Changing Our Perspective on Mental Health

On Thursday I shared the post, Don’t Make Mental Health Policy About Stigma. Jessica Dawson, the brave woman who was one of several individuals featured in the USA Today article I reacted to in my post commented that she was, “discontented [her] photo is being used on [my blog] to discredit the impact which stigma has on government policies.”

I took that personally pretty hard as I had a sense I was betraying someone because of my ignorance on a subject that I am very passionate about and for which I have advocated here in the Pub. But I have to stick with what I wrote: not because I am sure I’m right – but because it’s what I wrote. In my response to Ms. Dawson I noted that I didn’t believe we had different goals but rather different beliefs in how to most effectively achieve those goals.

And then this morning I came across an article from earlier this week by Judith Solomon for the Center on Budget and Policy Priorities that is thematically consistent for what I was advocating: the pragmatic role that research and evidentiary support should play in advancing policies supportive of mental and behavioral health access and affordability – relative to (i.e., not exclusive of) the role fighting stigmatism can play in our current economic and political environment.

The article, The Truth About Health Reform’s Medicaid Expansion and People Leaving Jail, presents evidence that facilitating Medicaid enrollment in states participating in expansion under the Affordable Care Act, “can enable more of them to avoid returning to jail or prison by connecting them to needed mental health, substance abuse, or other treatment.  This is why many state corrections agencies and county governments are collaborating with state Medicaid agencies on projects designed to enroll low-income people being released from jails or prisons.”

On average, approximately 75% of the US prison population consists of nonviolent offenders, many of whom have a myriad of mental and behavioral health challenges and/or are fighting addiction. According to Solomon, “alcohol plays a role in over half of all incarcerations, and illicit drugs are involved in over 75 percent of jail stays.” But only 11 percent of inmates receive any type of treatment, while comorbid conditions are prevalent.

I haven’t taken the time to explore the cites and research that Solomon provides, so I want to be careful not to be advocating for something that obviously needs to be carefully considered, debated and vetted. My point is simply this: we should be investing more to determine – and evidence – whether and how this type of policy intervention can help achieve a stronger, more accessible, more effective mental health system.

We need to change our perspective on mental health. Fighting stigmatism – yes, important. I get that. But I believe we should be investing more heavily to educate the country about how intervention and treatment works – and how it can lower costs to families, communities and the country in the long run. There is a much better chance of redirecting funding from other sources than securing funding for new initiatives. That’s the political reality – like it or not.


Coming to a State House Near You: Medicaid Wars

Did the June 28th Supreme Court decision disallowing the federal government to coerce state participation in the Affordable Care Act’s Medicaid expansion kick a hornet’s nest or just lay it bare for more to see? Currently at issue is whether individual states will now “opt out” of participation in providing Medicaid coverage to an estimated 15 million individuals across the country by 2019 under Section 2001 of the ACA.

This past week one of the most vocal opponents of the ACA, Florida Governor Rick Scott, was out and visible at numerous media outlets willing to give him a bully pulpit to reinforce his position – that not only will Florida opt out of Medicaid expansion, but will also refuse to implement Health Insurance Exchanges as well.  Whether he follows through (he is not up for reelection until 2014) will be another matter.

In fact, the political challenge for him and the 28 other Republican governors who have to mull over that decision is a choice between increasing already tapped out Medicaid budgets or foregoing billions of dollars of federal funding available to the states that do not choose to opt out.  Since the cost sharing is initially 100% federal funding, stepping down to 93% by 2019, opting out might be economically prudent but very difficult to sell politically.  There are only three Republican governors running for reelection this fall: Jack Dalrymple (North Dakota), Gary Herbert (Utah)  and Luis Fortuño (Puerto Rico).  So expect more chest thumping bravado before some very difficult choices have to be made going into the fall of next year.

Complicating matters, the SCOTUS decision has caused an unforeseen wrinkle, or  donut hole as it were – a new potential coverage gap in the decades’ long protraction to bring this country politically kicking and screaming into the 20th Century by providing universal healthcare coverage to its citizens.  The math (actually the overlapping regulations) gets very tricky, so I won’t begin to try and explain what I haven’t been able to completely understand myself.

The up shoot is that individuals living in states that opt out of the expansion with incomes above those states’ Medicaid income eligibility but below 100% FPL will neither receive coverage under the ACA Medicaid expansion, nor be eligible for subsidies to help purchase health insurance in the new exchanges.  It should be noted this does represent a reduction in current benefits to this population – but the assistance that had planned to be available under the ACA now would not in states that opt out.  In any event, it would seem to have the makings of a political sword that could be used quite effectively in the future against any of the Republican governors choosing the opt out.

Underlying this whole discussion, of course, are even more challenging issues – issues that Pub patrons should be very interested in monitoring.  In states that really do end up opting out of the expansion, will that leave additional state budget dollars for long-term care coverage? <insert your favorite political sarcasm here>  In states that don’t opt out (which I expect will eventually be just about all) how will future efforts to negotiate FMAP rates for cost sharing of long-term care be impacted by the new coverage benefit (i.e., will federal lawmakers be pressured to reduce their share in lieu of Medicaid expansion)?

What we have shaping up – and has been in the making for the past twenty years – is a fierce generational conflict: as the aging demographics demand a greater share of public assistance for needs of the elderly it will become more and more difficult to maintain assistance for the non-elderly indigent and disabled.  Lack of a cohesive and widely accepted policy on immigration will serve as a catalyst to intensify that conflict, and the battleground will be state capitals.

At a practical level what this means for providers of senior housing, aging services and post-acute/long-term care is being caught between the lines: a labor force sympathetic to the economic struggles of their generation providing care to a powerful demographic that will, in the aggregate, carry dominating influence in how public funds are allocated.  My immediate reaction to this is to recognize now how incredibly valuable brand positioning and brand awareness will be in the future – and how critically important brand management must become for those providers wishing to survive this coming policy maelstrom.

   ~ Sparky