Medicaid

The Fatal Flaw in Graham-Cassidy, and What Comes Next

JCheang — Wed, 27 Sep 2017 15:55:37 +0000

The Fatal Flaw in Graham-Cassidy, and What Comes Next JCheang Wed, 09/27/2017 - 11:55

By Paul Gionfriddo, MHA National President and CEO

Graham-Cassidy died a political death this week, but it isn’t the last we’ll hear of Affordable Care Act reform in this Congress.

Politics – and the reality that no more than 20 percent of the public supported the proposal (which still hadn’t actually been exposed to the light of day) – made the difference.

But here’s what should have made the difference: the fatal flaw in the Graham-Cassidy approach was that it intended to reward with more Medicaid money those states that have done the least to support their own Medicaid-eligible populations in the past.

If you think that the promise of more money would have changed that, think again.

Most of these states have gotten a higher federal match since the beginning of the Medicaid program, and these extra federal dollars have done nothing to improve health outcomes in those states during the past fifty years.

That’s because you can’t just send money to states and expect them to improve care, any more that you can take money that states have used to improve health care and not expect people to be worse off (something the Graham-Cassidy also would have done).

So, what’s next? We expect Congress to revisit ACA reform during the next few months. They’ve promised as much, and this is a promise I expect that they will keep.

They can continue to do this in the worst way possible, without input from experts, without hearings that include advocates and the public, and without drafting bills that can be read and reviewed by members of Congress before they are voted on.

Or they can do this in a thoughtful, bipartisan way – the same way they did mental health reform in 2016.

The most recent proposals that were introduced by the two political parties could not have been further apart.

However, they – and the earlier effort by Senators Alexander and Murray – did signal a continued willingness of members of both parties to improve existing laws and address the challenges that have emerged for so many who are affected by them.

While we continue to applaud the efforts of members of both parties to improve on the current system of insurance through amendments to, or replacement of, provisions of the Affordable Care Act, we believe that this work – like the 21st Century Cures Act of 2016 – can only be done in a collaborative, deliberative environment in which members work together across the aisle in the full light of day to develop comprehensive reforms with adequate public input.

We believe that the goal of a federal guarantee of universal coverage is still the correct one, but never at the expense of failing to offer and reimburse behavioral health services at parity with other services.

Additionally, we favor fostering a spirit of independence and creativity at the state level, but not without protecting against policies that single out people with serious mental illnesses and other chronic diseases and treating them as second-class citizens.

Also, we favor promoting innovation and true services integration among service providers and others in the field, without creating needless legal barriers to sharing of information and resources.

Furthermore, we favor rewarding this innovation with the kind of financial support that will bring new programs and new strategies – including those that use the talents and skills of people with lived experience in implementing those strategies – for serving people with mental health concerns to scale.

Finally, we continue to be the strongest advocates for giving much greater attention to the needs of all our children.

For too long, we have ignored mental health conditions as they have emerged in our children, either because we fear the unintended social effects of diagnosing them properly or because we have not been sure how to treat them effectively.

We have answers to these concerns today that include integrating health, behavioral health, and educational services for children, because this integration – along with prevention, early identification, and early intervention – is essential to their success in later life.

At Mental Health America, we believe that we must stop waiting for crises to occur, and must stop waiting until people are so ill that recovery is more challenging. We must act Before Stage 4 whenever possible, just as we do with every other chronic disease in America.

And our federal policy must embrace this approach.

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Time to Move Forward with a True Medicaid Reform

MPernell — Tue, 09 May 2017 19:17:17 +0000

Time to Move Forward with a True Medicaid Reform MPernell Tue, 05/09/2017 - 15:17

Medicaid is an expensive program. For elders in nursing homes, for adults with chronic conditions, and for children with health care needs, it is also a life-saving one.

Among the many messages the House of Representatives sent in its passage of the American Health Care Act (AHCA), it sent this one – the majority does not value Medicaid at the level of its current spending.

What can be done about this? Can Medicaid spending be cut and future growth be limited, without throwing millions of people off the Medicaid roles?

At MHA, we think it can, and we know the way to do it.

Here is our recommendation:

Congress should mandate that the Centers for Medicare and Medicaid Services (CMS), which oversee the Medicaid program, review current or proposed state plan amendments, waivers, managed care practices, and other innovations, and identify those that improved health outcomes. All of these – when successful – are successful in part because they reduce Medicaid spending.
Among those policies and practices that are identified as improving health outcomes, the Office of the Actuary shall identify those that reduced or are predicted to reduce the federal deficit.
From those, CMS shall identify those that may be implemented in other states with opportunities for comparable savings. The Office of the Actuary shall determine the predicted reduction in the federal deficit for appropriate states to implement the policy or practice.
CMS shall recommend that the state implement the policy or practice. If the state chooses to implement the policy or practice, then CMS shall offer technical assistance to ensure that the state maximally improves health outcomes and reduces the federal deficit in doing so. If the state responds with a valid reason for why implementation of the policy or practice would not be appropriate, then CMS shall move on to the next opportunity for savings.
If the state fails to respond with a valid reason for not implementing the policy or practice and takes no action, then CMS shall reduce its federal matching payments to the state by the amount that the Office of the Actuary predicted the policy or practice would have reduced the federal deficit.

In addition, in our proposal:

There would be no predicted reductions in the number of Americans covered by public or private health insurance;
There would be no reductions in the scope of mental health and substance use benefits provided under public or private health insurance; and
There would be no increases in health care costs for low-income Americans.

This approach would work for everyone. The federal and state governments would save money, outcomes for people would improve, and no one would be cut from his or her lifeline. It would make sense.

At MHA, we have been at the forefront of advocating that health care reforms take us forward, not backward, building on the progress we made in parity and acting Before Stage 4 in the 21st Century Cures Act.

AHCA does just the opposite. But the Senate has the chance to start over and do something meaningful, backed up by years of Congressional initiative and analysis – in other words, by investing in evidence-based approaches to policymaking.

This as an opportunity. It’s up to policymakers to make the right choice.

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What could be a valid reason for not allowing a pass?

Maybe CMS try to assist that state in overcoming or adjusting in a manner that allows it to participate, then, if CMS finds a valid reason for not implementing the policy they move on? What mode of investigation would the actuary take to ensure the reason truly is valid since they are relying on states to provide evidence against themselves? Does the evidence in evidence based reports get its own investigation? I agree that costs can be cut at the state levels without covering less people if states are highly motivated.

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Health Care or Health Can’t: Western Omelet Style

CHoward — Fri, 28 Apr 2017 04:00:00 +0000

Health Care or Health Can’t: Western Omelet Style CHoward Fri, 04/28/2017 - 00:00

By Caren Howard, MHA National Advocacy Manager

It’s hard to believe that the U.S. House of Representatives, the legislative body of the people, by the people, and for the people, would seriously consider a health care bill that harms people by eliminating their eligibility to a health insurance plan.

I think everyone agrees, Democrats and Republicans alike, that Obamacare was a start to making the American health care system better, but that it wasn’t perfect. It contained costs across the country by adding more healthy people to the insurance pool and it provided coverage to tens of millions of new people who were either getting sicker and avoiding doctor’s visits until stage four due to costs, or solely relying on the emergency room (the most expensive place to receive services) for their health care needs. The place to address a mental health crisis is not in the emergency room -- it’s before symptoms negatively affect behavior or lifestyle with regular treatment before a crisis or stage four (B4Stage4).

The Affordable Care Act (ACA or Obamacare), gave insurance providers incentives for covering preventive care, which includes annual screenings for mental health conditions, and other cool initiatives that ultimately help people get healthier and rely on emergency room care less or not at all.

Unfortunately, the individual market is still a heavy strain on the economy, and on insurers, regardless of Obamacare’s changes because it continues to provide plans to many people with very expensive health needs. Many people who saw premiums rise under Obamacare were in this individual market.

H.R. 1628, the American Health Care Act (AHCA) proposes a Federal Invisible Risk Sharing Program, as an amendment, to provide subsidies to insurers who cover these really expensive benefits in the individual market. You can read more about it here. The problem is, the bill does not specifically provide enough funding for this model to work, and in other states like Maine and Alaska, where this model was successful, it worked in tandem with changes the states made based on the Obamacare law.

Essentially, under the AHCA this new risk program would operate like making a Western omelet without the ham and peppers, significant parts of the omelet. The ham and peppers make a Western, not the eggs and cheese. Without them it’s a plain cheese omelet.

Another concern I have about the AHCA bill is the new MacArthur amendment, named after one of the sponsors, Tom MacArthur of North Carolina, which allows states to apply for waivers to opt-out of the most widely known consumer protections provided by Obamacare.

Once again insurance plans may not cover mental health and substance use treatment, they may choose not to cover people with pre-existing conditions (i.e., a bipolar diagnosis), they may not charge everyone the same cost-sharing amount, or premium, for the same benefit plan (i.e., charging someone over 60 years old more than three times more than a younger person), and they will be allowed to charge women more for services than men. Nearly one in four people at any time in their life will need mental health or substance use treatment. Congress should not make it harder for people to get well.

This is a bill I take personally. Congress even knows it is pretty terrible so they decided to write in a clause exempting themselves, their families, and their staff from the bill if it becomes law. That’s a telltale sign of trouble ahead.

I’m hoping this bill does not pass the House of Representatives this week or ever. And, I am urging you to speak up and tell Congress too why we cannot live healthier lives without a better fix. I think the right bill will allow all people win, including Americans with mental health and substance use needs.

Congress should listen to the people telling them to fix the law, not to dismantle the entire system. You can easily tell them that by taking action on MHA’s website here.

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Obamacare

policy

The Affordable Care Act

legislation

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Make the AHCA a BETTER health care bill! ALL Americans deserve health care coverage. Minimize the stronghold that insurance companies have on healthcare. Most of all don't repeal parity of mental health care, something that has taken decades to achieve. Don't increase the stigma toward mental health by telling US citizens mental health services don't have the same value as medical/surgical services. I urge the you to improve the bill!

Healthcare for All

I believe that ObamaCare had filled some gaps in the benefits of individuals who were sick or undergoing treatment so that even if they were in between jobs they would not get affected too much. With the new healthcare bill to repeal most of the conduits in healthcare this will make it even more troublesome.

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A Nonstarter: Repealing Mental Health Reforms Granted by Obamacare

CHoward — Thu, 23 Mar 2017 17:32:24 +0000

A Nonstarter: Repealing Mental Health Reforms Granted by Obamacare CHoward Thu, 03/23/2017 - 13:32

By: Caren Howard, Advocacy Manager

One in five people in their lifetime will experience a mental health condition and four in 20 people will experience chronic, ongoing issues. Mental health is integral to overall health of an individual throughout their lifespan.

The Affordable Care Act (ACA) or “Obamacare” helped people in need of mental health and substance use disorder (MH/SUD) treatment because it no longer permitted insurance companies to exclude MH/SUD treatment from benefits. Companies now have to provide insurance plans that cover annual doctor’s visits and other preventive benefits that save money and lives like screening at no extra cost to the consumer.

The law incorporated evidence into policy: any health condition is best addressed when treated early on, before stage four (B4Stage4). And, the ACA extended MH/SUD parity into more types of insurance plans so beneficiaries would no longer be forced to pay more for MH/SUD treatment than they would for other types of medical and surgical benefits.

Obamacare also expanded eligibility criteria for Medicaid and greatly increased funding to states to cover low income adults in a ‘Medicaid expansion’ population. This may not mean much to you if you have employer sponsored health care, but if an employed family member or loved one does not have a health plan through an employer and their income is below 138% of the poverty level, this is a big deal.

Nearly one in three Medicaid dollars is spent on MH/SUD services which helps catch conditions early, and when on-going treatment is required, helps to maintain employment, housing, and quality of life. Many states under the ACA have moved toward more integrated, patient-centered care through creative and innovate delivery models. This means that providers may treat together conditions that occur together. Simple, right?

Obamacare allows young people, regardless of student or work status, to stay on their parent’s insurance until 26 years old – an age by which most mental health and substance use conditions will initially appear. To me, this was an important provision that hit home.

In high school, I visited the 9^th grade guidance counselor to talk about anxiety that I experienced just before basketball tryouts began, and while it was nice for him to listen it was obvious he had little advice to offer. Several times throughout adolescence, my father and I had conversations about how anxious and moody I felt around the fall season and occasionally other times too. Infrequently, I attended grief therapy session to help me deal with the death of my mother at a young age, but it never occurred to me to talk about my feelings of anxiousness in that context.

When I was in college, I shared my “nervous” feelings with a trusted church member who happened to work in health care. She immediately encouraged me to seek treatment, saying “trying it out wouldn’t hurt.” And, nearly eight years after my first feelings of unknown butterflies, a psychiatrist offered a diagnosis. For me, the cost of waiting so long was dropping a full engineering scholarship and my varsity volleyball commitment as they had become too difficult to manage.

But, at 20 years old, I finally felt relief knowing there was a name for my feelings. Phew.

Looking back, I know that if I didn’t have health insurance through my school or my parent and I had to purchase it on my own, as many young people were unable to do before the ACA (indeed, this was the start of the Great Recession when jobs were slowing) I may not have seen a doctor for even more years and perhaps I wouldn’t be where I am today.

Right now Congress is debating the American Health Care Act (AHCA), a bill that puts all of the recent gains of mental health reform under Obamacare at stake. The Congressional Budget Office estimates that more than 24 million Americans will lose health insurance under the AHCA in ten years. Repealing the ACA will surely do greater harm by:

- slashing funding for the Medicaid program, the largest financer of MH/SUD

- discouraging healthy people from purchasing insurance until they need it by eliminating the penalty for not purchasing insurance

- repealing the ACA’s basic benefits package which includes MH/SUD treatment.

It is a critical time for the future of health care and mental health systems and Americans must weigh in now – while Congress considers the ACA replacement bill. The House vote is scheduled on Thursday, March 24^thand the following week the Senate is slated to take up the bill.

Do as I just did, share your story with Congress and your Governors NOW, and, encourage loved ones to do the same.

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More Challenges Emerge in the Effort to Enact AHCA

EWallace — Mon, 20 Mar 2017 18:47:41 +0000

More Challenges Emerge in the Effort to Enact AHCA EWallace Mon, 03/20/2017 - 14:47

By: Paul Gionfriddo, president and CEO

As the past few days and weeks have unfolded, it is becoming increasingly clear how the American Health Care Act of 2017 (AHCA) as currently drafted will have mostly unintended, mostly negative consequences for people with behavioral health conditions. We believe that these consequences easily could and should be mitigated.

At a very high level, the Congressional Budget Office (CBO) scoring analysis suggests that millions of Americans with mental health and substance use conditions will have less access to the treatment they need.

This could include up to five million people by 2026 who were covered by Medicaid expansion, based on reliable estimates of the number of people with behavioral health conditions included within the expansion population.

This will be mitigated to some extent by individuals living below the poverty level who will now be eligible for tax credits to purchase insurance in both expansion and non-expansion states. But let’s be honest. The CBO estimates that the number of newly insured will be no more than one million, and people with behavioral health concerns will represent only a fraction of those.

We continue to see these elements as essential to the health and well-being of people with behavioral health conditions:

Maintaining behavioral health benefits at parity with other benefits;
Maintaining guaranteed, continuous, and affordable insurance coverage for people with pre-existing and chronic conditions;
Maintaining a healthy Medicaid program for people with chronic conditions; and
Giving states more flexibility within Medicaid to cover earlier interventions.

The AHCA as it stands today will adversely affect these essential elements.

While the intent of AHCA was not to repeal behavioral health parity, as was made clear in the Energy and Commerce Committee colloquy between Rep. Murphy and Committee Counsel during the mark-up, according to the CBO the law will lead to broader availability of “plans that cover a lower share of health care costs,” and “that individuals’ cost-sharing payments, including deductibles, in the nongroup market would tend to be higher than those anticipated under current law.”

That’s clear. If plans cover less and prices go up, the concept of “parity” won’t mean tomorrow the same thing as it does today. Plus, if the Essential Health Benefits are fully repealed in the future as they are in the Medicaid program through the AHCA, then many insurance products might not contain behavioral health benefits at all.

While the AHCA does not repeal protections for individuals with pre-existing conditions, it does include a continuous coverage penalty. That’s inconsistent with our position that people are harmed by making it harder for them to maintain continuous insurance coverage.

And finally, Medicaid is cut – big-time – through a major shifting of costs to states.

So, what should be done to fix these flaws?

Here are three recommendations that flow naturally from what sponsors intended in crafting the AHCA.

First, let’s make sure that the dollars that remain are used for their intended purpose. For example, giving $8 billion in new short-term Medicaid funding to non-expansion states could help get more people with behavioral health needs the care and services they need, but only if states are obligated to use these dollars for that purpose, and not just to balance their budgets.

Second, let’s recognize the importance of early intervention across the board. The only reason insurance costs in the nongroup market will go down is because the AHCA is incentivizing younger, healthier people to purchase insurance. The Medicaid program should offer similar incentives to states to enroll eligible individuals at the earliest stages of their illnesses and move them along pathways to recovery well before Stage 4. And Congress shouldn’t be trying to save money by eliminating prevention funding, yet again, as the AHCA does.

Third, states – who will receive billions of dollars less from the AHCA than they would from existing law – must be given greater much greater flexibility through AHCA to use their Medicaid dollars for social support services for their future Medicaid populations. But the AHCA could go a step farther. It could incorporate everything we’ve learned from past successful waivers – which, by definition, all saved money while improving care, services, and supports – and build them into the new Medicaid program rules.

Otherwise, everyone loses.

Congress has a long way to go to make this AHCA right, and if it is going to move forward it should get there as soon as it can.

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Please do not cut these essential services for behavioral health.

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Reforming Obamacare: The Challenge Ahead for Mental Health

EWallace — Tue, 15 Nov 2016 17:32:12 +0000

Reforming Obamacare: The Challenge Ahead for Mental Health EWallace Tue, 11/15/2016 - 12:32

By: Paul Gionfriddo, MHA president and CEO

To contain costs, President-Elect Donald Trump has suggested replacing Obamacare with a package of benefits that might include:

Permitting Insurance to be sold across state lines
Retention of the mandate covering pre-existing conditions
Allowing young people to remain on parents’ insurance
Creating high-risk pools to provide insurance to people with chronic diseases
Using Health Savings Accounts (HSAs) as an alternative to tax credits
Expanding the use of high-deductible plans to lower premium costs

Several of the provisions could affect people with mental health concerns more than others. Let’s consider some of the challenges the President-Elect and Congress will face as they craft these – and other – possible changes to the Affordable Care Act (ACA).

Covering Pre-Existing Conditions

Trump has been clear that he would retain this provision. It is a lifeline for people with all chronic diseases and conditions. However, these conditions are often expensive to cover. Unless you mix them in a plan that captures healthier people, too, costs will rise no matter what else you do.

Allowing Children to Remain on Parents’ Insurance Until Age 26

Trump also favors this. It’s very important to families, because so many serious mental health concerns begin during childhood. Here’s the challenge. What is life-saving for young people with serious health conditions is a provision that also keeps healthy, younger people out of the exchanges.That has helped to drive up the costs of the plans in the exchanges. If you can’t figure out how to get health young people into the exchanges, you make insurance more expensive for everyone else.

Setting Up High-Risk Pools

Trump has also suggested that new high-risk pools could be the answer for people with chronic diseases who need insurance. We had a high-risk pool in Connecticut when I was a state legislator in the 1970s and 1980s. It was expensive, and the only people who chose to be in it were the ones who absolutely knew that the insurance would pay out more than the premiums cost. Unless these risk pools are heavily subsidized and include some incentive for healthier people to join them, they probably won’t work.

Expanding the Use of Health Savings Accounts (HSAs) Coupled with High-Deductible Plans

Trump has suggested coupling HSAs with the use of more high-deductible plans to lower costs. In “exchange speak,” think more bronze plans. Here’s the way this might work.

Assume that a single male with high healthcare costs who makes $50,000 per year buys a plan with a $10,000 deductible and pays $250 per month for the insurance. To use an HSA to cover those costs, he would deposit $13,000 into his HSA to cover the premium and the deductible. That would reduce his taxable income to $37,000. If he is in the 15% tax bracket, at the end of the year he would get back 15% of the $13,000 he deposited into his HSA, or $1,950.

Spending one-quarter of his income on health care to get back $1,950 would not make him feel too good about that high-deductible plan, and he would probably go uninsured.

Rolling Back Medicaid Expansion and Converting Medicaid to a Block Grant

Any debate about ACA change will include at least some discussion about rolling back the Medicaid expansion. This expansion has been a huge benefit to adults with serious mental illnesses.

Most states expanded Medicaid, including Michigan, Pennsylvania, Ohio, Iowa, and Arizona. The federal government is covering more than 90 percent of that cost. Trump has said that he does not want to roll back entitlements. Neither would the voters in these states.

Trump has also suggested converting Medicaid to a block grant.This could be done, because the Medicaid program is in reality fifty different state programs. But the question would boil down to this. Would the federal government provide the full share of Medicaid payments to states in the block grant, or withhold a few percent, as it did with past block grants? Withholding even 5 percent of $550+ billion Medicaid dollars would have an enormous impact on state budgets and people in need.

The Challenge Ahead

The goal of ACA was to get more people insured, using the health care financing system that was already in place.

The challenge ahead will be to keep them insured if ACA is changed. Probably the best way to do this – Medicare for all – won’t happen anytime soon. But if the new President and Congress don’t walk a tightrope in making their changes, single-payer may come along a whole lot sooner than anyone imagines.

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I should have figure that a millionaire(R) taking office would change benefits that help those that could not afford health insurance and return the saving back to those who have financial freedom, and those that make less then $15,000 dollars a year are again kicked to the curb. We are now back on track to where the wealthy don't have to pay higher taxes or high insurance cost and those of us who struggle in life to make ends meat are one again hung out to dry and have become a class of nobodies. So does this mean you are going to cut out The Mental Health & Substance abuse disorder parity task force? What other programs are going to be cut so that the poop can not afford to live in a home, have hot meals, warm clothes and living on the streets because now they have to pay more for medical and mental health or stop seeking that help because they can no long afford the care once again.

Mental Health

Greetings. My question is who benefits from serving the mentally ill, certainly not the patients. The food they are given is below the standard of any health care. Pizza for dinner, cornflakes and milk, coffee for breakfast, lunch 2 slices of white bread with a slice of package cheese and a slice of poison salami, cured ham or simmilar. a small water or a colored beverage. Something better must come, Lets see. The patients are so heavily medicated that they sleep a lot. NO REACREATION to keep the brain active.