Making People with Mental Illness Pay the Price

Isn’t it worth a few dollars to preserve essential mental health services?  It would appear that many state legislators would say no.

According to the National Alliance on Mental Illness, states have cut a total of $1.6 billion for mental health services over the past three years.

That was just the teaser. 

This year, states around the country are making people with mental illness pay the price for tax cuts and deficits.

NAMI state-by-state data show that the State of Florida spends no more for mental health services than it did in 2009.  But Health News Florida reports that the Florida Senate has proposed millions of dollars of cuts to mental health. 

Next week, its Appropriations Committee will vote whether to cut $137 million from adult mental health services, 57% of the total outpatient budget.  Anyone who thinks these services aren’t essential should think again.

On a single day this spring, in addition to offering its full array of group counseling, AA, NA, and individual support services, the only full-time peer drop-in center operated by MHA of Palm Beach County dealt with the death from natural causes of a middle-aged client (people with mental illness die 25 years earlier than normal), a former client’s suicide, a hospital patient discharged to the center for follow-up services, and a person with a traumatic brain injury who had no other place to go.

“Days like this are now common,” commented MHAPBC CEO Pam Gionfriddo, “and will become even more so if policymakers keep cutting.”

 Over 5,300 people in central Texas alone will lose services, according to the Austin American Statesman, if a proposed 20% cut in outpatient mental health services goes through.  The CEO of Austin’s major service provider said this would add to the suffering of families, and Lynn Lasky Clark, President of Mental Health America of Texas added that those affected would be “devastated.”

Texas already spends 3% less on mental health services than it did in 2009. 

Nevada spends 17% less on mental health services than it did in 2009.

But, according to the Las Vegas Sun, the Governor’s proposed budget includes millions of dollars of additional service cuts, including cuts to triage centers in Las Vegas and Reno and to outpatient counseling services.

Sen. Sheila Leslie termed the cuts “a mental health catastrophe.”

Tennessee already spends 10% less on mental health services than it did in 2009.

Now, Tennessee is proposing to cut $31 million more from mental health services, affecting all areas of the state.

The northeast is not immune.  New Hampshire has cut mental health funding by 8% in the last two years.  This year, the state is considering eliminating all services for two-thirds of the 20,000 people for whom it has responsibility. 

Ditto the northwest.  Oregon actually added 23% to its state mental health budget the past two years.  However, Disability Rights Oregon reports that the state is now proposing cutting mental health services by 30%, costing 45,000 Oregonians access to care.

Let’s call this exactly what it is – public officials across the country pummeling people who are the least able to defend themselves.

The bad economy is a phony excuse. 

Even in the Great Depression, state policy makers increased mental health services to meet increased needs.  The census of patients served in mental hospitals – the only care option available at the time – grew from 272,252 on January 1, 1929 in 1929 to 321,824 on January 1, 1934, and the number of first admissions – a signal that new needs were being met – rose from 60,500 on January 1, 1929 to 69,368 on January 1, 1933.

Do policymakers really think times are tougher today than they were then?

Most legislators pray to God for enlightenment and compassion at the opening of each session.  Here is an excerpt from a Florida Senate prayer this year, offered on March 16^th by Monsignor Thomas Skindeleski of Delray Beach:

“Open our minds to better understand the needs of those who have chosen us to serve them. Teach us how to craft laws that will better the lives of millions of people who are counting on our efforts to serve them well.  Let justice and peace be foremost in our minds as we endeavor to legislate in ways that will benefit the lives of our people. Direct our efforts to preserve the life and liberty of the most vulnerable members of our society.”

It’s a powerful prayer.  I hope our leaders listened. 

Don’t smirk.  When was the last time we told our own elected officials that we willing to pay taxes to provide services to people with mental illness?  Today – before it’s too late – is the day to call, email, or forward this column to a policy leader.

We must add our voices to those of the mental health advocates speaking up for some of the most vulnerable members of our society.

Would you like to be notified about new Our Health Policy Matters blogs via email?  Just send an email to gionfriddopaul@gmail.com and I'll add you to my list.

Health Reform's First Birthday

Babies crawl before they walk.



c. Microsoft Office Image

The Affordable Care Act (ACA) marks its first birthday this week.  It may not be off to a running start, but it isn’t exactly sitting still either.
 

The most debated provisions, like the individual mandate and the Medicaid expansions, are still three years in the future.

In the first year, ACA’s biggest developmental milestones have affected older Americans, people with mental and physical disabilities, and consumers in general.  Which of these populations is making the most progress?

Medicare recipients and early retirees have taken the most steps forward.   

As of January 1^st, all Medicare Part B recipients are entitled to a free annual physical, with free cancer, cardiovascular, and skeletal screenings, and free flu shots.  150,000 beneficiaries had taken advantage of this through February 23^rd.  This number will grow, to many millions before the end of the year.

Also, over 3.4 million Part D recipients who fall into the donut hole will receive an average savings of over $500 on brand name drugs this year.  Many already received $250 rebate checks last year, and the value of this benefit will increase annually as the donut hole closes over the next several years.

Early retirees are also keeping up.  The law allows employers to keep retirees between the ages of 55 and 65 on their plans, and to get reimbursed for some of the costs. 

As of December 31^st, 5,452 plan sponsors had been approved to participate in the Early Retiree Reinsurance Program (ERRP).  Two states – New York and California – had over 500 participants.  Eight others – Pennsylvania, Illinois, Michigan, Minnesota, Indiana, Massachusetts, Florida, and Texas – had over 200.

An estimated 4.5 million early retirees, spouses, and dependents were included. 

Also, the Federal Government had reimbursed $535 million in costs as of December 31.

There were huge differences in the amount of reimbursements paid, with just a few states claiming most of the money.  Georgia had been reimbursed for almost $52 million, with $35 million in direct reimbursements to the state plan alone.  All participating plans combined in its next door neighbor, my home state Florida, had collected a mere $305,000. 

Plans themselves are responsible for claiming reimbursement for high-cost retirees.  It's hard to imagine that Georgia has so many more than Florida.

People with mental and physical disabilities are struggling to move forward. 

Children with pre-existing conditions won coverage on their parents’ plans as of September, but the ban on denying adults with pre-existing conditions access to regular insurance doesn’t take effect until 2014. ACA established Pre-Existing Condition Insurance Plans (PCIP) all 50 states in the summer of 2010 to provide temporary insurance for these people.  

The Administration hoped that up to 250,000 people would find health insurance through these plans, but only 12,437 had enrolled in PCIP plans as of February 1.  Pennsylvania led the way with over 2,000 enrollees, followed by Texas, Illinois, Ohio, California, North Carolina, and Florida. 

Although the price of the plans (usually between $300 and $500 per month) is significantly lower than traditional individual plans for people with disabilities, it is still proving too high for many underemployed adults.

Consumers in general are taking one backward step for every two forward ones. 

The implementation of consumer protections was the biggest news of the first year.  As of September, as plans are renewed, parents can cover their children up to the age of 26, and insurance can’t be denied to children because of pre-existing conditions.  It also can’t be cancelled when children or adults get sick, and annual and lifetime insurance limits are on their way out.

However, not every consumer protection applies to grandfathered plans.

Also, to assure that low-cost, low-benefit plans would not go out of business abruptly, the Administration has granted hundreds of one-year waivers from the annual limit provisions.  As of late January, 733 waivers were granted for plans covering 2.1 million Americans.

Since then, the number of approved waivers for all reasons has increased to over a thousand, affecting 2.6 million Americans.  In early March, Maine received the first waiver from the most important consumer protection in the ACA, the one mandating that 80% of all premium dollars in individual insurance plans be paid out in benefits.

This year, Maine’s individual plans will only have to pay out 65% in benefits, meaning that they could theoretically make up to a 50% profit on every premium payment.  Several other anti-consumer states are asking for similar waivers to protect insurers.

While loss-ratio waivers demonstrably harm consumers, the Administration has announced that it is moving forward with another consumer protection.  It published a notice in early March to require any insurer proposing to increase rates by more than 10% to provide a breakdown to customers of the reasons for the increase.

Baby steps.  That’s what we’ve learned to expect from the first year of life, and that’s what we’re getting. 

The Nuclear Nightmare in Japan

The catastrophic nightmare in Japan could happen anywhere.  It is a reminder of the fragile relationship between our environment and our health.

As the tsunami waves swept over the land, they swept away any pretense that we are more powerful than our environment.  The mere shifting by several feet of two constantly moving plates of the earth resulted in the death of thousands, the destruction of a region, and catastrophic worldwide effects.

Experts have noted that as many as 24% of premature deaths can be attributed to environmental factors.  These result from our inadequate understanding of our environment, and/or our inability to manage its forces.

While the underdeveloped world is more susceptible, the Japanese tsunami reminds us that the overdeveloped world is not immune.   

The images are more powerful than their descriptions.  In the wake of such destruction, we can see -- as we do in the aftermath of hurricanes -- the breeding grounds for disease.  We know that many of the survivors of the initial devastation will still become its victims. 

There are clear psychological effects as well.  In a matter of minutes, the lives of the shocked and stunned people of northeast Japan were changed forever.  Up to 15% of children who survived the tsunami, twice the norm for adults, will likely be diagnosed with PTSD.

Still greater effects are hidden in what we can’t see.

The partial meltdowns of multiple nuclear reactors are resulting in the release of deadly radiation into the atmosphere that will compromise human health for decades. 

Our leaders have forgotten how dangerous nuclear power can be.  Even some who consider themselves environmentalists naively believe that we “harnessed” the atom and made nuclear energy “green.”

Nothing could be farther from the truth.

In the 1950s and 1960s, nuclear energy was promoted as “safe, clean, and cheap” by the brand-new nuclear industry.  It was said that it was safer than walking across the street and would be too cheap to meter.  School children toured nuclear power plants to learn about the “peaceful atom.” 

Our government knew better.  In 1957, it passed the Price-Anderson Act, limiting the liability of nuclear plant owners in the event of a nuclear accident.  This is still the law of the land.  Without it, not a single nuclear power plant would have been commercially viable in this country. 

Each reactor owner must carry only $375 million of insurance to pay for damages from an accident; up to $12.6 billion more is in a secondary insurance pool.  If you lost your home to nuclear contamination, your homeowners insurance would pay nothing.

To put this in perspective, the total cost resulting from the Japanese quake and tsunami is already estimated to be up to $60 billion, and Hurricane Katrina did even more damage than this.  The Chernobyl accident cost Ukraine alone an estimated $201 billion.  The total compensation for a nuclear accident in this country could be as little as five cents on the dollar.

Once their liability was limited, nuclear companies were free to put their plants anywhere – near population centers and even along earthquake fault lines.

After many “minor” incidents in the United States and around the world during the 1960s and 1970s, the Three Mile Island accident in 1979 proved once and for all that the safety systems in nuclear power plants did not work as advertised.    

Then came Chernobyl in 1986.  This was the defining civilian nuclear disaster of the 20^th century.  Twenty-five years later, experts are still tallying its effects.  The World Health Organization conservatively estimates the number of deaths at nearly 10,000, plus thousands more excess cancers, and other health and mental health effects. 

A YouTube video shows how radiation would spread into the atmosphere if a Chernobyl-like accident were to happen in the United States.  It is a frightening reminder of the risks we are taking.

There is a lot we don’t yet know as the fuel rods melt down and the crisis unfolds in Japan.  One thing is certain.  It will be years before we understand the full global effect on human life from this event. 

We can all put those years to good use if we finally take to heart the lessons from this unspeakable tragedy.  We cannot overcome the limitations of our planet.  We do not control the forces of nature.  We can choose, however, not to stand in harm’s way. 

There are 104 operating nuclear reactors in the United States today.  Just as in Japan, some are built near earthquake fault lines and most are close to cities. 

Any one of them could be a time bomb.  It’s time we lived a little greener, and not supply so much fuel for the next environmental health disaster.

We can pretend that what’s happening in Japan is just someone else’s nightmare, or we can wake up and start doing something about it. 

A Long Term Care Win for Everyone

Why is it so important that Florida has won a $35.7 million health reform act grant to participate in the federal “Money Follows the Person” program?

A recent news story provides the answer.   It tells the story of a 20-something Florida resident who is a quadriplegic living in a nursing home.  He doesn’t want to live there.  But he doesn’t have a choice.  It’s the only option for which the Florida Medicaid program will pay. 

We hope he’ll be alive for many years.  A back-of-the-envelope calculation suggests that the cost of his care could approach $4 million by the time he is 65.

A December, 2009, AARP Long Term Care Brief showed that Florida spent 86% of its Medicaid long term care dollar on institution-based services.  It spent about half the national average on home and community-based services (HCBS).

The “Money Follows the Person” program offers a low cost remedy. 

Enacted in 2007, the program has already provided over $1.4 billion to 30 states.  It has helped over 30,000 people transition from nursing home care to lower-cost community-based care.    

The result is improved well-being, greater independence, and more productivity at lower cost.  Not just young people benefit; many older Americans with chronic conditions also prefer living at home.

Wildly popular, the program was re-authorized by the Affordable Care Act.  It was extended for several years and expanded to allow more states to participate.  By accepting the new federal grant, Florida will be one of them. 

In spite of the bluster that Florida would refuse to implement any of “Obamacare,” AHCA and the Governor saw the wisdom of pursuing this piece aggressively. 

Florida may have come late to this party, but better late than never. 

The cost of long term care is one of the biggest drivers of the increase in health care costs in our country.  A majority of our population has one or more chronic conditions.  These conditions are often diagnosed and monitored using expensive medical tests.  They are managed with costly pharmaceuticals.  People with them often need physical and occupational therapy and other supports.  Treatment costs may rise in the future, because genetic therapies are on the horizon.

In a recent issue brief on Medicaid and long term care, the Deloitte Center for Health Solutions noted that Medicaid expenditures are projected to increase by 7.5% per year, largely due to the increase in the numbers of elders and others with chronic conditions on the program.  Examining Florida and nine other states, Deloitte estimated that the percentage of state resources devoted to long term care could double over the next twenty years. 

Controlling long term care costs should be a priority for everyone.  However, this isn’t always the case.  The report noted with concern that states are cutting back on lower-cost community-based services covered by Medicaid, instead of increasing them.

That’s what makes the “Money Follows the Person” program so important.  It helps expand community-based services, at a time they are sorely needed.

Florida’s action also serves as a reminder that the Affordable Care Act isn’t one big government health care program.  It is a collection of smaller, independent initiatives that affect many different components of our health care delivery system.

Another provision of the Act – the creation of the CLASS Long Term Care Insurance program, effective in October, 2012 – is also aimed at changing the way we finance long term care in the future.  It will make more private long term care insurance available for home and community-based care.  My wife and I purchased long term care insurance policies several years ago, when we were in our early 50s and healthy.  Unfortunately, many others wait until it’s too late. 

The HHS National Clearinghouse for Long Term Care Information notes that over 70% of us will need long term care services at some point in our lives.   HHS Secretary Sebelius has pointed out that one in six people who reach the age of 65 will spend over $100,000 in their lifetime on long term care.  The total cost could be upwards of $5 trillion.  The government can’t pay all this.  Private long term care insurance will be needed.    

However, as the planning for the CLASS program is unfolding, people who develop serious chronic conditions before applying for long term care insurance may be out of luck.  To keep insurance costs affordable, HHS is considering limiting the program to higher wage-earning, healthier people at the start. 

That means Medicaid will remain the main long term care payer for the foreseeable future. 

The more it can do to help 20-somethings stay in the community and be productive, the better off we all will be.  This is a health care reform with which no elected official should disagree.

The War on Health

Policymakers across the country have declared war on health.  You may have missed the headline, but this is a war with many casualties.

Its objective is to topple health care as we know it.  When health care falls, our health will be the victim.

Battles are raging in many states to cut the legs out from under health care financing.

The Arizona Senate Appropriations Committee recently voted to eliminate the Medicaid program.  This would make 1.3 million people uninsured and cost the state $7.5 billion in federal funding. 

A Florida Senate leader has threatened to eliminate Medicaid unless the federal government agrees to massive changes.  This would cost Florida over $10 billion, and make 3 million people uninsured.

Wisconsin’s Governor has proposed dropping over 60,000 people from Medicaid because they are too rich.  “Too rich” means a two-person household income of less than $29,100.     

Medicaid isn’t the only target. 

Pennsylvania just cancelled its state-funded health insurance plan for low income residents.  As a result, 42,000 people lost their insurance.  A half million more on the waiting list have to fend for themselves.

New Jersey’s Governor proposed a 15% reduction in state health appropriations this year, six times greater than the overall reduction in his budget in his recent speech to the Legislature.

Florida’s Governor proposed eliminating state-run health department clinics, even when they generate revenue.  In Palm Beach County alone, this would cost 60,000 people their regular source of care.    

This war began quietly while the eyes of the public were focused on federal health reform.  The Center on Budget and Policy Priorities has detailed a number of battles we have already lost:

• New Jersey lowered income limits and reduced eligibility for the state’s Children’s Health Insurance Program.  50,000 more people are uninsured as a result.  
• Mississippi reduced its mental health budget by 22% in the last two years. 
• Illinois and Ohio cut community mental health services for children and reduced or eliminated community mental health services for adults who are not on Medicaid.

Elected officials declared this war on health by suggesting that health care was the weapon of mass destruction of our state economies.  It wasn’t.  The real weapons were the war in Iraq and Afghanistan at a total cost of over $1 trillion (and counting), for which the federal government did not have the courage to pay, and the greed of a financial industry which fattened our burst housing bubble. 

Health care is not a foe of the state, and people who need it should not be treated as enemy combatants.

However, people with mental illness are this war’s prisoners, often jailed instead of given the care they need.  This is not an exaggeration. The three largest mental health institutions in the country are Riker’s Island, the Cook County Jail, and the Los Angeles County Jail.  The largest mental health institution in Texas is the Harris County Jail.  It has 2,400 “patients” on any given day. 

In 2011, Texas is considering cutting $1.1 billion from state mental health services.  

According to the US Bureau of Justice Statistics, in 2005, more than half of over 2 million prison and jail inmates had mental health problems.    Over 1.25 million Americans are being “treated” for mental illness in our prisons and jails.

Elderly women and children are this war’s hostages. 

The Medicaid program funds 68% of the 1.8 million nursing home beds in the U.S.  Almost a million people live their lives in these beds.

650,000 of them are women, the vast majority over 75 years old and widowed.  In his recent speech, New Jersey Governor Christie articulated a fearful future for them.  Others share his vision “to move our aged, blind, and disabled [Medicaid] recipients into modern managed care.” 

These sick, elderly women suffer the indignity of being blamed for the state budget crisis they had nothing to do with creating.  If the Governor’s vision becomes reality, they won’t just have to cope with incredible health challenges.  They will be put at the mercy of the discredited “modern managed care” denial system.

Mostly under the radar, 31 states have already implemented cuts in children’s health programs.  As representatives of the Iowa Child and Family Policy Center and Voices for America’s Children note in their recent publication, The Healthy Child Story Book, for the first time in our history children may live shorter and less healthy lives than their parents.

Meanwhile, legislative bodies in Ohio, Louisiana, and Arizona have found the time to pass laws banning animal-human hybrids.  This is no joke.  The Louisiana bill’s sponsor, State Senator Danny Martiny, said the Louisiana Conference of Catholic Bishops asked him to introduce it.    

Louisiana ranks 49^th among the states in health, ahead of only Mississippi.  While imaginary beings occupy the attention of political and religious leaders, this war will produce millions of all-too-real casualties.

Slaying the Medicaid Monster

Legislators have created a Medicaid monster, which eats up 22% or more of their state budgets.  Now they want to slay it. 

However, they’re not seeing the real monster clearly.  Cutting the legs out from under Medicaid recipients isn’t the same as cutting the monster down to size.

A Florida bill illustrates how states are attacking the wrong things. 

Under a Florida Medicaid reform proposal, Medicaid patients would be charged $100 for non-emergency visits to a hospital emergency room.  The purpose is to save money by discouraging unreasonable use of emergency rooms. 

Nearly half of all visits to emergency rooms are for non-emergency reasons.  This is true of Medicaid patients, insured patients, and uninsured patients.  The main reason the percentage is so high isn’t that people choose to go to the emergency room for minor complaints.  Laypeople aren’t qualified to diagnose their own emergencies.  Health professionals tell them to use emergency room because it’s better to be safe than sorry.

Here are three true-life examples that illustrate the point.

• A 56 year old man complains of chest discomfort and shortness of breath, and the paramedics who respond advise him to go to the hospital immediately.  Even though clinicians describe his symptoms as those of a classic heart attack, the tests are negative. It is a false alarm. 
•  A 35 year old woman walks into the emergency room complaining of an upset stomach.  She is examined and advised to take an antacid.  She reports feeling better and is discharged. Several days later she is admitted to the hospital in severe pain, and is diagnosed with an ovarian cyst. 
• Three times in two weeks, a young man enters the emergency room complaining of leg pain.  Clinicians suspect that he may be shopping for pain pills.  They find nothing wrong with his leg, and discharge him.  A few days later, the patient is in the hospital after attempting suicide.  His complaint was about his leg, but his problem was his mental illness.

Who is to say which of these patients shouldn’t have gone to the emergency room?    

When people need health care someone has to pay for it.  For too long, states have taken the position that this should be someone else.  Letting people at the poverty level shoulder more of the burden through $100 charges is just the latest strategy. 

This is because imposing a $100 charge on patients will cause care to be deferred, delayed, or denied.  People will try to wait out their emergencies.    

This won’t matter to the 56 year old who didn’t have a heart attack.  He’ll be fine the next day.  The woman with the ovarian cyst and the suicidal man won’t be so lucky.

Medicaid isn’t a monster.  It’s a lifeline for people who need health care. 

It is also a lifeline to the states.  It may absorb 22% of their budgets, but it also supplies 15% or more of their total projected state revenues.  The federal government reimbursed states for an average of 57% of their costs through 2009, 66% in 2010, and will pay 90-100% of the cost of program expansions under health reform. 

This payment results in four times the amount of revenue states receive from corporate taxes, and almost as much as they raise from all state income taxes combined. 

Like the governor of Texas, some Florida legislators are threatening to drop out of the Medicaid program unless the federal government agrees to let them cut Medicaid benefits to the elderly, children, and lower middle class families.  The Governor of Texas dropped this idea when his commissioner reported how much harm this would do to the state. 

The way for states to control Medicaid costs isn’t to make it harder for people to receive Medicaid benefits.  States need to fix the mistakes they have made over the years that have led to higher costs, not compound them. 

First, they reduced Medicaid reimbursement to physicians and other providers to such a low level that most dropped out of the program.  In many areas, the only Medicaid providers left are the hospitals, so that’s where Medicaid recipients go for care.  To its credit, Florida is following the federal government’s lead and considering higher reimbursement rates for some providers.   

Second, they limited community care, home care, and non-health care options to people on the program, and refused Medicaid to people with mental illness, pushing them into higher-cost treatments.

Third, they forced recipients into managed care programs that did a better job of denying care than coordinating it, making the population sicker.

Fourth, they put healthier, working people with incomes slightly above the poverty level onto county and local programs that receive no federal reimbursement.

Despite the harm they’ve done, some of these mistakes are still on lists of state-proposed “reforms.”   

That’s the real Medicaid monster.

Making Health Services Our Priority

Are essential health and behavioral health services a priority for our elected officials?  We got a clear picture when House leaders offered their 2011 continuing resolution and President Obama proposed his 2012 budget this past week.   

Both the continuing resolution to fund federal agencies for the current fiscal year and the President’s budget proposal for next year cut billions of dollars from the federal budget.  Some essential health services are surprising targets.

Cost Per Person to Restore Proposed Health Cuts

For a total savings of $2 billion, or just over six dollars a person, would we choose to slice what they chose to slice, or would we make health services a bigger priority?

The continuing resolution proposed to cut $1.3 billion from community health centers.  These centers are located in every state.  They provide comprehensive primary care to everyone, regardless of their ability to pay.  They employ doctors, dentists, nurses, counselors, and other health professionals. 

They treat a lot of elders, people with disabilities, and lower income working families because they accept Medicare and Medicaid in addition to private insurance.  They provide high quality services, and meet a significant consumer demand.  According to the National Association of Community Health Centers (NACHC), they served 20 million Americans in all income ranges last year. 

NACHC responded that the proposed cut would cost 3.3 million Americans their care during the next few months, worsening the health care crisis in our country and driving up costs for everyone.

The continuing resolution also proposed a $500 million cut to mental health and substance abuse services, reducing the federal Substance Abuse and Mental Health Services Administration (SAMHSA) budget from $3.7 billion to $3.2 billion.  This is a 10% reduction from actual FY2010 funding.  It affects hundreds of thousands of children and adults with serious behavioral health problems. 

Elected leaders are betting that reducing services won’t backfire and leave more people with behavioral health problems without any treatment.  However, in providing the justification for her budget request, SAMHSA Administrator Pamela Hyde noted that over 10 million Americans already have unmet mental health needs and mental illnesses cost our economy over $100 billion per year, making this at best a risky, pound-foolish bet. 

Essential health services weren’t spared by President Obama in his proposed 2012 budget either.   

The President proposed taking $133 million from prevention by eliminating funding for the Preventive Health and Health Services Block Grant and halving funding for the Healthy Environment program aimed at preventing asthma and other chronic conditions. 

Though asthma has become one of the most common chronic conditions in our country, the President’s budget seems to be throwing in the towel on asthma prevention.  In justifying the cut in his proposed budget, his budget office writes “there are currently limited proven means of asthma prevention. In asthma care, the key intervention is to increase use of inhaled corticosteroids...” This is an uncharacteristic and remarkably one-sided rationale for emphasizing treatment at the expense of – instead of in concert with – prevention.

Each state decides how to allocate the prevention dollars it receives through the Preventive Health Block Grant, choosing 265 programs of local importance to support. 

In Florida, for example, the block grant has been used for chronic disease prevention programs, water fluoridation activities, and services for victims of sexual violence.  In Connecticut, it has funded childhood lead poisoning prevention, youth violence prevention programs, older adult fall-related injury prevention, and cardiovascular disease prevention.  In Texas, it has been used for sanitation services in rural border counties, support for a trauma registry, and support for local public health services.

While the President argues that there are other prevention services available, the long-standing problem in this country is not that we fund too many prevention services, but too few.    

Funding for this block grant is already $50 million less than it was in 1994, and it should come as no surprise that our health status as a nation has declined across a number of indicators since that time. 

What if we said no to cuts to these community health centers, behavioral health services, and prevention programs?  The $2 billion this would cost would add up to approximately $6.19 per person for the year.  Spending this $6.19 would result in the retention of hundreds of prevention programs across the country, up to 11 million physician visits, and services to over 200,000 adults and children with behavioral health problems. 

Have our nation’s resources really become so scarce that we can’t afford $6.19 a person to buy all this?

Maybe so, but I suspect the real answer lies in our priorities.  They spend this much every week on the war in Afghanistan, and both the President and Congressional leaders have made Afghanistan their continuing priority.  It’s past time for some new ones.

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.

How Did We Let This Happen to Our Children?

The late comedian Jack Benny made himself the butt of a running gag about how cheap he was.  A crook would come up to him and demand “your money or your life!”  After a long pause, Benny would deadpan to the increasingly impatient crook, “I’m thinking about it.”

It’s funny to think about someone who would hold onto his own money so tightly that he would put his own life at risk.  It’s not funny to think about people who would do the same and put their children’s lives at risk.

At the beginning of the 21^st century, we could feel good about the progress we were making to improve the health of our children.  While child poverty rates were doggedly high, other key indicators, including infant mortality rates, low birthweight rates, immunization rates, and violence rates, were all improving.  We had reason to believe that even the “compassionate, conservative” approach to policymaking would continue to get results.

It didn’t happen.  Some data from the Annie E. Casey Foundation’s KidsCount program tracking children from birth to adulthood show just how poorly we've been doing these last few years:

• After dropping from 38,351 in 1990 to 28,035 in 2000, the number of infant deaths increased to 29,138 in 2007;
• The number of low birthweight babies increased from 289,418 in 1990 to 354,333 in 2007, and the percentage increased from 7% to 8.2% of all births during the same time period;
• 75.7% of children age 2 are properly immunized, up from 72.5% in 2003 but down from 77.4% in 2005; 
• 52% of children age 6-17 do not engage in exercise at least five days a week, and 32% of 10-17 year olds are overweight;
• 14,140,000 children in 2007 had special health care needs, up from 9,360,356 in 2001;
• There were 10,198 teen deaths from accident, homicide, and suicide in 2007, age 15-19, a number that has remained steady over the decade.

When some political leaders hold up a mirror to these facts, they see them backwards.  They see decline and call it exceptionalism; they see investment in our children and call it waste.

In the early part of the past decade, we cut our taxes and got involved in two wars.  We paid less attention to the health of our children than we should have.  We put too little money into their well-being, and the trend line is still going in the wrong direction.  

Where children are concerned, American exceptionalism has become American “except-ionalism.”  We’re taking care of everyone “except” our children.

Governors have asked the federal government to let them cut children’s health programs this year, when they should be expanding them.  Twenty-six of them even went to court over the Medicaid expansion mandate, arguing that they were being “coerced” into providing needed services for families and children (see below).

There was a time when we invested in programs for our children because we understood that letting any children go hungry, be homeless, or become sick and not be able to get care was unacceptable in the greatest nation in the world.

We created mandatory immunization programs to protect them from deadly diseases.  I've still got the polio immunization card my mother was given by the public health department when I received my vaccine.  No one argued that we didn't have the resources to pay for this.

We didn't always need a crisis to take care of our children.  We built playgrounds and sports fields to give them plenty of opportunities to exercise.  We protected them from weapons and violence to keep them safe.  We invented Medicaid and Children’s Health Insurance Programs in part to make sure they had health care when they needed it. 

Today, we have elected officials saying we can’t afford all these things.  It’s not really because the money’s not there.  It is.  It’s because they think we’re too cheap to part with it.  They have us playing Jack Benny's old role, except no one's laughing.    

The decline in the health status of our children is where the political fantasy that we can cut and do no harm is introduced to reality.  Children get sick, and some even die, when we stop investing in their health.

Some brave political leader needs to step up and ask: What's more important, your money or your children's lives?  Will we really need to think about it for long?

A note about the Florida court ruling on health reform:  A short version of what the judge decided on Monday was that the individual mandate is unconstitutional, but that the Medicaid expansions are not.

The Supreme Court will have the final word on the individual mandate, probably in 2012 or 2013, but before it takes effect in 2014.  The judge's ruling in that area will have no effect for now.  States that don't want to implement the provisions that are already part of the law probably will not be let off the hook.

Though it wasn’t part of the headline, the judge also found that states are not being “coerced” into participating in the Medicaid program and providing the expanded coverage mandated under the law.  This finding means that the 26 states battling against the law have been defeated on one of the two main fronts on which they joined the battle. 

The Medicaid expansions will cover over 15 million Americans by 2016, and will be paid for almost entirely by the federal government.  How the states respond will be a test of their support for children, elders, and low income families.