax credit for people to use to pay for it themselves.       

They’re now reading the Constitution in Congress.  I hope they don’t skip over the part of Article One Section 8 that reminds Congress of its duty to provide for the general welfare – meaning the health, happiness, prosperity, and well-being of our people.

The Top Ten Health Policy Stories of 2010, Part 2

Last week, I reviewed five of my top ten health policy stories of the year.  Here are the other five, all of which involved matters that will have a major impact on our day-to-day lives in the coming years.

5.  The Enactment of CLASS.  Private long term care insurance has been on the policy agenda since the 1980s.  Seniors realized that the cost of long term care could bankrupt them, so they began protecting their assets by transferring them to their children.  The state and federal governments were left to pay the tab, and went looking for help.

Private long term care insurance products were developed as a solution.  However, not enough people bought them.  When they were young, people didn’t think they would need the insurance, but once they got into their 60s and 70s, the premiums were too high.  This year, the federal government took action. 

Tucked into the pages of the health reform legislation is a new government-sponsored long term care insurance program starting in 2012, called CLASS, aimed at making long term care insurance more common and more affordable.  It will probably take a generation or more before its benefits are fully realized, meaning that this was a vote for our children and grandchildren.  Passing it knowing they won’t be around to get the credit for it was a class act on the part of the members of Congress.

4. The Closing of the Medicare Donut Hole.  The Medicare Donut Hole was more like a black hole for the seniors who fell into it each year.  As of 2010, consumers paid the first $310 in drug costs, and were reimbursed for 75% of their drug costs between $310 and $2,830.  Then they entered the donut hole, where they were completely responsible for approximately the next $3,600 in costs.  Finally, once their out-of-pocket drug costs in a year hit $4,550, their prescription benefits kicked in again and paid 95% of whatever remained. 

This was confusing and expensive, and it came to embody the worst of our confusing system of insurance reimbursements for over two million people trapped in the donut hole each year.

Reform legislation is closing the Donut Hole over the next ten years.  When the first $250 rebate checks arrived this year, Medicare beneficiaries could see the light again. 

3.  The Enactment of Consumer Protections in Health Reform.  By now, we’re all familiar with the new consumer protections we have.  Insurers can’t deny coverage for pre-existing conditions, they can’t drop people who become sick, and they can’t cap annual and lifetime benefits.    Several are already in effect.  Others are on their way.

Some states are arguing that they don’t have the authority to enforce them, and that could present a problem for consumers in the short term.  However, these provisions are so popular that it is likely that if states don’t enforce them, Congress will probably take further steps to ensure they do.

2.  The Comeback of Government Regulation in the Private Health Insurance Market.  For the past thirty years, the mantras of government have been “protect the free marketplace” and “less regulation, not more.” 

First, opponents of health reform argued for a freer marketplace to bring down insurance costs.  Then proponents argued that if the federal government could provide insurance at a lower cost than the private sector, it should be allowed to compete in that market. 

When the public option died, however, the alternative was to establish a more regulated, less-free market.

When Congress set minimum loss ratios (of 80 for individual policies and 85 for most group policies, meaning that insurers must pay out 80 to 85 cents in benefits for every dollar they collect in premiums), this was a very traditional, back to the 1970s, regulatory response to a problem.  Private insurers won’t have to compete directly with the government, but they will have to meet standards the government sets.

And number 1, the Passage of Any Health Reform at All.  We forget how much in doubt this was after the election of Senator Scott Brown in Massachusetts.   When Brown won in an upset, it looked for several weeks like there would be no bill at all.  Finally, President Obama and Congressional Democratic leaders hammered out a compromise that could pass with simple majority votes using the budget reconciliation process, and the most significant health care legislation since Medicare and Medicaid was signed into law in late March.  In the true spirit of representative government, the final compromises left no one completely happy, setting the stage for more health policy debate in the future.

Happy New Year!  Thank you for helping me launch Our Health Policy Matters over the past two months.  I’ll kick off 2011 next week by making some predictions about some upcoming health policy debates.

The Top Ten Health Policy Stories of 2010, Part 1

2010 was the most significant year in health policy since the 1960s.  It dominated the policy agenda for the first few months of the year, and it stayed in the news throughout the election season.  As the year drew to a close, conflicting lower court decisions about the constitutionality of the individual mandate foreshadowed a continued policy debate into the foreseeable future. 

What makes a health policy story big in a time of change?  It’s not just the attention it commands in the media.  It’s the impact it has on our lives. 

This week and next, I’ll countdown ten.   Using the impact criterion, there were actually some that weren’t part of health reform!   

Here are my choices for numbers ten through six.

10. The Election of Senator Scott Brown.  It is hard to remember that as we entered 2010, the Democrats seemed to be putting the finishing touches on a bill that could pick up 60 votes in the Senate.  Lincoln, Lieberman, and Nelson were among the ones to whom everyone was paying attention.  Then, Scott Brown was elected in Massachusetts, and everything changed.  The Democrats lost control of the issue and public opinion.  That one special election almost derailed the entire effort and ultimately changed the look of the final legislation.

9.  The Change in Tax Treatment of Dependent Health Insurance.  Until the IRS changed the rule in March, when you kept your child on your health insurance up to age 26, you paid taxes on the benefit.  Had this not been changed, then the health reform provision allowing parents to keep adult children on their insurance would have been a mixed blessing at best.  Many might have refused or been unable to do so when they factored what could have been hundreds of dollars of increased taxes.

8. The Death of the Public Option.  Even though it had majority support in both chambers, Congress put the public option to rest early in the year when leaders realized that they could not muster the 60 votes necessary to overcome a Senate filibuster against it.  Once it was gone, public sentiment tilted slightly against health reform.  Reform-minded Democrats were upset with their Congressional leadership, and a portion of the Democratic base disappeared along with it.  Proponents and opponents of reform seemed to agree on one thing – if a public option had been offered to people, many would have chosen it because it likely would have been less expensive than some or all of the private alternatives. 

7.  The Rebirth of the Public Option.   No one called it this, but when the final health reform bill included an expansion of Medicaid reaching 17 million new people in 2014, including nearly every family with income under $30,000, the public option was alive again – at least for people at lower income levels.  With Medicare also a public program, the only people left in the private insurance market were those under age 65 earning $30,000 and up.  And the reform law provided for subsidies for most of them.  We may not yet have the single payer system that progressives wanted, but we might still be headed in that direction. 

Public options are not going anywhere soon.  Mike Huckabee, who will likely be a significant early player in the Presidential campaign, favors repeal of the new law.  This fall he argued for a further expansion of the Medicaid program as an alternative to the mandate that insurers cover people with pre-existing conditions.  It’s pretty clear.  In the light of the day and out of the heat of the moment, so long as public options are called something else, they often generate support across the ideological spectrum.

6.  Mental Health Parity.  Mental health parity this year was an under-the-radar policy story with sweeping consequences. New mental health parity provisions, enacted in 2008, finally became law in 2010.  For the first time ever, mental illness must be given the same treatment in insurance as other chronic conditions. 

It became harder than ever for public officials not to do this as increasing numbers of people with mental illness advocated for fairness, and as other chronic conditions, like diabetes and hypertension, became more common and more costly.  Parity is a big deal, especially to the millions of people with serious mental illness, but when it happened at the beginning of the year it got little attention in media consumed by the fiery health reform debate.

Ironically, the mental health parity law also attracted little news attention when it was passed in late 2008.  Why was this?  It was tacked onto the first major financial bailout bill signed into law by former President Bush!

Next Wednesday, I’ll give you my top five health policy stories of the year. 

Healthy Reforms

In the 1990s, the Department of Health and Human Services looked at health spending versus the improvements in the health of our population in the 20^th century.  The results were startling.

97 percent of our spending was in health care, versus 3 percent in wellness and prevention – the activities of public health.  Despite the meager investment in public health, however, 50% of the improvement in our health status could be attributed to it.

Managing our health and preventing disease means a longer life. 

I admit that this lesson wasn’t lost on me. 

I run or take long walks at least three times a week, eat five portions of fruits or vegetables a day and no red meat, enjoy a glass of wine with dinner, and do my best to manage my stress.  My weight today is just a little higher than it was when I was in high school forty years ago.

Those are the things I can do by myself, but they’re not enough.

Without statins my cholesterol numbers would be a nightmare.  So I also go for my annual physical.  I review my blood work and have an EKG. I discuss with my physician the vitamins and medications I may need for the coming year.

Not everyone puts that much effort into being healthy.  This is because we expect to be healthy and take it for granted until we get sick.  Then we hope modern medicine can fix us.

In a nutshell, this probably explains why we spend so much for health care, and so little for prevention.  We literally leave well-enough alone. If there’s no crisis, we’re not motivated to act.

Fifty or a hundred years ago,  when doing nothing about our wellness meant that our drinking water was polluted, communicable diseases crippled or killed our children, and our air was thick with haze, our grandparents understood the consequences of doing nothing.  So they cleaned up our environment and invested in our health, and that’s why we live longer lives than they did. 

But spending on prevention for the past few decades has been more like rowing against the current.  It has been overwhelmed by the tide of spending on health care.

That’s about to change, however.  This is because our crisis meter is ticking upward along with our weight, the number of chronic conditions from which we suffer, and the huge amount of money we’re spending to try to get well again. 

Congress noticed this year, and took some major steps this year to get our minds off of sickness and back on wellness and health.  Note that none of these provisions are affected by any of the court battles over reform.

Here are several of the most significant, cutting across populations and strategies: 

·         Beginning in 2011, all Medicare recipients will have access to a free, annual check-up, other free preventive services, and free colorectal and cancer screening.

·         Private health insurance plans established after September, 2010, must cover preventive services, including immunizations, without charging deductibles, co-pays, or co-insurance.  These provisions also apply to Medicaid as of January 1, 2011.   “Grandfathered” private plans will not be required to do this immediately, but some may anyway.  Most others will be adding this coverage over the next three years. 

·         Employers will be allowed to offer employees a health insurance discount of up to 30% if they participate in wellness programs.

·         Employers with fewer than 100 employees will be eligible for grants totaling $200 million nationwide from 2011 through 2015 to create comprehensive workplace wellness programs for employees.  If successful, these could in turn lower the premiums these employers have to pay for health insurance.

·         Up to $1.5 billion from 2010 through 2014 are being granted to states and nonprofits for maternal, infant, and early childhood home visitation programs to improve infant health, child development, and school readiness.

·         A Public Health and Prevention Fund has been established with $6 billion through 2015, and $2 billion a year thereafter, to support investments in public health and prevention programs authorized under the Public Health Services Act. 

·         Community transformation grants will allow communities to attack and mitigate environmental factors, such as a lack of playgrounds and unsafe neighborhoods, which lead to poorer health among residents.

·         Restaurants with 20 or more locations must provide nutrition labeling on standard menu items.  Vending machine operators with twenty or more machines must provide calorie counts for all machine items.   The regulations implementing these programs will be issued in 2011.

These gifts to our health will go a long way toward improving both the length and quality of our lives.  Of course, we’ll have to work just as hard to keep our bodies running well.  It’s good to know that our elected representatives are alongside us in the effort.   

Extra: Read my Guest Blog in Health Affairs Grantwatch Blog on how foundations can invest to improve access to care.

The Brick Walls in the Battle Against Health Reform

States battling to repeal new health reform mandates have settled on two issues that may well turn out to be political brick walls. 

One issue is the requirement beginning in 2014 that individuals purchase insurance or pay an income tax surcharge, the so-called “individual mandate.”  The other is the federal expansion of the Medicaid program. 

The battle is being joined in the courts, the Congress, and state legislatures.

Most of the action so far has been in the courts. 

Florida has filed a suit challenging both the individual mandate and Medicaid expansion.  CNN calls it the “highest profile” lawsuit of many, and 19 other states have joined it.

Florida argues that the individual mandate is unconstitutional, contending that it’s unconstitutional for the federal government to require individuals to purchase health insurance by taxing them if they don’t.  As of last week, federal judges in both Michigan and Virginia have ruled against this position in other cases, but these decisions will be appealed. 

Florida’s argument against expanding the Medicaid program is more about public policy than the constitution. The Medicaid expansion will add 17 million uninsured people nationwide to Medicaid beginning in 2014.  This will cost a lot of money, and that’s the basis of the objection. 

However, for the first few years the federal government will pick up the entire cost of the expansion.  This means that states and localities initially will actually save millions of dollars they’ve been using to pay for care for the uninsured.

Also, the federal government doesn’t require states to participate in the Medicaid program.  Medicaid is not administered as one big federal program, but as fifty different state programs.

Why don’t states simply opt out?  When Governor Rick Perry of Texas floated the idea earlier this year, his own Health Commissioner quickly shot it down.  It’s because the Medicaid program draws down billions of federal dollars.  These pay not only for health care for poor people, but also for nursing home and home health care for seniors and intermediate care for people with disabilities.

A state opting out of Medicaid would be between a rock and a hard place.  It would bankrupt and alienate seniors and people with disabilities, while killing off some hospitals, nursing homes, and home health agencies that rely on these payments.  Or it could pay the whole bill itself, and its political leaders would have to preside over the biggest tax increase in state history.

Still, today’s court cases are only the opening volleys in this battle.  Even though they raise issues that seem today to create losing scenarios for the states, at least one case – perhaps Florida’s – will eventually reach the Supreme Court.  Health reforms will have been in place for years by then, and no one can say what the Court will focus on, what it will decide, or what the political landscape will be.

How will the other two battlefronts play out for states this coming year?  They’ll be noisy at times, but little ground will be gained or lost.

First, some members of Congress will try to choke off some funding to slow down reform implementation while introducing bills aimed at paving the way for more state challenges to reform.

Senator Roger Wicker (R-Mississippi) is introducing one of these this week.  They’ll argue “states’ rights,” noting that states – not the federal government – should determine how best to protect the health and well-being of their citizens.  None of these measures will pass, but they will give some cover to politicians trying to appease angry voters.

Second, state legislators will introduce and pass legislation that will be carefully crafted not to do too much too soon. 

Florida’s legislature is already working on its plan.  As Jim Saunders reported in Health News Florida on November 23^rd, Florida legislators are reviving a proposed constitutional amendment giving Florida residents the right to opt out of purchasing health insurance.  Voters may eventually get the chance to air their frustration by voting for the amendment, but even if it passes, it won’t affect anyone until 2014. 

By then, many of the crusading legislators will be out of office, and the Courts will all have ruled.  If they find the individual mandate constitutional, will anyone refusing to buy insurance want be the first one who refuses to pay the federal income tax surcharge?   That fight will be a lonely battle against the IRS, and not one the individual is likely to win.

The Mental Illness Epidemic

There is an epidemic of mental illness in America.  It’s time policy leaders did something about it.

They could start by acknowledging just how widespread this epidemic is.  According to the National Institute on Mental Health, it affects one-fourth of our population – over 57 million adults and over 15 million children. 

Why are the numbers so staggering?

No one knows for sure, but the bad economy, wars, and abuse are all probable factors.

According to a Gallup Poll released last year, the bad economy led to an increase in emotional illness among all adults.  Especially hard hit were those between the ages of 30 and 55, the family breadwinners.

CNN reported in 2007 that one-third of all veterans returning from Iraq or Afghanistan were treated for mental illnesses.  Their children were also affected.  According to a survey of health records released this past month and reported in the New York Times, children between the ages of 3 and 8 with parents in the military had 10% more visits to mental health providers than their peers.

Also in 2007, 5.8 million child neglect or abuse allegations were reported to state child protection agencies.  Almost 800,000 of these were confirmed.

Simply blaming economic and environmental factors isn’t enough, however. 

Researchers have achieved some breakthroughs, but they still don’t know why 17 million adults have serious mental illnesses like schizophrenia, bipolar disorder, and major depression.  These are not caused by economic or environmental factors, and they have devastating consequences.

Homelessness and incarceration are two of them.  According to the National Coalition for the Homeless, 25% of homeless people have severe mental illness, and mental illness is a leading cause of homelessness in our country. 

County jails, where inmates usually stay for under six months either awaiting trial or serving time for minor offenses, are teeming with people affected by mental illness.  Some officials report that up to 85% of jail inmates have mental illness.  They are also three times more likely to have serious mental illness than someone not in jail, and a 2009 study found that nearly one in three female jail inmates had serious mental illness – five times the prevalence in the population as a whole. 

This isn’t acceptable.

Policy leaders need to take this epidemic seriously.

First, they need to do more to identify and treat serious mental illness in children.  The Mental Health Association of Palm Beach County (FL) has offered a creative idea.  It suggests adding periodic mental health screening to pediatric care for all children, to identify and treat mental illness in children at the earliest possible age.  All state legislatures, not just Florida’s, should look closely at this.

Second, they need to decriminalize mental illness.  Simply exhibiting symptoms of mental illness in public can sometimes be cause for arrest, wasting precious resources.  A few years ago, a schizophrenic homeless person was arrested for “sitting or lying on a public sidewalk.”  He missed his court hearing because he was in jail for violating his probation on an earlier offense by being arrested again.  When he finally got to court, no one except the homeless person could keep track of what time he was actually serving for which offense, so he was released. 

People with mental illness don’t belong in jail.  If policy leaders changed the laws that send them there, as a side benefit jail overcrowding would end overnight.

Third, they need to create an emergency mental health response system that looks more like the rest of our emergency response system.  In a health emergency, an ambulance responds.  In a mental health emergency, a law enforcement officer responds.

They should be sainted for taking on this role.  They have diverted many people in crisis away from jails.  But it is no more reasonable to ask law enforcement professionals to evaluate mental illnesses than it would be to ask them to evaluate diabetes, heart disease, or cancer emergencies.

Local and county emergency mental health services systems should be staffed by mental health professionals.  Policy makers should use the new federal insurance parity laws to assure that insurance covers the cost.

Fourth, they need to rebuild our safety net system of care for people with mental illness.  When we emptied our large state institutions beginning in the 1970s, we were supposed to replace them with community mental health centers. But we stopped building these new centers before we were finished. 

It’s time to start building them again, and to pass laws giving them preferred Medicare and Medicaid rates, discounted drug pricing, and access to ongoing federal grants like the ones supporting community health centers.  Then policy leaders should integrate safety net health and mental health care.

These are just four ways policy leaders could start dealing with the epidemic of mental illness.  There are more.  75 million Americans in crisis are waiting patiently.