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

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

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

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

The odds of recovery are long.

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

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

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

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

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

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

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

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

That finally may be about to change. 

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

And this will make a huge difference.  

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

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

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

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

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

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

States Refusing to Set Up Health Exchanges are Helping Their Children - But Not in the Way They Think

The reasons that 25 states chose not to participate in creating a new health exchange aren’t exactly the ones they’ve been claiming – that Obamacare is too complicated, too anti-consumer, or too politically unpopular. 

The truth is that they have never done a very good job of protecting the health and well-being of their people – especially their children – and they were not ready to start now.

Now that all fifty states have decided whether or not they will at least participate in running their own health insurance exchanges as allowed by the Affordable Care Act (you can see the updated information about what each state decided on my state rankings page), a clear picture is emerging of what distinguished the states choosing to participate from those refusing to do so.

On the whole, when compared to one another, the 25 states that have chosen to participate in running their exchanges (17 by themselves, 8 in partnership with the federal government)do a much better job of taking care of their people than do the 25 states that have deferred to the federal government.

So, just as we imagined a few months ago, residents in the states that refused are likely to be much better off with the federal government running their exchanges.

In many cases, the differences between the states choosing to participate and those refusing to participate are significant.

Let me illustrate why by showing you some updated numbers.  But first, let me explain briefly how I get to them. 

If you rank the states from best to worst, and assign the ranking of 1 to the best and the 50 to the worst, then two “averages” result.  The average ranking of all the states will be 25.5.  And if you divide the states into two equal groups of 25, with all the top-ranked states in one group and all the bottom-ranked states in the other, then the average ranking of the top group will be 13, and the average ranking bottom group will be 38. 

So keep in mind that 13 is the best possible average ranking for any group of 25 states to have, and 38 is the worst possible.

Now here are some average health-related rankings of the group of 25 states choosing to participate in establishing their own exchanges:

• Overall health (OHPM 2012 rankings):  21.5
• 2012 Kids Count ranking: 21.2
• Percentage of uninsured: 21.7
• Percentage with employer-based insurance: 22.4
• Ranking in spending on mental health: 24.7

And here are the average rankings of the group of 25 states refusing to participate in establishing their own exchanges:

• Overall health (2012 OHPM rankings): 29.5    
• 2012 Kids Count ranking: 29.8
• Percentage of uninsured: 29.3
• Percentage with employer-based insurance: 28.6
• Ranking in spending on mental health: 26.3

In every instance, states choosing to participate in setting up their own exchanges have a much better track record than states refusing to participate.   In only the mental health spending ranking is it even close. 

Those of us living in one of the 25 states refusing to participate ought to be thankful that our state policymakers punted on the exchange, because it is more likely than not that we’ll be much healthier and better insured in the long run. 

Especially our children.  States choosing to participate rank an average of almost ten places better than the states refusing to participate.  Children may have literally won the health lottery when those states decided that the federal government could do a much better job of assuring access to health care in the future.

The differences among the states are not just political ones, either. 

Solid Republican states like Utah, Idaho, and Kentucky are all creating their own exchanges, and states like Arkansas, West Virginia, and South Dakota are partnering with the feds.  Meanwhile, Maine, Wisconsin, Ohio, and Pennsylvania are all letting the federal government create their exchanges.

And the decisions have turned the traditional north/south, “state’s rights” argument on its head.  States’ rights states, like Texas and Florida, are refusing to participate, while states like Connecticut, Massachusetts, and New York are choosing to do so.

States refusing to participate may have tried explaining their decision by claiming that the federal government created a program that was too complex, too controversial, or too anti-consumer.  But those clearly aren’t the reasons. 

No, the real reason is that they know that the federal government has already proven itself over time to be better equipped to protect our health than they are.

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

Failure to Expand Medicaid: Just Another Death Penalty?

For many, the fight over whether or not to expand Medicaid is just about the money.  But they overlook the fact that the lives of more than 36,000 people may hang in the balance. 

That’s the conclusion that can be drawn from a study published last summer in the New England Journal of Medicine.  The study was entitled Mortality and Access to Care Among Adults After State Medicaid Expansions.  In it, the authors calculated the numbers of lives saved as a result of an earlier Medicaid expansion in three states.

The three states were Arizona, New York, and Maine.  And while none of these expansion populations matched exactly the expansion population in the Affordable Care Act, they were similar enough to suggest that we might see the same results in the ACA Medicaid expansion population.

The authors concluded that Medicaid expansions could save 19.6 lives for every 100,000 people between the ages of 20 and 64. 

There are over 185 million Americans between the ages of 20 and 64.  That comes to 36,301 lives saved.

These lives are more important than the money. 

These people have families and friends who care about them.  And while some would like to think they should be able to make it on their own, the truth is that they need our help.

Most elected officials seem to get this.  I don’t see why it should even be newsworthy that six Republican governors have now said they support the expansion.   They understand reality.

For example, Governor Jan Brewer of Arizona favors the ACA expansion.  Expansion will save her state money, and it could also save an estimated 723 lives.  For a pro-life governor, what’s not to like about that?

Arizona was the last state to embrace the original Medicaid program.  Perhaps the people of Arizona learned from that experience something that the rest of us take for granted – Medicaid makes a big difference in the lives of people in the state as a whole.

In the four most populous states alone, the numbers of lives hanging in the balance is in the thousands. 

California and New York are already moving forward with the expansion.  That’s good news for an estimated 6700 people, 4421 in California and 2325 in New York.  One of those California lives saved could be my son’s.

But in Texas and Florida, two states at the epicenter of the anti-expansion universe, over 5000 lives still hang in the balance – 2925 in Texas and 2162 in Florida.  The decisions of those state legislatures will have a profound effect on the lives of many other fathers’ and mothers’ sons and daughters.

But expansion means lives saved in every state.  North Carolina can save 1126, Connecticut 422, and Utah 304. 

The table I’ve created with the calculations for all the states is here.

Every study has its limitations, and this one is no exception. 

However, the authors openly acknowledged the limitations of their study when they published it.  They noted that other analyses of the data led to similar results.  By one alternate analysis, they found that for every 176 new adults covered by Medicaid, one death was prevented.

That doesn’t seem like many at first.  However, the ACA Medicaid expansion, if fully implemented by every state, will cover an estimated 15.1 million new adults.  By that measure the expansion would save even more lives – a total of 85,568 nationwide.

What about the money?

In March of last year, the Congressional Budget Office calculated the cost of a full Medicaid and SCHIP expansion to be roughly $103 billion per year.  (More recent CBO Medicaid cost estimates are lower because CBO assumes not all states will expand.)  That comes to $2.8 million per life saved. 

The state share of that cost would be about $198,000.

I’m sure that some might argue that we can’t afford $2.8 million per life – unless of course, the life is their own or their child’s.

But more objective researchers with no political agenda to promote have actually taken the time to calculate the economic value of a life.  It comes to $7 million or more, making the paltry $198,000 one of the best investments a state could make.

So the questions become first, how much are our lives worth to our states?  And second, is the failure to expand Medicaid just another death penalty – one that targets the sick and innocent?

To reach 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/

Is the NFL Dying?

Here is one of the more intriguing headlines of Super Bowl week:  “Is the National Football League dying”?

Probably not, but too many of its former players are dying young, and for reasons that may be preventable.  Many people are concerned about growing evidence of brain injury from the violence of the game. But that’s just part of the story.

Linemen are too heavy. Their excessive weight is a danger to running backs now and to their own health after they hang up the cleats.

Baltimore Ravens safety Bernard Pollard raised the issue when he was quoted as predicting the demise of pro football, in part because of its violence, but mostly because of the way the rule makers are responding to that violence.  “I hope I’m wrong,” he added, “but I just believe one day there’s going to be a death that takes place on the field because of the direction we’re going.” 

President Obama weighed in on football safety, too, but in a less dire way.  “I think that those of us who love the sport, he said in an interview with the New Republic, “are going to have to wrestle with the fact that it will probably change gradually to try to reduce some of the violence.”

Both Pollard and the President were alluding to head trauma – a growing concern for athletes and others exposed to repeated brain injury.

Last month, the New York Times summarized a number of studies related to football and brain injury.  One concluded that 60% of NFL players had a least one concussion during their football playing years, and 26% had 3 or more.  

Another was published in the Journal Brain in December 2012.  Researchers examined the brains of eighty-five deceased individuals who were subjected to repeated minor head trauma during their lives.  They looked for evidence of brain damage called chronic traumatic encephalopathy, or CTE. 

They found that 80 percent of the brains (or 68 of the 85) showed evidence of CTE. 

Thirty-five were from former professional football players, all but one who played in the NFL.  Thirty-four of those showed signs of CTE.  The brains from those who were hit most during the game – linemen and running backs – were most likely to have it.

CTE is clearly a significant health problem for NFL veterans, but it isn’t the only one. 

We learned recently that the brain of former player Junior Seau showed evidence of CTE at the time he took his life in the spring of 2012. 

His death stood out in part because he was the 8^thplayer from the 1994 San Diego Chargers Super Bowl team to die young.  I wrote about this in a column last year.

But among the Chargers who died young, Chris Mims was reported to have weighed 468 pounds (170 pounds over his playing weight) when he died at the age of 38 of heart disease.  Lew Bush, who played at 245 pounds, died of a heart attack when he was 42.  Shaun Lee was reported to be over his 300 pound playing weight and have diabetes when he died at age 44.

So it is not just the hard hits.  Weight-related chronic disease is also a significant health problem for many football players.

And this year’s Super Bowl teams are heavier than ever, putting them at greater risk than ever.

The linemen on Pollard’s Ravens team weigh in at an average of 308 pounds.  Without the tight ends, their average weight is 318.

The San Francisco 49ers linemen average 296 pounds.  Without the tight ends, their average weight grows to 311.

To put this in some context, the 1994 Chargers linemen were thin by comparison, weighing in at 289 pounds.  And the linemen (absent tight ends) from last year’s Super Bowl teams averaged 306 pounds – 12 pounds less than the Ravens this year.

But the CTE and obesity-related disease we see today occurs among players who played at the time of the 1994 Chargers, not the 2012 Ravens and 49ers.

The eleven running backs on the Ravens and 49ers weigh an average of 222 pounds.  And that’s only because 260 pound Ravens fullback Vonta Leach is one of them. 

Without Leach, they average 217 pounds – almost 100 pounds lighter than the linemen who block for, and tackle, them.

So, among rules and equipment changes, why doesn’t the NFL also introduce an upper weight limit for players in the game?

Then maybe we wouldn’t have to read so many obituaries of great athletes who die young. 

Go Ravens!  

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

Will Obama's Bold Vision End the Myth of Entitlement Reform?

As President Obama begins his second term, he does so with an expansive vision for America.

“America's possibilities are limitless,” he said in his inaugural address, “for we possess all the qualities that this world without boundaries demands:  youth and drive; diversity and openness; an endless capacity for risk and a gift for reinvention.   My fellow Americans, we are made for this moment, and we will seize it - so long as we seize it together.”

There are many potential roadblocks toward achieving that bold vision.  One is the myth that entitlement reform must be a part of it.

The reason that entitlement reform is at the top of some political agendas has nothing to do with the growth in entitlement programs today.

Some people with these agendas don’t like any government-run programs and won’t listen to the facts about them. 

Those who do look at the facts see the rapid growth in Medicare and Medicaid spending through 2009.  According to the Center for Medicare and Medicaid services, Medicare spending increased by an average of 10.9 percent per year between 1967 and 2009, and Medicaid spending by an average of 10.7 percent per year between 1975 and 2008.

They believe that this rate of growth is not sustainable.  But since the beginning of President Obama’s first term, we haven’t sustained a growth rate even close to this.

A report from last September and two more reports released in the last couple of weeks – one from the Department of Health and Human Services (HHS) and another from the Bureau of Labor Statistics (BLS) – show just how far the myth is from today’s reality.

The new HHS report found that per capita Medicare spending increased by just four-tenths of one percent in 2012, following increases of only 3.6 percent in 2011 and 1.8 percent in 2010.

And according to some new BLS data, the overall medical inflation rate last year – which should tell us something about Medicare and Medicaid growth in the coming year – was 3.2 percent. 

There is a much more immediate health spending problem about which policymakers should be worried – one that entitlement reform could make worse. 

High health costs may burden state and local governments.  But they burden people who rely on Medicare and Medicaid far more.

In an article entitled the High Cost of Out-of-Pocket Expenses published in September by the New York Times, Judith Graham summarized from a third recent study.  The study found that during the last five years of life:

• People on Medicare spend $38,688 on medical costs.
• People with Alzheimer’s spend $66,155. 
• The top quarter of spenders spend a whopping $101,791.

Some policymakers love talking about the unfairness of the “death tax.”  How about the unfairness of this hidden “pre-death tax” that gets bigger every time elected leaders cut entitlement spending? 

Entitlements are not the problem.  The cost of health care is.  Entitlements are – and always have been – the solution to the problem of a middle class forced into poverty by high health care costs near the end of life. 

And while entitlement reform may reduce government expenditures, it will only do so at the expense of those who need Medicare and Medicaid the most.

President Obama said it well in his address. 

“We must make the hard choices to reduce the cost of health care and the size of our deficit.  But we reject the belief that America must choose between caring for the generation that built this country and investing in the generation that will build its future.  For we remember the lessons of our past, when twilight years were spent in poverty, and parents of a child with a disability had nowhere to turn.  We do not believe that in this country, freedom is reserved for the lucky, or happiness for the few.  We recognize that no matter how responsibly we live our lives, any one of us, at any time, may face a job loss, or a sudden illness, or a home swept away in a terrible storm. The commitments we make to each other - through Medicare, and Medicaid, and Social Security - these things do not sap our initiative; they strengthen us.  They do not make us a nation of takers; they free us to take the risks that make this country great.”

Contact Paul Gionfriddo at gionfriddopaul@gmail.com. Twitter: @pgionfriddo.  LinkedIn: www.linkedin/in/paulgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.

The Shock of Sudden Violence

The shock of sudden violence is so severe it takes your breath away.

When it happens in a time and place where it is unexpected, it does more than just remind us that no one is immune to it.  It also reminds us how pervasive it is, how much it affects us all, and how important it is that we do something about it. 

In the summer of 1989, I imagined that sudden, random violence was something far removed from my hometown.  But I was about to learn differently.

An article in The Atlantichas just detailed the event, dredging up some quarter century old memories of a day that changed my community’s life.

I was running for Mayor of Middletown, Connecticut, at the time, and had reserved a booth at the city’s annual Sidewalk Sale in late July.  I was handing out yardsticks, asking for a vote “for government that measures up to your expectations.”

Suddenly, there was a commotion about a block north of where I was standing.  I noticed people running in two directions, both toward and away from the Woolworth’s store in the center of downtown. 

A young girl, randomly chosen, had been grabbed outside the store and then repeatedly stabbed by a 38 year old man.  She died on the spot.  Hundreds of people witnessed the event.

Over the next weeks and months, Middletown was in shock, just as other communities – Newtown, Aurora, Tucson, Blacksburg VA, Littleton CO, and others – have been shocked since.

The trauma in Middletown almost killed our downtown.  Its suddenness and randomness made everyone feel unsafe.  It killed much of our sense of community and personal safety.

The healing didn’t happen very quickly.

It took at least a decade or two of steady changes to the Main Street area for that to happen.  These changes were so significant that – with the exception of a few businesses, nonprofits, and restaurants that remain from that time – one would barely recognize the Middletown of twenty-five years ago in its vibrant downtown today.

The trauma to which Sandy Hook and other communities have been exposed is even greater. 

To appreciate fully the scale of the Sandy Hook tragedy, we must realize that because of it Newtown’s 27611 residents – who experienced zero murders in 2011 – may well have experienced the highest homicide rate in the nation in 2012.

The healing time will be long.  And, at some level, my limited personal experience in Middletown suggests that a community exposed to that level of violence may never fully recover.

And this suggests something even more frightening about the shock of violence in communities across the nation.

There were 14,612 murders in the United States in 2011.  That’s 4.7 homicides for every 100,000 people.

In Middletown, Newtown, and Blacksburg, the homicide rate was zero.  In Aurora, it was 3.  In Littleton, it was 5.  Even in Tucson, which lived through the shopping center massacre that year, it was under 10.

Murders are uncommon in these communities, contributing to their newsworthiness.

But elsewhere, the everyday shock and trauma of violence is so much more powerful.  And because it is so prevalent, media headlines cannot capture fully its true effect. 

The murder rate per thousand in Miami in 2011 was 17, in Philadelphia 21, in Jackson 30, in St. Louis 35, in Detroit 48, and New Orleans 58.

Here is another way to look at this.  The Aurora massacre this past summer will double Aurora’s homicide rate in 2012, by a factor of 3.6 per hundred thousand residents. 

The people of St. Louis collectively live through the trauma of an Aurora-level massacre an average of once every six weeks, the people of Detroit live through it every month, and the people of New Orleans live through it every three weeks.  No one gets used to this.

If this is hard to absorb, imagine what these war zones must be like for the children and families living in them.  Every year, 3.5% of adults have diagnosable PTSD, and almost 8% will have it at some point in their lives.  Half will have PTSD before they reach the age of 18.

What are we doing about the traumatic effect of all of this violence in all of our neighborhoods – including those where it is commonplace?  And, more importantly, what are we doing to prevent such violence in the first place?

Email Paul Gionfriddo at gionfriddopaul@gmail.com.  Follow Paul Gionfriddo on Twitter: @pgionfriddo.

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.

In the Fiscal Cliff Deal, A New Push for Long Term Care in 2013

When the House of Representatives voted by a comfortable margin a few hours ago to approve the American Taxpayer Relief Act (ATRA) and step away from the "fiscal cliff" for another two months, it agreed to two Senate provisions affecting elders and others with long term care needs.

The first was the "doc fix," which prevented a nearly 30% cut in Medicare payments to physicians.  This was important.  If it hadn't happened, doctors would have fled the Medicare program.

The second was tucked away into Section 643 of the Act.  It establishes a new 15-member Commission on Long Term Care, replacing the CLASS Act provisions of the Affordable Care Act that are now finally, formally repealed by ATRA.

The Commission could turn out to be a very big deal if it does it job well, because it could lead the way in changing our system of providing and financing long-term care in America.

The Commission is charged with writing a bill over the next six months "to establish a plan for the establishment, implementation, and financing of a comprehensive, coordinated, and high-quality" long term care system for elders, people with cognitive impairments, people needing help performing activities of daily living, and all "individuals desiring to plan for future long term care needs."

The Commission will focus on three things:

• the interaction and coordination of new services with Medicare, Medicaid, and private long term care insurance;
• improvements to Medicare, Medicaid, and private long term care insurance needed to ensure availability of long term supports and services; and
• long term care service workforce needs.

If the Commission completes its work on time, it could mean the introduction of new long term care legislation as early as the fall of 2013.

What could this legislation mean for us?

It could be the first step on our nation's long and necessary path to bring long term care costs under control, and make long term care services available to individuals without first impoverishing and exhausting them or their families.

It could also help states bring Medicaid costs under control, and the federal government better manage Medicare costs, too.  Long term care costs are the real culprits in rising Medicaid costs for state budgets and state taxpayers.

Let's keep our eyes open, and hope for two things.  First, that this new Commission does a better job fixing our nation's long term care problem than our broken Congress has done with the Fiscal Cliff.  And second, that if it does bring some recommendations forward, Congress listens.

This column is an Our Health Policy Matters extra.  Read on below for this week's regular column.  Follow Paul Gionfriddo on Twitter @pgionfriddo.  

Three Magical Numbers for 2013

Will health and mental health spending be part of the next Grand Bargain, Mini-bargain, or No Bargain at all?2013 could be the ultimate transition year for health policy – a wait-and-see time before the big changes ACA brings in 2014.  Or it could be much more.

Forget this week's latest budget drama.  Three often little-noticed numbers over the next few months will tell us much more about how this health policy year will eventually unfold.

The first is the Medicare “cost rate” projection for the next 75 years.  It will arrive in April in the Annual Report of the Medicare Trust Fund trustees.  This projection will tell us how much we need to worry about the present and future cost of our favorite entitlement program.

The second – especially in the aftermath of Sandy Hook – is the number of cuts or additions states make to their mental health budgets.  We’ll know this by the late spring or early summer.  It will tell us just how much our legislators have been moved by recent news to improve mental health services around the country.

The third will come in July.  It is the health care inflation rate for the past year, which is typically published in July in Health Affairs.  This will tell us all we need to know about the cost of health care in general, and the Affordable Care Act in particular.

The overall health care inflation rate matters to everything and everyone. 

In both of the past two years, the health care inflation rate was below 4% - the first time this has happened in a generation. 

This went largely unnoticed, because insurance costs are just beginning to catch up. 

But in a $2.7 trillion health economy, every 1% reduction in inflation is worth about $27 billion. And with health inflation currently projected at 5.7% annually over the next decade, more low numbers could eventually mean a difference of about $50 billion in health care spending per year. 

Over ten years, that’s around $500 billion of avoided spending – half of the total cost of the Affordable Care Act.

The Medicare “cost rate” projection could have just as big an effect on the way we address the long-term cost of Medicare. 

The Medicare Trust Fund trustees quantified the Medicare crisis this way on page 32 of their 2012 report.  They wrote that the average “income rate” for Medicare would be 3.86% over the next 75 years, and the average “cost rate” would be 5.12%.  That leaves an average deficit of 1.35% annually – the amount by which we would have to raise Medicare taxes or reduce Medicare services to keep the program solvent.

But there are two factors that influence the cost rate – the increasing Medicare population and the increased cost of health care services.  We already have a pretty good idea about the projected Medicare population over the next 75 years.  What is less certain is how much health care will cost.

That’s where health care inflation comes in again.  If it goes down, then so will the projected Medicare cost rate.

Then the life of the trust fund will be extended beyond 2024, Medicare’s projected share of GDP will go down, and the feeling of crisis around the Medicare program may dissipate in the coming year.

Mental health spending levels will tell us even more than lagging public health expenditures about how serious we are about prevention.

This is because states have been cutting both public health and mental health budgets for the last few years.  States will have to revisit both of these decisions in the wake of Sandy Hook.  Public health cuts are predictors of crises to come.  But mental health cuts are predictors of crises of the day.

Mental health cuts have so squeezed providers that they can no longer meet the service needs of our population.  Court systems and prisons are absorbing the pressure, increasing costs to states.  And when state mental health cuts are aimed at children’s services, we all eventually pay the price. 

There will be plenty of opportunities for states to improve mental health services.  Periodic mental health screening for children and adults, improving special education services, and re-directing adult mental health spending from jails to community mental health centers are just a few examples. 

Even before Sandy Hook put a spotlight on the lack of mental health services, the tens of thousands veterans returning from the Middle East were becoming a growing constituency for increased mental health funding.

We often say that there can be no disagreement about supporting our troops or our children.  And - despite the recent compelling evidence that our elected officials are incapable of rational, timely compromise - we’ll have our chance to prove it yet again this year.

Let us hope we don’t come up short.

Questions?  Email gionfriddopaul@gmail.com.  Follow Paul Gionfriddo on Twitter @pgionfriddo.