Obamacare Has Been Compromised Enough

I have never been the biggest fan of the Affordable Care Act. 

I believe that since the government is already paying over 70% of our nation’s health care bill and we’re paying another 12% out of pocket, this colossal effort to preserve the small share financed by privately-funded private insurance without bankrupting the nation may not have been worth the effort.  Medicare-for-all would have been a much better approach.

But now that an emerging group of at-risk Democratic senators have joined the Republican chorus to delay the individual mandate, I want to offer an opposing view to theirs. 

Obamacare has been compromised enough.

Since it was enacted in 2010, Obamacare has undergone the following significant changes:

• The minimum medical loss ratio requirements were delayed in several states.
• The long-term care insurance program has been repealed.
• The prevention fund has been raided.
• The reductions in payments to providers have been put off.
• The mandatory Medicaid expansion has been made optional.
• The employer mandate has been delayed.

These have all occurred before the program was fully implemented.  And this has had more to do with public pressure than public policy.

Now there are at least three more changes gathering steam – a delay in the individual mandate (favored by conservatives), a delay in the reinsurance pool tax (favored by liberals), and a delay in the 2.3% excise tax on medical equipment (favored by both).

The irony is that members of Congress think these changes will make them more popular with their constituents.  But that isn’t going to happen.  The popularity of Congress is at an all-time low.  Obamacare is at least four to five times more popular than Congress.

So enough already.  How about trying leadership for a change?

Democrats reversing course on the Affordable Care Act’s individual mandate is only today’s news.  Even though they now count on short memories, the Republicans and their conservative allies, who for the most part laid the philosophical foundation of the Affordable Care Act, including its individual mandate in the first place, also used to favor the individual mandate.  They reversed their position on it around the time President Obama embraced it.

So here is the question.  Are any of these people capable of staking out a position on this law as a matter of policy and then actually sticking by it – at least until the law is implemented?

When John Kerry said in the 2004 Presidential campaign that he voted for an appropriation for the Iraq War before he voted against it, it became a national joke and added “flip-flopping” to the political lexicon. 

A decade later, flip-flopping on the Affordable Care Act seems to have replaced leadership as a requirement of public office.

And here’s why a little leadership today could go a long way: because most of what is being argued about doesn’t really affect anyone anyway.

All the news this month about both the non-working federal exchange and the individual mandate affects about seven million people this year.  They are all either uninsured or have really lousy employer-based insurance.  That’s a little over 2 percent of the population.

For the rest of us who are not yet eligible for Medicare, the Obamacare consumer protections are what matter – no lifetime caps on benefits, no denial of coverage based on pre-existing conditions, no cancelling of coverage when people get sick, and mandated minimum medical loss ratios.  And these have all been in place, for the most part, for the last couple of years.

And for Medicare beneficiaries, the closing of the donut hole and the new prevention benefits are pretty much all they need to be concerned about, and they, too, have been in place for a couple of years.

No one objects to these.  And so far as I can tell no one is begging the members of Congress to change them.

So why don’t we just wait and see how the other 2 percent make out?  They have until March 31^stto sign up for insurance through the exchange.   And if in February they cannot because of technical problems, there will still be plenty of time to help them out by delaying the March 31^st “individual mandate” deadline.

In the meantime, let’s stop pretending that members of Congress have our interests in mind when they advocate delaying the individual mandate.  Or that they’re showing any leadership at all.

Because pandering and leadership are not the same thing.

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

President Kennedy's Unrealized Promise

Exactly a half century ago, in October, 1963, President John F. Kennedy signed the Community Mental Health Centers Act into law.  It affected two very different classes of people - people with mental illness and people with developmental disabilities.

In many ways, it was a civil rights act, promising to replace large, segregated institutions with integrated, community-based services.

It made a huge difference for people with developmental disabilities. 

But for people with mental illnesses, its promise is unfulfilled and the dream sometimes feels like it is dying.

When President Kennedy signed the Mental Retardation Facilities and Community Mental Health Centers Construction Acton October 31st, he did so with optimism. The law specified that the new community mental health centers would offer four services – prevention, diagnosis, treatment, and rehabilitation or recovery – to people with mental illness.  And the result would be that all people, no matter what their disability, would live freely and comfortably in their home communities.

Had he lived to today – into his late 90s – President Kennedy would be appalled at what became of this vision.

He would have witnessed in 1981 the replacement of direct federal funding for community mental health services with an inadequately-funded mental health block grant to the states.  And he would have seen the result.  Chronic homelessness grew, and jails and prisons became the new warehouses for adults with mental illness.  Here is a statistic that would have stunned President Kennedy – women in prison today are twice as likely to have serious mental illnesses as are men.

President Kennedy would also be dismayed that his vision for community-based special education for children with emotional disturbances became so clouded, and with such tragic consequences.  The Act provided for demonstration grants to improve special education services.  He never could have imagined that fifty years later, only 389,000 children would be receiving special education services because of emotional disturbances.  And if one in five school-aged childrenactually has a mental disorder, then this means that we are identifying only one in every 28 for special education services.

And, notwithstanding the promise of the Affordable Care Act, President Kennedy would also be far from satisfied with some recent federal foot-dragging.  In 2008, the Mental Health Parity and Addiction Equity Act passed with the help of his brother and nephew.  It guaranteed equitable insurance coverage for mental health and health conditions.  But it has taken five years for a final rule to implement that law (a rule now promised within days or weeks).  And at the same time funding for SAMHSA – through which federal block grant dollars flow – has declined.

He would have seen states do no better.

I was in the Connecticut State Legislature when we received our first block grants in the early 1980s.  There was zero interest in using state funds to continue building the community mental health center program. 

That was long ago.  So let’s look at today. 

In the five years between 2008 and 2013, states cut $4.6 billion from mental health services, often citing an unwillingness to burden state taxpayers with these services. 

But even when states were offered a free ride, many still refused to authorize additional spending on mental health services.  This year, twenty-two states refused to expand their Medicaid programs, even though the federal government agreed to pay 100 percent of the cost for three years and told states that they could contract the programs again as the federal share went down.  No surprise – many of the 5 million left behind will be people with mental illnesses.

If we wanted to realize the vision of President Kennedy, it would not be hard.

We could offer all children mental health screening as part of well-child exams, and admit more children with mental illnesses to special education services.

We could provide insurance coverage to more people with mental illness, and appropriate more funding to community mental health services. 

And we could opt not to send adults with mental illness to prison, at least until we have guaranteed them access to care and worked with them to develop a meaningful recovery plan that might help them avoid hospitalizations, homelessness, and imprisonment in the future.

If we did these five things, we could give vigor to the dream and honor the promise President Kennedy made when he signed the Community Mental Health Centers Act into law:

“It was said in an earlier age that the mind of a man is a far country which can neither be approached nor explored.  But today… it will be possible for a nation as rich in human and material resources as ours to make the remote regions of the mind accessible.  [People with mental illness]… need no longer be alien to our affections nor beyond the help of our communities.”   

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

Myth and Miriam Carey

This is Mental Illness Awareness Week. But the sad tragedy of Miriam Carey is another reminder of how deeply unaware we are about mental illness in general and its relationship to violent behavior in particular.

And how much we rely on myths to fill in the gaps in our knowledge.

We all heard the news about Ms. Carey last week.  But we were not exactly informed by it. 

Ms. Carey drove her car onto a White House driveway, hit some temporary fencing, backed up, and then pulled away. She was pursued toward the Capitol by law enforcement officers in what became a high-speed chase.  Ms. Carey was eventually cornered near Garfield Circle.  Six officers, with guns pulled, approached her car there.  She apparently panicked, scattering the officers as she drove away.  At least nine shots were fired at her as the chase began again.  She eventually got stuck on a median near a Capitol guard station, where she was shot to death by an officer.

As I watched the unfolding news that afternoon, the story was embellished, to say the least.  There were reports of a possible terrorist attack on the White House and the breaching of a White House barrier.  And gunfire had been “exchanged” in an apparent attack on the grounds of the U.S. Capitol, as Senators cowered in their offices.

But then the real story began to emerge.

Ms. Carey hadn’t breached a White House barrier; she had hit a fence or a gate.  No gunfire was exchanged, because Ms. Carey was unarmed.  And Ms. Carey wasn’t attacking the Capitol; she had fled in her car in that direction.

So the narrative changed.  Now Ms. Carey – suffering from mental illness – had “rammed” a barrier at the White House.  She was “obsessed” with President Obama.  She used her car as a 1300 pound “weapon” to mow down law enforcement personnel as she continued on her “rampage.”

And she “chose” to ignore officers who tried to subdue and pursue her.

Words themselves are powerful weapons.  And these new words helped paint the mythical picture of the seriously mentally ill person who stalks, snaps, and kills without warning. 

But this narrative proved to be wrong, too.

We later learned that Ms. Carey apparently drove all the way from Connecticut to Washington with her one year old baby in the car.  So she didn’t “snap.”  And there was no evidence in her home that she had been plotting against the President with whom she was “obsessed.”  And she wasn’t on a “rampage.” Not only was she unarmed, but she apparently managed to avoid pedestrians and other motor vehicles as she raced down Pennsylvania Avenue at speeds up to 80 miles per hour.

But because she is dead the pieces missing from her story – like what she was actually thinking at the time – will probably remain missing. 

And the myth-makers will have another field day at the expense of people with mental illnesses.  Because the facts about mental illnesses don’t fit the narrative.

These are the facts.

People do not acquire mental illnesses by choice.  They can’t turn them off like a faucet.  The people who knew her best said Miriam Carey was not out to harm anyone last week, and that her mental illness was being treated successfully.  But if she was suffering from a mental illness-induced panic in the final minutes of her life as she was chased and under fire, she would have been no more able to turn that off when the police yelled stop than to will herself to stop bleeding from her gunshot wound. 

All mental illnesses are not the same, but none is a very strong predictor of violence.  Postpartum depression – for which she had been treated – is not the same as schizophrenia or bipolar disorder.  But if you believe the myth that any of these conditions by themselves leads to violence, then take a look at the chart accompanying this column about the low lifetime prevalence of violence among people with serious mental illnesses, from an article published almost a decade ago in the New England Journal of Medicine.

And people with mental illness do not “snap” without warning.  There are often years of warnings that go unheeded by payers looking to save a dollar.  And by public officials who cut mental health budgets and deem mental health agencies and services as “non-essential.” And then cower in their offices at the first sign of trouble – the one part of the initial reporting that was, apparently, accurate.

Let’s deal with facts, not myths.  After all, this is Mental Illness Awareness Week.

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

Malice in Wonderland

As we gaze this week at the wonderland we call Congress, it might amaze us that Congress actually shut down the federal government over the implementation of the Affordable Care Act.

Rep. John Culberson of Texas grinned like a Cheshire Cat as he explained it this way in an outlandish interview on CNN, “we do not want the federal government socializing health care as they have in England and in France.”

This is socialized medicine?  Really?

He wasn’t content to leave it there, adding a new “sacred” right to the Constitution to explain further his position.

“The right to be left alone as Americans is probably our most important right.”

As the Mad Hatter would say, “Why, you might just as well say that ‘I see what I eat is the same as I eat what I see.’” 

But Representative Culberson was on a roll.  Literally.  This was two days after he was reported to have shouted “let’s roll!” as House Republicans concluded a caucus in which they re-affirmed their intent to shut down the government if Obamacare weren’t defunded. 

He explained that he was invoking the memory of the 9/11 heroes who brought down the airplane in Pennsylvania that was headed to Washington.  Was the irony lost on Representative Culberson?  That plane was in all probability heading toward the Capitol, and the heroes who brought it down may not only have kept our government open that day, they may have saved Representative Culberson’s life, and the lives of many of his colleagues.

Meanwhile, as Representative Culberson – a House member since 2000 – was giving his interview, some really bad things were happening to Americans hoping for an end to the economic quagmire he helped to create.

The Dow was shedding 129 points in anticipation of the shutdown.  In the last week, U.S. companies lost about $200 billion in value – more than the combined value of every company in Poland.

And we have had to suffer through all this because giving a $6000 tax credit to families earning $50,000 per year who purchase their own private health insurance is too “socialist” for Culberson.

I believe in our government.  I believe it is there to protect our actual rights (not ones Representative Culberson invents) and to work toward the common good.

And I am bothered because there is no charity in Representative Culberson’s view, only malice.

Toward the people who are helped most by Obamamcare – people with serious mental illnesses and other chronic conditions, lower-income workers, and uninsured people, for sure.

And toward the President on a disturbingly personal level, too – because this shutdown is not really about debt or deficit either.

Does anyone really think that if Ronald Reagan – not Barack Obama – were to be magically transported down a rabbit hole to the presidency today, then Representative Culberson would be saying the same things?

Five years into Reagan’s presidency, our national debt, which would triple during his term, was up over 100 percent – more than it has grown during Obama’s presidency.  Our federal deficit had grown from $74 billion to over $212 billion.

Medicaid was being transformed from a mostly long term care program for elders to a safety net health insurance program for families.  By 1988, eligibility was increased to 185% of poverty for pregnant women and children and even more for some through the Katie Beckett waiver.  These are far more generous than the 138% of poverty level Obamacare established for adults with chronic conditions.

Before he left office, piled on top of all that debt, Reagan even proposed the bare outlines of much of what became the Affordable Care Act.

He asked Congress to include catastrophic insurance, limiting out-of-pocket costs to $2,000, for every American covered by Medicare – along with a $60 a year increase in premium to pay for it.  He proposed a federal/state partnership to promote the formation of state-based risk pools to provide insurance for those who could not obtain it.  He called on states to mandate enhanced employer-based health insurance coverage.  And in his February 1987 radio address calling for all of these things, he said that the federal government should work with the private sector to promote public education about the choices and options available.

Representative Culberson was serving his first term in the Texas House of Representatives in 1987.  Do you imagine he – one of only two sponsors of legislation to put Ronald Reagan’s image on the $10 bill- favored a government shutdown to prevent Reagan’s “socialized health care?”

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

On the Brink of a Government Shutdown over Obamacare

It is hard to imagine a political strategy less likely to achieve its intended outcome while simultaneously harming the economy than shutting down the government to prevent the implementation of Obamacare.

But that probably won’t stop Senator Ted Cruz from trying.  And unless cooler Congressional heads prevail this week, while he will do no real harm to Obamacare, he may well do harm to the economy.

Obamacare is the law, shutdown or not.  And no matter what, on Tuesday you will still be able to go to any hospital in the country and get treated, your doctor’s office will still be open, and your insurance company will still expect you to pay your premium.

But when the government is shut down, the stock market suffers. 

And a few points on the downside in our stock market that are attributable to a single event may be more significant than you think.

Let’s go back to 1995.  The Newt Gingrich-led House shut down the government twice – on November 14, 1995 for a week and on December 16, 1995 for three weeks.

Until then, 1995 had been a boom year for the U.S. economy.  The S&P Index rose 34 percent for the year.  But on the day of the first shutdown, the S&P was down 3 points, or one-half of one percent.  And on the next trading day after the second shutdown, it crashed 9 points, or 1.5 percent.

What is a one-half of one percent drop in the markets worth today?   

We can do the math for Senator Cruz.

At the end of 2012, the total market value of every company listed on our U.S. stock markets was $18.6 trillion.  The markets are even higher now, so we can estimate that today all those companies combined are worth around $20 trillion.

So one half of one percent – or about 9 points on today’s S&P – would subtract around $100 billion from the value of those companies.  That is roughly equivalent to the annual cost of Obamacare!

So isn’t it ironic?  A shutdown won’t shut down Obamacare, but it could hit businesses harder in one day than Obamacare would in an entire year.  And that’s on the conservative side.

People like Senator Cruz don’t want to think about this, so they might look at it another way.

They will tell you that we spend around $3 trillion annually on health and healthcare in the United States.  That is about 15 percent of the market value of all of the companies that are publicly traded on our stock exchanges.  They will argue that this is way too high.

I agree. We can probably do it much less expensively if we put more resources into prevention and public health, like other countries do.

Of those $3 trillion, federal state, and local governments directly or indirectly pay about 71 percent of the bill.  We pay another 12 percent out of pocket.  The remainder is paid by privately funded private health insurance.

So can Senator Cruz assume that if we repeal Obamacare, we won’t have to pay that 71 percent?  The answer is no, because these are pre-Obamacare percentages.

And what effect will this government takeover of healthcare formerly known as Obamacare have on these percentages?

Thegovernment’s share might go up 2 or 3 percent, private insurers might pay 1 percent less, and our out-of-pocket share will go down a couple of percentage points.

It is hardly seems worth working up a Congressional lather over this.

But consider something to which all members of Congress ought to be paying attention. 

If our stock market were to go down just 1.5 percent because of a shutdown, as it did after the last shutdown, then $300 billion will be lost to publicly-traded American companies.  That is equal to the total market value of every publicly traded company in Belgium, Turkey, or Chile.  It is twice the market value of every publicly-traded company combined in Israel, and three times the market value of all the publicly-traded companies in Ireland, Austria, or Kuwait.

Remember the years-long effect that the collapse of the Greek economy has had on the European and world economy?  $300 billion is approximately four times the total value of every publicly-traded company in Greece before the meltdown.

That’s something to think about on the brink of a shutdown.

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

Hypocrisy In Motion

The latest Obamacare navigator “compromise” may calm one small battle in Florida.  But it won’t end the war on Obamacare being waged by hypocritical public officials around the country.

A couple of weeks ago, I wrote about the Congressional effort to undermine the Obamacare navigation program in its entirety.  A House Committee has ordered nonprofits winning navigation grants to produce reams of material, and promises to punish those that have failed to comply. 

Source: US Census Bureau

Navigators will assist people in applying for public or private insurance to pay for their health care.  

Navigators are not a new concept, created by Obamacare.  They are as old as Marco Rubio, and Obamacare is not the first federal initiative ever to fund them.  In fact, I implemented the policy of the Nixon Administration as a VISTA paralegal 35 years ago, navigating underinsured elders to the Medicaid program.

So we know that navigators can be trusted to do their jobs.

But that hasn’t stopped some public officials from sudden “worries” that navigators hired by nonprofit agencies will disclose private information that clients voluntarily give to them.

Three weeks ago, Governor Rick Scott of Florida – apparently trying to re-establish his credentials as the nation’s leading gubernatorial opponent of Obamacare after openly flirting with it during the 2013 legislative session – joined this chorus, wondering “how the federal government will prevent personal information from being stolen” by these nonprofits.

This was quite a contrast to enrollment efforts already well underway in states like Connecticut that actually want to help people get insured.

Then Governor Scott raised the stakes last week.  He ordered that no navigators be allowed in any state health department offices.  The reason this mattered is because in Florida, county health departments are actually arms of the state government, and their employees are state, not county, employees. 

So in banning the navigators from state offices, he was in effect banning outside navigators from enrolling people in county safety net clinics, federally-qualified community health centers, and a host of other facilities staffed by state employees.

He came under immediate fire from shocked public health officials, one of whom called the edict “cruel and irresponsible,” and said that it would compromise access to healthcare for “a multitude of needy Floridians.” Florida has the second highest percentage of uninsured people in the nation – two and a half times the rate of Connecticut.

A day later, state officials backed away after having an Emily Litella moment.  They realized that the counties actually own and control the properties in which the health department clinics operate.  The state employees, like the navigators, are just outside guests in these county buildings.   

A compromise of sorts was struck.  The state acknowledged that it had no authority to keep navigators out of the county buildings so long as the counties had them work outside of the actual clinic space.

Now most thoughtful people with any knowledge of history would probably use a colorful term here to characterize the state’s position.  I’ll just call it hogwash.

Public officials like Rick Scott are not the least bit worried about navigators being able to protect the privacy of individuals. How do we know this? 

Because Rick Scott was CEO of Columbia/HCA until 1997.  Like every hospital chain in the country, HCA hospitals have worked with navigators for years to capture Medicare, Medicaid, and insurance reimbursements for uninsured patients.  The navigators are often employees of outside entities working under contract.  Many even take a percentage of the billings for every person they enroll.

I know this because I competed with these companies when I was overseeing navigation programs for community nonprofits in Texas and Florida in the 2000s.  And these outside companies had access to all the private information about which Governor Scott professes to be worried today.

But there is more. 

In Florida, my nonprofit placed navigators in state health department clinics almost a decade ago and helped capture reimbursements for the state, relieving taxpayers of the bill.  No one accused us of breaching confidentiality.  But Jeb Bush – who had some common sense – was Governor then, and George Bush was President.

Hypocrisy is always in motion, and tough to pin down.  But in this instance, certain public officials made it too easy for us to see the real reason they want to prevent uninsured people from getting help paying the bills that clinics and hospitals must, by law, present to them.

They know for a fact that this part of Obamacare will work, and they desperately don’t want that to happen.

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

Suicide and Obamacare

In 2009, there were 36,891 suicides in the United States, according to the CDC.  This translates to a rate of 11.9 for every 100,000 people.

And rates among certain groups were even higher.  For example, the suicide rate among veterans, according to the Veterans Administration, was three times higher – or 35.9 per 100,000 veterans.

Suicide is a problem that ought to command our attention.

And it does.  For many years we have used suicide data as surrogates for documenting the consequences of serious mental illness.  We all know that the “danger to self” standard we use for determining when people with mental illness qualify for emergency care is, in effect, a “suicide may be imminent” standard.

As a result, for many years community mental health organizations have also been asked to track suicides as a measure of the effectiveness of their programming. 

But there are reasons why focusing on suicide rates too closely leads to inadequate public policy.

Suicides are just the tip of the iceberg.

Many more people consider or attempt suicide than die from it.  If you really want to be staggered by a national statistic, CDC reported that in 2011 7.8 percent of the teenage population had attempted suicide.  That is one thousand times as many as had died from it.

Also, the overwhelming majority of people with serious mental illness who die early do so not because of suicide, but because they are undertreated for other chronic conditions (such nicotine addiction, diabetes, and cardiovascular problems).  Some of these are linked to treatments they receive for their mental illnesses.

Finally, at the community level the number of suicides is usually so small that it is nearly impossible for any single organization to affect the rate more than anecdotally.  The agency may be able to point to individual cases where its intervention made a difference, but it will probably never be able to move the rate on its own.

And when the suicide rates don’t move, policy makers use this to justify decisions to reduce or eliminate program funding. 

So what does Obamacare have to do with suicide?

Many other provisions of the law have been lost in the din surrounding the most visible parts of the Affordable Care Act.

One of these was a mandate that the Department of Health and Human Services focus on the quality of our health care.  Since 2012, it has been doing this, along with a number of agencies in the Department, including the Substance Abuse and Mental Health Services Administration (SAMHSA). 

SAMHSA has just invested over two years in developing a National Behavioral Health Quality Framework (NBHQF). 

When the NBHQF is finalized, it will open the door to the use of new standard outcome indicators in determining the effectiveness of health and behavioral healthcare in our communities. 

We will be able to add these indicators to suicide rates, giving state and local officials much more powerful tools in judging the effectiveness of community mental health programs.

For example, suicide risk assessments (NQF #0104) will become a standard diagnostic tool in provider settings.  Providers will also be expected to use depression screening tools such as the PHQ-9 at six and twelve month intervals to monitor patients consistently over time (NQF #0710-0712).  And risky behavior assessment and counseling for children under the age of 13 will become a standard of practice (NQF #1406), as will diagnostic evaluation of children with major depressive disorder (NQF #1364-1365).

These all focus our attention on the 999 in every 1000 who consider and attempt suicide in addition to the one who tragically commits it.

We can also expect the integration of health and behavioral healthcare to become more systematic. 

Cardiovascular and diabetes monitoring of people who are prescribed antipsychotics (NQF #1933-1934) will become a standard of practice, as will management of ADHD in children in primary care settings (NQF #0107-0108). 

These indicators focus our attention on some of the other reasons people with mental illness die so young.

We all have an opportunity to say how we feel about these indicators. 

SAMHSA has released the NBHQFin draft form, and is accepting public comments on it until September 17, 2013.  Comments can be submitted using an online form, and don’t have to be formal or comprehensive.

The NBHQF will be finalized after the public comment period.  Then it will begin to guide the funding and delivery of mental health services. 

But for the next week, we all can say how we think the government should measure the quality of our behavioral healthcare services.

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

Members of Congress Scrutinize Navigators More Than a Run-up to Possible War

In the nervous run-up to a possible military strike in Syria, fifteen members of Congress last week took time from their busy vacations to sign a letter demanding more information from governmental contractors. 

But the targets of their attention were not the defense contractors who received $161 billion for their services.  They were universities, legal aid organizations, and small nonprofits who will share $67 million to help citizens apply for health insurance beginning in October.

The Congressional Gang of 15 included Fred Upton from Michigan, Pete Olson, Joe Barton and Michael Burgess from Texas, Tim Murphy and Joseph Pitts from Pennsylvania, Marsha Blackburn from Tennessee, Phil Gingrey from Georgia, Steve Scalise from Louisiana, Gregg Harper from Mississippi, Corey Gardner from Colorado, Morgan Griffith from Virginia, Bill Johnson from Ohio, Billy Long from Missouri, and Renee Ellmers from North Carolina.

They sprang into action after the grants were awarded in mid-August, demanding a response in writing within two weeks.

Here are some of their demands (thank you to Kaiser Health News for linking to the letter):

• “a written description of the work that will be performed,” including “a description of the number of employees, volunteers, or representatives that will be utilized and the pay and duties for each.”  
• A detailed budget for the program.
• “a written description of the training or education employees, volunteers, or representatives must complete,” plus educational requirements of the organization “beyond that required by any federal or state entity.”
• Supervisory processes and procedures.
• A description of how the organization will use the information obtained, including in follow-up communications with anyone with whom the organization speaks who might want to register to vote.
• Any communications with any health provider or any health insurance carrier to whom any individual might be referred for health care or coverage.
• All materials related to the grant application and award process.

Imagine being a 20 year old navigator in Florida just trying to help someone get insurance.  Do you really want some Congressman from Michigan “ACORNing” you if the person also asks you how to register to vote? 

Florida’s governor and do-nothing insurance commissioner aren’t going to help you.  They’ve already signaled their mistrust of navigators. 

You might think that any member of Congress who devotes so much vacation time to finding out whether sick people are getting help in finding a doctor would pay even more attention to matters that could soon drag our nation into another war.

And you might think that any member of the Congress taking time demanding this level of scrutiny about a program to help people get insured would apply a similar standard to other federal contractors. 

But you would be wrong.

When there’s more at stake, they sit back and wait.

Fred Upton, who has been on the job for twenty-five years and wrote the letter to the community agencies, hasn’t said a word in public about Syria.  He did, however, help a Vietnam veteran get his long-deserved service medals this month.  Pete Olson has no public position on military action, but said Congress should approve any.  Tim Murphy and Steve Scalise are among 140 members who want Congress “consulted” before the U.S. goes to war. And Billy Long went out on a limb when he asked the President to “tell his side of the story.”

If only they were as deferential about demanding the details about a paralegal contacting an insurer on behalf of a man with mental illness or a woman with cancer.

And take a look at the chart.  The value of the navigator contracts is so small compared to defense services contracts that you can’t even see it with the naked eye. 

As for the scrutiny they give to these other contracts that are worth 2499 times the value of the navigator contracts:

• They don’t demand educational credentials.  In the Snowden case, a 29 year old high school dropout was given access to “some of the most highly classified information in our government,” according to Sen. Susan Collins.
• They don’t t-cross and i-dot in advance. “According to the US Government Accountability Office in December 2012, there was a backlog of approximately 25,000 audits of DOD contractors as of the end of FY2011. “This backlog represents hundreds of billions of dollars,” GAO reported, and “has quadrupled over ten years.”
• And they don’t demand details about the numbers of employees, volunteers, or representatives, including their pay and duties.   Over 6500 contractors are working on $2 billion NSA expansion projects, according to a recent article.  As to who those contractors are, that information is simply described as “hush-hush.”

There is reason for outrage here.  You can decide over what.

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

The Ten Worst States for Your Health, 2013

Arkansas supplants Oklahoma in the 2013 OHPM rankingsas the worst state for your health. 

Arkansas was joined in the bottom ten by five other southern states and four states from the west.  And here's all you need to know about why states in the bottom ten are bad for your health.  Life expectancy in those states is the same as it is in Paraguay - 76.6 years.  This is four years fewer, or an entire Presidential term less, than life expectancy in Massachusetts and Connecticut - the two states at the top of this year's ranking.

Two states – Texas (39, up two places from last year) and West Virginia (38, up five places from last year) – escaped the bottom ten this year.  Kentucky found its way back after one year in 35^th place, and South Carolina entered the bottom ten after dropping eight places from 40^th last year. 

Here are the bottom ten, with the change from last year in parentheses:

41. Kentucky (-6).   Kentucky entered the bottom ten this year not because it did poorly in most rankings (its 44^th place healthy state ranking was its only bottom ten finish), but because it places in the bottom half in every category except Medicaid access.

42. Alabama (+3).  If Alabama’s 35^th place Kids Count health ranking can help to improve its 45^th place healthy state ranking in the future, then it may be poised to escape the bottom ten in the next couple of years.

43. Oklahoma (+7).  Oklahoma moved up from last place this year on the basis of a top 15 performance in Medicaid access and per capita Medicare community spending.  But 43^rd place finishes in both the Healthy State and Kids Count Health rankings cemented its position in the bottom ten.

44. Louisiana (0).  Louisiana is top ten in Medicare community spending and percentage of people on Medicaid, but bottom ten in the Healthy State rankings, the Kids Count health rankings, access to primary care providers, and the percentage of people with employer-based health insurance.

45. New Mexico (+4).  New Mexico is 5^th in percentage of people on Medicaid, and 50^thin percentage of people with employer-based insurance.  Not exactly an indication of a “worker-friendly” environment.

46. Montana (-5). Montana is last in the Kids Count health rankings, and next-to-last in the percentage of people with private health insurance and Medicare community spending.  These offset its middle-of-the-pack healthy state ranking (29^th).

47. Mississippi (0).  At least Mississippi is consistent, finishing 48^th, 47^th, and 47^th during the last three years.  Although it boasts top ten rankings in Medicaid access and Medicare community spending, it is 45th in employer-based insurance, 48^th in the Kids Count health rankings, and 49^thin the Healthy State rankings.  Mississippi has downside potential.  It hasn’t embraced Obamacare Medicaid expansion.  But both Arkansas and Nevada – the bottom two states in the rankings - have.

48. South Carolina (-8). South Carolina’s dive in the rankings is attributable to the fact that it doesn’t do well in any of the categories. In fact, its highest ranking among the states is only 20^th in Medicare community services spending.

49. Nevada (-1). Nevada’s only top thirty ranking is in Medicare community spending.  It is 47^thin the Kids Count health rankings and number of high-quality hospital programs.  But it is one of four bottom ten states to embrace Medicaid expansion.

50. Arkansas (-4).  What is Arkansas’ recipe for failure? Start with a 48^th place Healthy State ranking.  Add in a 49^thplace finish in access to primary care providers, a 46^th place ranking in the percentage of people with employer-based health insurance, and a 44^th place finish in number of high quality hospital programs. Arkansas ranks in the top ten in just one indicator.  It is 9^th in the percentage of people on Medicaid.  Of course, that’s a pre-ACA percentage, but it may explain why Arkansas – a conservative state – has embraced Obamacare’s Medicaid expansion.

Some interesting notes:

Colorado has the greatest difference in the two prevention rankings – it is 11^th in the healthy state rankings, and just 42^ndin the Kids Count health rankings.

Hawaii (+23.8) and Vermont (+22.5) are the only two states that rank more than twenty places better on the average of their prevention rankings than on the average of their health care rankings.  Rhode Island (+17.9) and New Hampshire (+17.9) tie for third on this measure.

Mississippi (-22.9) and Louisiana (-20.6) are the only two states that rank more than twenty places worse on the average of their prevention rankings than on the average of their health care rankings.  Tennessee (-18.6) is third on this measure. 

The states that are most balanced in their prevention and health care rankings are Kansas (+0.6), Colorado (+0.5), and Montana (-0.7).

Connecticut (2^nd overall) favors prevention and public health (+8.2, on average), and Florida (34th overall) favors health care (-11.9, on average).

To see the full rankings, click here.

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

The Best States for Your Health, 2013

After a year in second place, Massachusetts is once again the best state for your health in the 2013 Our Health Policy Matters rankings.

In first place in 2011, Massachusetts dropped to second last year behind Connecticut.  It edged out Connecticut this year based on the rankings of all fifty states in a combination of seven national source rankings and/or spending categories.

Here are the top ten states, with the change from last year’s ranking in parentheses.

1. Massachusetts (+1).  Among the seven components of the rankings, Massachusetts was only 4^th in the Healthy State rankings, and 11^th in the Kids Count health rankings.  But it earns its top rank overall because of consistently high placements in five other health care rankings.

2. Connecticut (-1).  Last year’s winner, Connecticut ranks 2^ndoverall in the Kids Count health rankings and in the percentage of residents with employer-based private insurance.  But it is only in the middle of the pack (20^th) in total number of high-quality hospital programs.

3. New York (+3). Never highly ranked in the healthy state rankings (18^th this year), New York has jumped from 19^thto 3^rd in two years on the strength of its hospitals, and good access to care for both younger and older residents.

4. Vermont (+3). Vermont tops the healthy state rankings and is 4^th in the Kids Count health rankings.  With an earlier investment in universal health care for its residents offsetting its lack of high-quality hospital programs, it may go higher in the future.

5. Maine. (+3). Maine tops three individual categories – the Kids Count health rankings, Medicaid access, and primary care access – accounting for its three-place gain this year.

6. Minnesota (-2). Minnesota scores highly in the Healthy State rankings, and also has high-quality hospital programs and a highly-insured population.Wisconsin (+6).  

7. Wisconsin owes its improvement in the ranking to healthy kids (3^rd) and solid performances in most other categories.  But it lags a bit in the Healthy State and primary care access rankings.

8. Utah (0). Utah scores well in the Healthy State rankings (7^th), but less well in the Kids Count health rankings (14^th).  It also has a high percentage of its population covered by employer-based insurance.

9. Washington (+7). Like Wisconsin, Washington made a big move into the top ten this year on the strength of a solid Kids Count health ranking (6^th).

10. Maryland (+2).  Maryland is in the top ten in the Kids Count ranking and in the percentage of its population with employer-based insurance.

In individual categories, Maine had the most first place rankings – the Kids Count health ranking, the primary care access ranking, and a tie for first in Medicaid access. California (19^th overall, up 3 places from last year) placed first in the number of high quality hospital programs and tied for first in the Medicaid access rankings.  Vermont topped the Healthy State rankings and tied for first in Medicaid access.  New Hampshire (11^th overall, after a 4^th place showing last year) placed first in employer-based health insurance. 

And Florida (34^th this year, down one place from last year) was first in community Medicare spending.

These rankings are the last before some significant Obamacare changes go into effect next year. For example, Vermont (ranked 4^th), Maine (5^th), Wisconsin (7^th), and Rhode Island (12^th) have all announced plans to cut their Medicaid rolls to encourage people to enroll in the exchanges, according to an article this week in Kaiser Health News.   Next year’s rankings may be adjusted to take into account insurance exchange enrollments in all the states.

Washington (9^th), Delaware (18^th), and Oklahoma (43^rd) were the biggest gainers this year.  They all gained seven spots in the rankings. New Jersey (13^th) experienced the biggest drop – 10 places. Virginia (23^rd) lost nine places, and Pennsylvania (16^th) and South Carolina (48^th) each lost eight.

Next week: the ten worst states for your health.

To see the full rankings of all fifty states, click here.

How These Rankings Are Developed:

OHPM combines seven rankings of the states to create this Top Ten.

Two of the rankings among the most highly-regarded public health or prevention-focused rankings – the United Health Foundation/APHA/Partnership for Prevention America’s Health Rankings and the Annie E. Casey Kids Count state health rankings.  The most recent America’s Health (Healthy State) Rankings were published in December 2012, and the most recent Kids Count health rankings were released in June 2013.

Because prevention and public health account for 50 percent of the gains in life expectancy over the last century, these two rankings account for 50 percent of the weight in the OHPM rankings.

The other five components of the ranking account for the other 50 percent, and are related to health care access and quality.  This year, they include the number of nurse practitioners and physician assistants per capita in the state (as a measure of the strength of the state’s primary care system), the percentage of state residents with employer-based private insurance and with access to Medicaid (as a measure of the availability of third-party payments for health services in general for the under 65 population), community-based Medicare spending (as a measure of the availability of elder health services), and, from the 2013 US New and World Report Hospital Rankings, the total number of high quality hospital specialty programs in the state (as a measure of the availability of specialty care for all chronic diseases and conditions).

To see the full rankings of all fifty states, click here.

Source links:

http://www.americashealthrankings.org/mediacenter/mediacenter2.aspx

http://www.statehealthfacts.org/comparetable.jsp?ind=125&cat=3

http://datacenter.kidscount.org/data/acrossstates/Rankings.aspx?ind=7248

http://kff.org/medicaid/state-indicator/medicaid-enrollment-as-a-of-pop-fy09/

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsStateHealthAccountsResidence.html

http://health.usnews.com/best-hospitals/area

http://data.bls.gov/oes/search.jsp?data_tool=OES

http://samhsa.gov/data/NSDUH/2k11State/NSDUHsaeTOC2011.htm

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