OBAMACARE: Was The Runner’s Knee Down?

NFL-REF-WATCH-BREAKING-BAD-bigger-300x211The play lasted only eight seconds out of 3,600 in the entire game. The distance traveled roughly 16 inches out of 3,600 across the field. Yet what occurred during those 8 seconds and 16 inches could make the difference between immeasurable joy or profound sadness. It all depends on how the referees view the play.

Of less substantial consequence in the minds of most Americans, starting tomorrow the Supreme Court will begin hearing arguments over 6 words of the Affordable Care Act – out of roughly 382,000: “through an exchange established by the State.” In November of last year when the Court determined (or at least four Justices did) to hear King v. Burwell I wrote, Does Legislative Negligence Trump Legislative Intent? I discuss there the background and ramifications of this case.

Here I am more interested in briefly sharing some thoughts on the relative influence of sociopolitical factors in SCOTUS’s review and consideration of this case. Whereas our historical view of the Court is one of great reverence and respect – the last bastion wherein ethics and morality trump politics – I think the image I chose for this post today more accurately reflects public opinion of that institution today – right or wrong.

I am not about to argue that politics has only recently become an unsightly element of the Court. Justices are appointed and approved by those who are elected, and they don’t get to the position of being considered by living out an apolitical professional career. From accusations against President Grant for court packing to FDR’s proposal to add members (conjectured to dilute a conservative bench) to more recent skirmishes over presidential nominees (e.g., Bork and Thomas) the Court has been steeped in political undertones for decades.

But what we are witnessing today is beyond just the politicization of appointees and the legacy influences of political ideologies. Like all things touched by our modern media the Court is engulfed by a sea of opinions and editorials in anticipation of a “wrong” decision – having not even heard one word of oral argument. How can the justices not hear the deafening crowd noise any less than the referees on the field looking under the video replay monitor. What influence, if any, will that carry on how they view King v. Burwell?

Regardless of how you hope the case is adjudicated you must see the irony in 8 million lives potentially being negatively impacted by 9 individuals out of 320 million based on the arbitrary interpretation of 6 words among 382,000.  Welcome to 21st century democracy in America.

  ~ Sparky

Stupid Is As Stupid Does

If you haven’t heard or read about the recent uncovering of remarks made by Jonathan Gruber in relation to the crafting and passage of the Affordable Care Act (i.e., ObamaCare: pub patrons will note I rarely use that term even though I have largely supported it), then it is most likely because you are stupid. Yes, sorry, but that’s the sad reality of affairs according to intelligentsia types like Professor Gruber.

Aaron Blake writing in the Washington Post yesterday argued effectively that Gruber’s remarks will likely have little effect on any legislative initiatives to fully repeal the ACA. And as Kevin Drum pointed out in MotherJones, while Gruber’s choice of wording may have been very poor, he is right in noting that most of the electorate knows very little about public healthcare policy – if that’s what Gruber indeed meant. To me, stupid implies the inability to learn. I think Gruber may have accurately depicted an electorate that is disinterested in and/or unwilling to learn. Even still, I question how someone supposedly so smart could be so stupid.

Whatever term might best describe the initial benchmark of the electorate’s understanding of healthcare delivery, policy and regulations back in 2010, it has certainly advanced substantially from then. I’d like to think I’ve contributed a smidgeon since I started this blog in May of 2012. Whether the ACA is repealed, amended or dismantled one line at a time (parish the thought – I read the whole damn thing) healthcare public policy debate between January 2015 and the November elections of 2016 promises to be as energized, contentious and fraught with misinformation and misunderstanding as ever.

And knowing that, I am hoping to take the PolicyPub to a higher level next year. I am hoping to invite guest bloggers representing differing perspectives and backgrounds. Through my firm’s recent strategic alliance with Healthcare Lighthouse we are exploring ways to collaborate on sharing of healthcare public policy knowledge and information in ways that bring real value to organizations involved in healthcare. I am hoping to reenergize our free private discussion group where healthcare public policy is debated based on the merits of ideas and beliefs, and not sound bytes and news clippings.

To accomplish this I am going to need help. I am going to need to find others who share my passion for wanting to learn, understand and share their knowledge on the inner workings of healthcare public policy – and more importantly, the impact of that policy on patients and provider organizations. If you know of anyone who would be interested in adding to the discussion, please have them contact me.

I would like to commit myself in 2015 to proving how wrong Mr. Gruber is: not only is our electorate not stupid – but neither by implication are they willing to allow college professors to determine the future of our healthcare delivery system while they sit back and accept what’s given to them.

  ~ Sparky

You’re No Prince, Mr. President

Last week the Administration announced that the Employer Mandate would be again further delayed – at least in part. Businesses with between 50 and 99 employees working 30 hours or more will not be required to make available mandated healthcare coverage until 2016. While businesses with 100 or more employees working at least 30 hours only need offer coverage to 70% of their employees in 2015, rather than 95% (which will not be mandated until 2016).

“Well, isn’t that conveeeeeeeenient . . .”

A little too thinks Senator Mike Lee (R-Utah). On this morning’s Fox News Sunday with Chris Wallace, Lee said that he believes the President is creating a “government of one” by further delaying the mandate – and in his view, ignoring the Constitution in the process.

Sidebar: how much longer do you think Mr. Wallace will be able to withstand Fox’s propaganda machine?

E.g., watch embarrassing exchange between
Chris Wallace and Tucker Carlson.

The premise of Mr. Lee’s position was that the president’s choice to delay the employer mandate was, “a shameless power grab that’s designed to help the president and his particular party achieve a particular outcome in an election. And that’s wrong.”

I think Mr. Lee is right.

Rep. Xavier Becerra (D-Calif.) defended the initiative on Fox News Sunday by claiming, “the president is simply providing small businesses with the flexibility they need.”

Sorry Mr. Becerra, that rings hollow and you should have been embarrassed to even pretend to believe that had anything to do with the delay. I obviously can’t speak for other supporters, but from my vantage Mr. Obama’s renegade approach to policy making has gone too far.

I have been  a pretty ardent supporter of the Affordable Care Act, and I continue to believe that, on balance, it will ultimately bring about necessary and desperately needed changes in the way our healthcare delivery system is designed. I also continue to believe that our failure to address the cost trajectory of our delivery system would have ultimately resulted in fiscal choking from within and ultimately destroy our economy. Finally, because of the unique characteristics of healthcare as an economic commodity – as well as the regulatory infrastructure that has already been in place for decades – I do not believe it is either wise nor prudent to think that a market-based system of healthcare can be successfully compatible with a progressive society. Most of the rest of the developed countries in the world agree.

Those beliefs notwithstanding, the wisdom of Nancy Pelosi grows daily: it’s not just that the ACA had to be passed to find out what’s in it – it’s that clearly the promulgation of regulations implementing the ACA under executive authority has at times supplanted the function of legislative authority. Regardless of how frustrating and demoralizing this Congress has been, there are reasons why certain powers are reserved to the legislative branch and certain powers are reserved for the executive branch.

But the timing of this latest action – whether a tipping point or accumulative – is not only a supplanting of legislative authority but also crosses an ethical line between governing and politics, which of course in Washington requires quite a journey to traverse.  In using what I will term, Obamavellian Authority, the president has repeatedly overstepped executive authority and dared to tread over boundaries that presidents of both parties from the past respected (well okay, maybe not Nixon).

It’s time the president’s supporters call him to account in the interest of democracy and respect for a way of life that transcends political allegiances. Hope you agree, but if not, I would love to hear from you.


Repeal & Replace Becomes Fix & Embrace

So we can add the U.S. Chamber of Commerce as one of the ACA’s stalwart detractors dedicated to Repeal & Replace now reluctantly advocating for Fix & Embrace© (you heard that term here first – I Googled it). Last week Chamber President Tom Donohue said, "we’re not going to get rid of that bill [actually, it’s been an enacted law since 2010, Mr. Donohue], and so we’re going to have to devise ways to make it work."

This of course begs the question just how is he hoping to define, “make it work.” How do you make something work that you’re already convinced – at least that’s what you said – absolutely cannot work? Wouldn’t you be better served to just pack up your bags, feel sorry for the country you’ve left behind and head for greener pastures? To a country that isn’t saddled with the weight of a social conscience advocating for equal access and affordability to a basic human right: healthcare.

Having a family history in this country that dates back to the 1670’s (including relatives that fought in both the Revolutionary and Civil Wars) I feel some sense of hosting duties here. I feel compelled to offer some assistance to our departing friends that no longer find this country palatable because of its social largesse. As you depart – besides not letting the proverbial door of fairness and equality hit you in your hard ass on the way out – here are a few countries you probably ought to avoid:

In Africa: Rwanda, Algeria, Egypt, Ghana, Libya, Mauritius, Morocco, South Africa and Tunisia

In Asia: Bhutan, Bahrain, Brunei, China, Hong Kong, India, Iran, Israel, Japan, Jordan, Kazakhstan, Kuwait, Macau, Malaysia, Mongolia, North Korea, Oman, Pakistan, Qatar, Saudi Arabia, Singapore, South Korea, Sri Lanka, Syria, Taiwan, Tajikistan, Thailand, Turkey, Turkmenistan and UAE.

In Europe: Albania, Austria, Andorra, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, the Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Moldova, Monaco, the Netherlands, Norway, Poland, Portugal, Romania, Russia, San Marino, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Ukraine,[and the United Kingdom.

In North America: Barbados, Canada, Costa Rica, Cuba, Mexico, Panama, Trinidad and Tobago.

In South America: Argentina, Brazil, Chile, Columbia, Peru, Uruguay and Venezuela.

Oh, almost forgot – Australia and New Zealand should be avoided too. They, like all of the countries listed above, provide some form of universal healthcare for their citizens. So you couldn’t possibly find happiness there.

But you won’t find North Korea listed above. Happy trails!!


The Realities of Defunding

obamacarefingerbitingLG-300x158Last week the once relevant political operative of right wing influences, Karl Rove, wrote an editorial in the Wall Street Journal, Republicans Do Have Ideas for Health Care. In case you were concerned that defunding the Affordable Care Act would leave the country’s healthcare system in chaos and peril you can now rest easy – the Party of No has a plan. Except they don’t if you go by Mr. Rove’s article.

Before I continue I should note that high hopes of defunding the ACA may reflect a personal perception of authentic patriotism but for most those hopes belie an understanding of our healthcare delivery system, the Affordable Care Act – and most pragmatically, political realities. At the request of Tom Coburn (R-OK), the Congressional Research Service recently published Potential Effects of a Government Shutdown on Implementation of the Patient Protection and Affordable Care Act.

As discussed in that memorandum, defunding of the ACA via government shutdown would not have the intended consequence of stopping much of its implementation while risking the consternation of various constituencies that the Republican party has yet to alienate. Of course, that won’t stop Senators Cruz (R-TX), Lee (R-UT) and Rubio (R-FL) from making political hay out of an issue that strikes a harmonious chord with their conservative bases, and why should it. Those who look for sincerity in the motivations of either (any) political party fail to accept the realities of campaigning and democratic elections in the 21st century.

I should also note that Mr. Rove is on record of disagreeing with these senators. He believes defunding the Affordable Care Act through a government shutdown would give the President, "a gigantic stick with which to beat [Republicans]." I tend to agree and would hope the Republican party could spend more time on developing new ideas that reflect the realities of our current delivery system instead of just being against the ideas of others (and sometimes their own).

In his editorial, Mr. Rove points out several Republican policy initiatives that taken one by one have some merit – both within the context of ACA implementation and under the unlikely hypothetical assumption of its outright repeal. But it is beyond a stretch to suggest that even taken together those several examples he cites constitute a legitimate alternative to the comprehensive approach of the ACA. And therein lies the challenge that many (most?) political wonks, talking heads and sound bite artisans face when discussing healthcare policy. Our healthcare delivery system is complicated and complex beyond reason, and certainly way beyond necessity. But you have to play the game on the field you’re given not on a chalkboard.

Several of the policy initiatives Mr. Rove cites deal with health insurance: portability of policies, employer risk pooling and selling premiums across state lines. I think these are plausible modifications and/or addendums to the ACA approach that are worth circumstantial testing.  But part of the recognized challenge up front is that these approaches are dependent upon employer-based insurance, which most policy experts agree was never a good idea to begin with. And they leave out a wide swath of the population that doesn’t receive employer-based health insurance. If we didn’t think there was merit in providing healthcare benefits to those unable to afford such coverage, then these would be top of mind ideas.

Another initiative cited, medical liability (or tort) reform is a bit like the weather: everyone complains about it but nobody really ever does anything to change it. Perhaps that’s because of the preponderance of Congress who are also lawyers. But there is another line of thought that believes increasing quality and safety might also be a pragmatic approach to lowering malpractice liability. What would we rather have: the forbearance of frivolous suits that also risk restricting justice to individuals – or the reduction in the basis upon which such suits are brought. In reality, we probably need both.

Of the several reform initiatives Mr. Rove shared transparency has to be the weakest example of meaningful policy. Pulling the cover off of the Invisible Man won’t change your view of him. And mandating that meaningless provider charge rates (prices) be published won’t enable better decision making by consumers (patients). I addressed this back in February in a post I entitled, Pick a Price.

Moving on, allowing Medicaid patients to apply their governmental benefits toward private insurance sounds reasonable enough. Unfortunately, it would be bad policy. Although there are already a number of states seeking to leverage private insurance capitation models as a hybrid compromise to Medicaid expansion within the context of the ACA, those models still maintain control over risk pooling so as to address adverse selection.  While allowing funds to be indiscriminately repurposed may sound like an idea promising to partner individual choice with market efficiencies, as Naomi Freundlich addressed in her Healthcare Blog post, the reality of implementing such an idea is another matter entirely.

Finally, Mr. Rove writes that, “the president and his liberal posse have a fundamental, philosophical objection to conservative ideas on health care. They oppose reforms that put the patient in charge rather than government, that rely on competition rather than regulation, and that strengthen market forces rather than weaken them.”

Disingenuous assertions like this do little to advance meaningful healthcare policy discussion. This is no different than liberal talking heads claiming that conservatives seek to advance healthcare policies that benefit (or are structurally biased toward) the wealthy at the expense of the poor. More generally, asserting that the ACA’s hidden agenda is to abscond personal liberty in favor of governmental control misses the point of the real debate entirely. Both the theoretical and practical debate is not over whether the government knows better than the individual what is best for the individual. The debate is in how public policy can best balance the protection of personal liberties while morally advocating for the rights of those individuals with far less ability to secure affordable, quality healthcare. Some feel healthcare is a basic right secured by the Constitution. Others do not. What do you believe?


QAPI ~ Ready (or Not?)

2013-01-09_14251sI have been receiving a fair amount of anecdotal intelligence that many post-acute/long-term care providers are not at all prepared to implement the Affordable Care Act’s QAPI when (still waiting . . . ) those regulations ultimately get published. So I thought sharing this post again might be useful.

Section 6102(c) of the Affordable Care Act – Quality Assurance and Performance Improvement Program (or QAPI) requires the Secretary of Health and Human Services (as delegated to CMS) to, “establish and implement a quality assurance and performance improvement program …” and to, “…establish standards relating to quality assurance and performance improvement with respect to [nursing] facilities and provide technical assistance to facilities on the development of best practices in order to meet such standards.“

Last Friday CMS released a memorandum to state survey agency directors announcing the rollout of electronic assistance and compliance-oriented materials on the QAPI website. HHS/CMS has still not yet published the condition of participation regulation that will provide nursing facilities with compliance guidance (facilities were to have already been compliant in March of this year), but there already exists comparable regulations for other healthcare provider types that will serve as a template. Once that regulation is finally published nursing care providers will have one year to develop an acceptable QAPI plan.

QAPI compliance for nursing facilities is not entirely new. The nursing facility QAPI is based in part on existing Quality Assessment and Assurance (QA&A) regulations. However, the new planning and reporting provision significantly expands the level and scope of QAPI activities that nursing facilities must enact in order to ensure they continually identify and correct quality deficiencies as well as sustain performance improvement.

It is a tad ironic that in promoting a key differentiator between historic, traditional quality assurance – now being coupled with performance improvement – that while quality assurance is to be viewed as a requirement and reactive, performance improvement should be viewed as discretionary and proactive. Never mind that performance improvement is being mandated as part of the QAPI program. Sort of like being able to choose any whole number between zero and two, right?

Anyway, I really fear that for a lot of nursing facilities – particularly smaller and/or single site organizations – this requirement is going to sneak up on them. And the true impact of that reality will not just be the regulatory and economic consequences but the lost opportunity to utilize the QAPI process to drive better quality, higher safety and better outcomes – while lowering the overall cost of care.

There are two ways to view the new QAPI requirement: another onerous regulation designed to burden caregivers with unnecessary compliance requirements at additional cost; or an opportunity to sponsor and embrace a process that – if done strategically and conscientiously – should improve productivity and efficiency while strengthening market position based on quality and outcome characteristics.

So my counsel is don’t wait for the regulation to be promulgated. Start now to learn and understand the tools that have already been made available. CMS has stated that, once provided, the QAPI formal regulation will not contradict the materials that have already been developed and provided.

And for those organizations that are truly interested in taking a strategic approach to developing a continuous quality improvement system that has the complimentary advantage of combining regulatory compliance with value-driven financial performance, please review the white paper that I drafted with colleague Nathan Ives of StraegyDriven Consulting, Aligning Healthcare Organizations: Lessons in Improved Quality and Efficiency from the Nuclear Power Industry.


The Political Realities of Sequestration

imageNow be honest, before last summer had you ever heard the term, sequestration? Though I’m sure I did, I can’t recall when, and I am quite certain I wouldn’t have known the correct Jeopardy question, “What is the term used to describe the legal confiscation and possession of a defendant’s property in lieu of a judgment or court order?” And that’s not even the popular meaning now embedded into our political lexicon.

I have come to understand that Congress’ use of that term dates back to the 1985 Gramm-Rudman-Hollings Balanced Budget and Emergency Deficit Control Act in which it was used as a means of reforming Congressional voting procedures and intended to raise that body’s consciousness that budgeting should be a process of allocation from funds available – rather than an exercise in arithmetic reflecting the outcome of decentralized appropriations (insert favorite form of sardonic humor here).

The idea was that if the combined totals of appropriation bills passed separately by Congress resulted in spending in excess of the limits agreed to by Congress in the annual Budget Resolution, and then if Congress could not agree on ways to reduce that spending (or did not pass a higher Budget Resolution), then there would be an automatic reduction in spending: the aforementioned sequestration.  For me (and I’m sure many of you), this is a rather easy concept to understand because that’s how sequestration works in our house when our appropriations exceed our funding: we often call it, “cancelling our dinner reservation for Saturday evening.”

Back in fantasyland, however, the automatic reduction was to be sequestered by the Treasury and not disbursed as originally appropriated by Congress. In theory, the application of the sequestration is to be regarded pro rata across all agencies, though Congress has typically exempted certain programs such as Social Security and Defense.  The practical result has been that agencies not exempt would experience a disproportionate share of the spending reductions in order to achieve the total sequestration amount mandated.

As retired Senator, Phil Gramm, noted, “it was never the objective … to trigger the sequester; the objective was to have the threat of the sequester force compromise and action.”  Well, as we’ve seen, there is one thing that simply cannot be forced in Washington right now, and that is compromise. The reason for this is the stark contrast in political realities currently characterizing the two major parties.

The Obama Administration believes it won an electoral mandate to advance the country further in the direction of European style Social Democracy (different than Socialism, but closer than many in this country probably realize). And as Bob Woodward recently found out, they are taking a Machiavellian approach to whatever – and whoever – stands in their way. Woodward has lifted the curtain on the Administration, and he has garnered the attention and concern of a lot of folks, life myself, who have generally been supportive of it. And though I very much doubt it was his intention – or concern – he has created a strategic political opportunity for Republicans.

Unfortunately for their party, however, the Republicans are still wandering aimlessly in the sociopolitical dessert of the late-middle 20th Century, looking for the ghost of Ronald Reagan – or any ideological mantra that could garner greater than 50% support of their tattered leadership. In addition, because of the tremendous expense involved in campaigning in an era of modern media and super PAC’s (even in fending off same-party candidates in primaries), having party power of the House of Representatives is like having a gun with one bullet.  The party in power now gets one shot in a Congressional session to make a political impact.

So what we have is not a game of Chicken, where we wait to see which side blinks first.  We have a legitimate ideological stalemate that is being advanced and dominated by the promotion of minority interests holding sway over the respective parties. I say this because according to opinion polls I’ve seen, a significant majority of this country is in favor of raising taxes in order to pay down debt. What that majority is not in favor of is raising taxes to expand entitlements (there is also significant support for raising taxes and reducing entitlements).

The Administration wants to raise taxes to protect and expand the entitlements that are a critical component of their social agenda, while the Republicans want to reduce entitlements without raising revenue (taxes) so as not to alienate their primary campaign funding sources. The sad irony here is not that elected officials from both parties are acting selfishly in their political self-interests. That we’ve come to expect.  The sad irony is the perceived belief that placating minority interests is in their political self-interests more so than acting in harmony with the majority. Now, why is that?


Gun Control and the ACA

imageThis is the second occasion I have had in the past four months to correct a news piece that has appeared on the Breitbart web site regarding the Affordable Care Act.  Last November, I shared my disagreement with Dr. Susan Berry’s fallacious interpretation of a Journal of American Medical Association article on knee replacements under the Affordable Care Act.

Interestingly, that post – Death Panels Just Won’t Die – remains the most popular PolicyPub article landed upon.  Visitors come to it by using search engines and wanting to learn more about “Obamacare and knee replacements.” But today I am writing about Awr Hawkins’ piece from January 9, Obamacare Amendment Forbids Gun and Ammo Registration.

A good friend brought this to my attention via  forwarded e-mail. As with many topics of this type, the news gets passed around in emails, blogs and web sites and then reproduced, repurposed and morphed into all varieties of content (just as I am doing here).  As I did in my post on death panels referenced above, however, I will try again to be diligent here in providing to readers original source content, so that you can do your own research – and thinking.  I wish Mr. Hawkins had gone to such effort.  Here is what he wrote:

“Good news — it has become known that hidden deep within the massive 2800-page bill called Obamacare there is a Senate Amendment protecting the right to keep and bear arms.

It seems that in their haste to cram socialized medicine down the throats of the American people, then-Speaker Nancy Pelosi (D-CA) and Barack Obama overlooked Senate amendment 3276, Sec. 2716, part c.

According to reports, that amendment says the government cannot use doctors to collect ‘any information relating to the lawful ownership or possession of a firearm or ammunition.’

CNN is calling it ‘a gift to the nation’s powerful gun lobby.’

And according to Senate Majority Leader Harry Reid (D-NV), that’s exactly right. He says he added the provision in order to keep the NRA from getting involved in the legislative fight over Obamacare, which was so ubiquitous in 2010.”

In his piece, Hawkins references an article produced by HotAir.com, which, in turn, references a video report produced by CNN on the subject that Hawkins’ references in his article (following, so far?).  What the original reporting claims is that Title X, Sec. 2716, Subsection C was a, “little known” piece of the Affordable Care Act that was unwittingly passed in support of the gun ownership lobby by lawmakers whom many would assume are gun control advocates.  In particular, Harry Reid.

As the CNN piece points out, however, up until very recently, Harry Reid has been a rather reliable gun rights advocate.  More importantly, as Ed Morrissey writes on the HotAir site, “this isn’t that much of a bar on Congressional action. What can be done in this manner can be undone in the same manner.”

Even beyond Mr. Morrissey’s interpretation, however, what the above referenced section does is make it explicit the ACA does not empower the Federal government (primarily under the Secretary of the Department of Health and Human Services) with the right to collect, analyze and/or report data and information on gun ownership.  And it was rather widely understood at the time (sorry conspiracy theorists) that in order to achieve some measure of political support of the ACA by the Gun Lobby, this section was intended to provide assurance the ACA was not granting new Federal powers.

That is not the same thing as saying such powers have been henceforth forbidden or cannot be achieved through other means (i.e., through future legislation).  In other words, if Congress were to advance gun control legislation currently under consideration that requires stricter registration, tracking and reporting of gun ownership, there is nothing in the ACA that would conflict with that legislation.

President Obama recently issued 23 executive actions on gun control.  One of these is to, “clarify that the Affordable Care Act does not prohibit doctors asking their patients about guns in their homes." This has also been unfortunately interpreted by some media sources as a new Federal requirement that doctors are being required to act as deputies in ferreting out individuals at risk of committing gun violence.

In any event, while speaking on gun control during last week’s State of the Union, the President noted that, “each of these [gun control] proposals deserves a vote in Congress.  If you want to vote no, that’s your choice. But these proposals deserve a vote. Because in the two months since Newtown, more than a thousand birthdays, graduations and anniversaries have been stolen from our lives by a bullet from a gun."

What I believe this to mean is the President does not have the votes in Congress to pass any meaningful gun control legislation at this time.  But he is seeking to gain some measure of political capital by getting those opposed on record.

This is a very difficult ball of public policy yarn: wrapped in together you have healthcare delivery policy, mental health policy and gun ownership/gun control policy.  It requires serious efforts in research, understanding and debate.  It requires, wherever possible, a clear articulation of the known facts.  Although my readership is paltry compared to what Breitbart controls, I hope my efforts here will combat this latest demonstration of reporting laziness, manifested in unhelpful misinformation.


Blog post picture courtesy of www.sodahead.com

Mental Health Realities

As mentioned here before, WordPress allows me to track blog visits based upon search strings that were used to refer visitors to the PolicyPub.  I have noted recently a prevalence of searches on Mental Health, likely owing to the national discussion and debate on Gun Control now taking place in lieu of the Sandy Hook Elementary shooting in December.

I recently wrote a post (Obama’s Opportunity Missed) explaining why I feel the President missed a golden opportunity to raise the level of social awareness and consciousness concerning the difficult and growing challenges that mental and behavioral health present to our society.  As a follow up to that, I wanted to share with Pub visitors information that was recently presented by Pamela Hyde, the Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), at the Third Annual Public Health Law Research Meeting in New Orleans on January 18th.

According to Ms. Hyde, “people are just beginning to wake up to the knowledge that behavioral health issues are so common . . . “ yet among the eight million people worldwide in the past year who had a mental illness or substance abuse disorder, only 6.9% received treatment.  She added that, “the country has to spend as much time helping children develop their emotional skills as they do their soccer skills.” 

Links to Ms. Hyde’s slide presentation, data cites, and meeting Q&A can be found at the bottom of this post.  Provided below are a few snippets taken directly from her presentation that I found particularly impactful.

Prevalence & Incidence
Approximately one-half of all Americans will meet criteria for mental illness at some point in their lives

Mental and Substance Use Disorders rank among the top 5 diagnoses associated with 30-day readmissions, accounting for about one in five of all Medicaid readmissions (12.4 percent for Mental Disorders and 9.3 percent for Substance Use Disorders)

7% of the adult population (34 million people), have co-morbid mental and physical conditions within a given year

Co-morbid depression or anxiety increases physical and mental health care expenditures

Impact on Physical Health
24 percent of pediatric primary care office visits and ¼ of all adult stays in community hospitals involve Mental or Substance Use Disorders

Adults who had any mental illness, serious mental illness, or major depressive episodes in the past year had increased rates of hypertension, asthma, diabetes, heart disease, and stroke

Cost of Care
Average monthly expenditure for a person with a chronic disease and depression is $560 dollars more than for a person without depression

General medical costs were 40% higher for people treated with bipolar disorder than those without it

Perception of Value
Mental illnesses account for 15.4% of total burden of disease, yet mental health expenditures in the U.S. account for only 6.2%

The public is less willing to pay to avoid mental illnesses compared to paying for treatment of medical conditions

Top reasons for not receiving treatment include:
     • Inability to afford care (50.1%)
     • Problem can be handled without care (28.8%)
     • Not knowing where to go for care (16.2%)
     • Not having the time (15.1%)

The SAMHSA Web site referenced above includes a large knowledgebase of useful, understandable resources and information on mental/behavioral health and substance abuse.  If you are interested in learning more about the very difficult public policy issues surrounding Mental Health, I invite you to check it out.


Link to Slides: Click …

Link to Q&A: Click …

Obama’s Opportunity Missed

The human mind can be a very scary place.  There is where originates the electrochemical impulses that direct the body in carrying out some very heinous acts – such as the violence witnessed in Newtown, Connecticut just over one month ago today.

The mind can also be a fascinating study of unimaginable intricacy. In some infinitesimally small space wherein exists a hidden mystery explaining the difference between a physiological existence and conscious existence lies all of the energy necessary to create and destroy humanity (sort of like Einstein’s Special Theory applied to neural mass). Can you think of a more interesting basis upon which to initiate a metaphysical discussion over Creationism?

But alas, this isn’t Sparky’s Philosophy Shop.  As alluded to above, the topic of this post is Mental Health and the policy discussion it is receiving in lieu of the fatal connection between mental illness and gun violence.  Earlier today, President Obama announced a Plan to Protect our Children and our Communities by Reducing Gun Violence.  The plan outlines a number of initiatives – including 23 Gun Violence Reduction Executive Actions – that, taken together, is an attempt to put forth a reasonable agenda on gun control policy.

Of course, the cable news networks will be filled over the days ahead with talking heads who would have us believe we are now full bore on the doomsday expressway with the only two exits ahead being socialism or anarchy – and little room in between to continue having intelligent and constructive debate on how to find the most broadly acceptable policy balance between honoring and defending the second amendment while doing whatever is possible and pragmatic to prevent future tragedies like that at Sandy Hook Elementary School.

I hope rigorous and informed debate continues on the role mental illness plays in the tragedies that have brought us to this place.  And I desperately hope that debate will raise awareness of just how acute the challenges are we face as a society  resulting from mental and behavioral health issues.  If you have not already read Liza Long’s blog post, I am Adam Lonza’s Mother, it poignantly depicts the painful and helpless reality that mental illness can cause in a family.

I believe the President’s Plan on gun control offers some reasonable ideas, most of which probably won’t go very far in the House – partly because their source is the White House and partly because of understandable concerns by some House members that significant elements of their constituencies equate any discussion of gun “control” with an armed government takeover.  But the politics of gun control aside, the reality is that very often a mentally ill individual with an agenda can kill with or without a gun.  Getting guns out of the wrong hands does not address this challenge.

Or, to look at it another way – if I had to choose one investment over the other as having a greater long-term probability of reducing gun violence, I would choose investing in mental health over more gun controls.  Yet while mental health is addressed in the President’s plan, it seems like it was almost an afterthought.  The irony is disturbing because not only do policy issues stemming from mental illness and gun violence warrant a great deal more attention – but so do a host of other issues that recognize the growing awareness of the costs that poor mental health have on society – especially healthcare costs.

Although it is still a very long journey, every day science advances a step closer to understanding the raw dynamics of how the mind and body work in synthesis to have a dramatic impact on our health. Community and individual health and wellness initiatives are now focused on taking a holistic approach.  The connection between mental health and chronic disease and disability, particularly in the senior population (see my post on substance abuse among that population) offers promising opportunities to reduce disease incidence and increase the value of treatments.

To achieve the benefits of those opportunities, however, mental and behavioral health services must be socially and culturally viewed on a par with traditional medical/health services.  In defining essential health benefits that insurance companies must provide, the Affordable Care Act helps advance that initiative.  It falls short, however, of achieving true parity status for mental and behavioral health services.

The President attempted to address that discrepancy today through executive order by committing to finalize health parity regulations – and he also outlined the need to bolster mental health counseling and awareness through additional resources that will certainly not be forthcoming from a Congress (which includes the Senate) that cannot even agree to disagree for fear of reprisal (or am I getting that confused with accountability).  But I think the President missed a tremendous opportunity today to raise awareness and urgency on the critical role mental and behavioral health services must play in developing a healthcare delivery system that is truly committed to improving outcomes while reducing costs.