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.


Medicaid vs Education

In The Hill yesterday, Dick Morris, one-time Republican strategist and advisor to President Clinton beginning with the 1994 midterm elections, wrote about the looming social battle between state funding of Medicaid v. Education

Even in those states that have chosen not to expand Medicaid through the Affordable Care Act’s benefit opportunity Morris believes they will be, “unable to provide decently for education without cutting back on the ambitious Medicaid expansion” as insurance exchanges provide coverage to individuals already eligible for Medicaid without the ACA.

He points out that Medicaid’s recently modest spending trajectory is set to increase substantially with increases in enrollment (spending is projected to rise 12.2 percent in 2014, 7.9 percent in 2015 and 2016, and 6.6 percent per year thereafter). But with state budgets overall not increasing commensurately, that means Medicaid spending must take a bigger share of the budget pie – and something else must get less.

Morris believes that will be education and has issued this dire warning: “we cannot afford both [education and Medicaid]. Of course, states can still raise taxes and join jurisdictions like Detroit into their slow spiral to oblivion.”

What really puts this suggested tradeoff on the razor’s edge is the evidence of failure that Medicaid expansion efforts have generated. Of course the Oregon Health Insurance Experiment is both timely and top of mind here. If you haven’t already, I encourage you to take the time to at least survey that research. In a nutshell, the experiment found that expanding Medicaid resulted, “in no measurable health benefits in the Medicaid group for several chronic conditions, including hypertension, high cholesterol and diabetes.” It did result, however, in a significant increase in ER utilization, where relative costs are substantially higher than primary care settings.

Expanding healthcare coverage to those who cannot otherwise afford it is both a noble and moral obligation of a progressive society. But making choices to pursue noble pursuits with limited resources is a reality that becomes more urgent every day in the face of what we have seen  happen in other countries due the lack of fiscal responsibility.

Mr. Morris has pointed out an important and challenging debate that states will have to wrestle with in the years ahead. It’s hard to make the argument for defunding children’s educations to support a program that has so far not achieved the desired ROI. But while we’re focused on relative social ROI we might also want to look critically at the success of state investments into educational programs.


Blog image from The Hill ~ Jenny Francis

Turning Up the Heat on Medicaid Expansion

There was a study published last week in the New England Journal of Medicine that is getting a lot play in the popular media – which as I have written before is the sharpest of double-edged swords where issues of truth and reality are concerned. Nonetheless, the timing of the research reported is well done in light of a number of states still wrestling with whether or not to accept the Affordable Care Act’s Medicaid expansion.

The Oregon Experiment — Effects of Medicaid on Clinical Outcomes

Back in 2008 approximately 90,000 individuals in Oregon signed up for a lottery that would subsequently provide Medicaid coverage to approximately 30,000. In doing so, Oregon created two randomly selected groups that could be analyzed to determine the comparative effects of having access to health insurance via the state Medicaid program there.

Two years later the relative impact of being insured through Medicaid produced what on the surface appears to many as conflicting results. Use of medical services (i.e., physician services, medications and hospital services) by those covered by Medicaid increased 35%, while access to preventative services and screenings increased by 50% or more. The rate of depression incidence in the Medicaid covered population was reduced by 30% compared to the control group. In addition, the financial impact on families was dramatic – e.g., it was reported the probability of having to endure financial hardship to pay medical bills was reduced by more than 50%.

On the other hand, the health impact in terms of outcomes for those individuals covered by Medicaid was less impressive. In fact, while those receiving the Medicaid benefit were more likely to be diagnosed with diabetes as compared to the control group, their blood sugar levels were not markedly impacted. And the same held true for blood pressure and cholesterol levels.

So in a nutshell, what the research shows is that having health insurance can drive higher access and utilization of available medical services. If you provide it, they will use it – a good thing. But it very well may not have a significant impact on health outcomes – particularly outcomes that are largely influenced by chronic conditions such as obesity, diabetes and hyperlipidemia (high cholesterol). Providing it won’t change lifestyle behaviors – a bad thing.

As this research demonstrates, addressing the behavioral elements that impact health outcomes is far more difficult and far more complex than just an access issue. But I think it is certainly shortsighted and faulty logic to fail Medicaid based on health outcome data alone. Improving access and utilization of medical services by the un- and underinsured population is a progressive advancement that has merits independent of outcomes, which is further reinforced when considering the relatively short time period covered by this research.

But the more salient if not subtle point of these results is that chronic disease management requires a coordinated effort of social, educational and medical influences that clearly place expectations of behavior modification beyond the sole responsibility of healthcare practitioners. That reality neither bolsters nor detracts from the arguments being made in support of state Medicaid expansion under the Affordable Care Act despite what you may read or hear otherwise.


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

Implications of SCOTUS Decision on Medicaid Funding of PA/LTC

Before I get to the heart of this post (the Medicaid story), please allow me to share some additional thoughts up front.

Dewey Wins Moment
First, as was announced this morning, the Supreme Court has found the Affordable Care Act is constitutional in its entirety (noted exception regarding Medicaid expansion).  I was following the announcement on the
SCOTUS blog this morning (where it was shared that the Individual Mandate was upheld), and so I had a very hearty laugh listening to John King of CNN go on for nearly five minutes about the implications of the Individual Mandate being struck down.  Apparently, a reporter in the Court read the opinion passage that, “the individual mandate thus cannot be sustained under Congress’s power to ‘regulate Commerce’ ” and failed to keep reading.  Ah, the risks of wanting to be first.

Maintaining Political Perspective
Second, a modest word of caution.  As I have written here and shared with industry peers and constituencies in various other formats, this is another step along the path of Healthcare Reform.  The next challenge the Affordable Care Act faces is the fall elections.  And I would not be the least bit surprised – or really, at all disappointed – to know that Republican strategists are in a back door way pleased with this decision because they can
now use it to energize their voting base.  It will be a rallying cry to get the vote (and donations) out.  Democrats will have to redouble their efforts (if not their campaign fund raising) if they want the ACA to survive in tact beyond the 113th Congress.

But, it will be very difficult now to rescind the entire Act regardless of what Messrs. Romney, Boehner, McConnell, et al would like us to believe.  First, there is the political reality of having to not only win the Presidency but to maintain a majority in the House and take back control of the Senate.  I think retaking the Senate will actually be a longer shot than Romney defeating Obama.  Second, by the time any new legislation could be drafted, vetted and passed, the ACA will be well into implementation.  Trying to go backwards at that point would have devastating social and economic consequences that elected officials of any stripe are unlikely to want to be associated with.

There very well could – and I would expect, regardless of election outcomes, will – be some modest tinkering in the future.  We still have the economic realities of a very fragile world economy that keeps us teetering on the brink of another deep recession.  So I think it is likely the essential benefits definitions and actuarial soundness of insurance plans under standardization of coverage will be tightened up in ways that improve budget projections. 

Medicaid Expansion
To some, like me, this part of the decision was more of a surprise than the IM being found as constitutional – and there could, potentially, be rather significant implications for post-acute/long-term care providers.  I am not by a long stretch a legal scholar, but I will try to give you my best understanding.

Title II, Section 2001 of the Act – Medicaid Coverage for the Lowest Income Populations – expands coverage for individuals with incomes at or below 133 percent of the federal poverty level ($14,856 in 2012).  As a practical matter, this means expanding coverage for adults without children or disabilities.  According to a May 2010 Kaiser Family Foundation Report, it is estimated that an additional 15 million individuals will receive beneficial healthcare coverage under this provision by 2019 at an estimated cost of $465 billion.

According to 42 USC § 1396c – Operation of State plans, the Secretary of HHS has the ability to withhold federal funding of a state’s Medicaid program for failure to comply with federal requirements (this was existing code not altered by the ACA).  Thus, states not complying with provisions of Section 2001 of the ACA would be at risk of having all federal Medicaid funding cut off – not just funding of the Medicaid expansion.  In lieu of the ACA’s Medicaid expansion, the Court found that application of 1396c in such instance would be unconstitutional because states could not have anticipated such an onerous exercise of coercion when electing to participate in the original Medicaid program.

The remedy of this finding is that the Act must be amended such that 1396c would not apply to a state’s decision whether or not to participate in the Medicaid expansion under Section 2001.  So, in theory, states now have the option of whether they want to participate in the Medicaid expansion or not.

Now, given that the program’s design will initially provide 100% federal funding for newly eligible enrollees under the expansion program – declining to 93% by 2019 – I cannot imagine how any state would choose not to participate.  It would seem to be political suicide for an elected official to forgo federal funding to expand healthcare coverage to the poor when the relative impact on that state’s budget is, by comparison to federal spending, rather small.  And by not participating, that state would essentially be choosing to lose a portion of the taxes paid by its citizens that will benefit the poor in other states.

On the other hand, as we witnessed when several Republican governors chose not to accept economic stimulus funding, there is a very real possibility that some states may choose to opt out of the Medicaid expansion as objection or disagreement with the expansion (or the Affordable Care Act in general).  Add to that concern over the potential Medicaid Crowding Out effect, and you can see where some states may choose to opt out of Medicaid expansion.

In as much as many post-acute and long-term care providers are very dependent upon state Medicaid funding, the ripple effect of how this plays out in the months ahead will be something such organizations will want to watch closely.  And, of course, we will be actively monitoring such developments here in the Pub.  There could be significant state policy ramifications impacting the budgeting of Medicaid funding for post-acute and long-term care.

That’s what I think, anyway.  I would be very interested to know what you think.

  ~ Sparky