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Will you treat me?

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This is the text of the keynote presentation given for the Virtual Ability Mental Health Symposium April 27th.

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Will you treat me?

  1. 1. Will you treat ME?Funding mental health care treatment - Now and Under the Affordable Health Care Act"Mental Health SymposiumGood Morning. It is indeed an honor to be asked to speak at today’s mental healthsymposium. As my introduction as mentioned, my “hats” are many. As a nurse practitionerworking in a free clinic, I worked with many clients who struggled with issues related tomental health, addiction, and chronic health conditions. As a professor of nursing, I havetaught many classes on the topic of health care ethics, justice and health care reform. Thismorning, I would like to talk about the topic of our current situation with funding mentalhealth care treatment. *In order to understand the way in which mental health care has been regulated and fundedin the United States, it’s important to understand a bit of historical context regardingmental health treatment. While this is a fascinating topic (which I’m really interested in)full of horrific abuses (think “Bedlam” - the Royal Bethlem Hospital in London – one of theoldest and most infamous asylums), the most relevant historical context for today’s talk isthe notion that historically, there has always been a separation of mental health care fromall other “traditional” areas of medical treatment. *As you can imagine, it’s not a far stretch that this “split”, this separation and idea thatmental health care treatment is different from the treatment of the body, led separation inhow we pay for mind treatments and body treatments. Historically, insurance companieshave separated out mental health care treatments and placed separate limitations andinstituted independent requirements for mental health coverage. *These sorts of limitations have led many who advocate for mental health care to perceivegrave injustice in our health care system. When I’m teaching about such things, we talkabout this in great depth. The United States has one of the most expensive health caresystems in the world, with health care costs accounting for about 17.6% of the grossdomestic product in 2010 – holding steady from 17.7% of the GDP in 2009. *This means that American’s typically spend $8233 on health care per capita per year. Thisis twice as much as what folks spend in relatively rich European countries like France,Sweden and the United Kingdom, places thought to have decent health care. Thebreakdown on this graph shows you where we typically spend it – you can see that thisgraph doesn’t show mental health care. Now there are a lot of reasons that the USA healthcare is so expensive. Rich countries across the board will spend more than poor countries,but even accounting for the relative “wealth” of America – health care spending isextremely high. Statistically, we know that hospital spending is higher than in similarlydeveloped countries, spending on administration costs in America is particularly high(about 7%), some prices are higher and that in some cases the American health care systemprovides more (not necessarily better) health care. For example, in America there aremore C-Sections, more total knee replacements, more coronary angioplasties, moretonsillectomies, and more CT and MRI scanners than in similar countries. *
  2. 2. What does not appear to be the case is that mental health care spending is much differentfrom what is spent world wide on mental health care. I’m sure this doesn’t shock orsurprise many of you. I doubt that any of you who have had any experience with themental health care system believes that there is so much mental health care happening thatthis is single-handedly driving the American health care system to it’s knees. Many of youmight be acutely aware of the fact that access to mental health care professionals is worsethan for other health care providers. 89.3 million Americans live in federally designatedmental health professional shortage areas. In fact, the United State’s mental health carespending is right on par for what other countries tend to budget and spend in the provisionof mental health care services. *When we look at how the mental health care dollar is typically spent in America, we can seethat outpatient treatment and prescription drugs are the top expenditures. Recent studiesindicate that increasing numbers of people are being treated for depression, but variousstudies have shown that the care is substandard. Medications seem to be the mainstay,with little follow-up. General practitioners prescribe about 3/5th of all psychiatric drugsand what is considered the “gold standard” – drugs and therapy – has become increasinglyuncommon. Thus, even though many more people are being treated for mental healthconditions, overall spending for mental health only grew by 31% while other medicalservices grew much more. Medicaid, the crucial safety net for those with the most seriousof mental health illnesses only increased its expenditures for mental health 1% from 1996– 2006, while expenditures for other conditions increased approximately 25%. *Whenever we consider what we spend, and what we pay for as a society, we aredetermining what we value and what we prioritize as important and meaningful.Sometimes we don’t often think about the “big picture” this way, but that’s really what ishappening. I’ll give you an example from my nurse practitioner practice several years ago.There is a medication called Zyban (bupropion). This particular medication is anantidepressant that is also very useful in helping patients with smoking cessation. With thepatient population that I worked with at the time, I could get the medication covered forthe patient if the patient said that they were interested in stopping smoking, but I could notget the medication paid for if the patient had depression. Now this was a free clinic,operating under a different set of rules (free samples, etc.), but you can see how these sortsof situations set up issues related to justice and fairness and equity. It’s the samemedication. It’s the same patient. It is one person that I’m to care for – yet the “system”will pay for one condition – thereby in effect saying one “matters” and will not pay for theother – does the other condition not matter as well? *These issues of equity and justice and “parity” (or on par, equal to other things) came tothe forefront in the early 1990’s. In 1992, two senators – Senator Domenici and Danforthauthored the nation’s first bill targeting mental health parity. Mental health advocatesargued that health insurance companies should no longer be allowed to have separate anddifferent deductibles, co-pays and levels of services for mental illnesses, but that mentalillness coverage should be “on par with” physical or surgical conditions. At the time, the
  3. 3. Senators found that only 21% of insurance policies provided for inpatient mental healthtreatment, and over 60% of insurance policies explicitly excluded severe mental illnesses.These gaps in health insurance coverage left millions without adequate coverage in theevent of significant and severe mental health crises. The bill garnered quite a bit of pressand raised awareness of the issues related to mental health parity. Unfortunately, the billfailed.But, Senator Dominici didn’t give up and in 1996, he partnered with Paul Wellstonefor the Mental Health Parity Act (MHPA), which did successfully pass albeit with gapingexceptions and lots of loopholes. Many called it a “toothless” victory, but it was, I believe,the beginning of the movement in this country that set the stage for at least somebeginnings of mental health parity. The “toothless” aspect of the law is that it does notrequire insurance companies to provide mental health benefits. However, if the insurancecompany does provide mental health benefits, they have to be in line with the coverageprovided for medical or surgical conditions *One of the most interesting issues going forward will be how the recently passed (andupheld by the Supreme Court) healthcare reform legislation – the Patient Protection andAffordable Care Act (PPACA) also known in the media as “Obamacare” will affect mentalhealth care in the United Sates. Perhaps surprisingly, there is a lot in the Affordable CareAct that offers great potential for the expansion of mental health services, as well as hopefor better integration within the context of the American health care system as a whole andimprovement in the quality of care being offered. Historically, most people in the UnitedStates with significant mental health illnesses have not had private insurance coverage.They have either had to obtain coverage through some kind of publically funded programor they remained uninsured. Like it or not (and many do not like it), one of the mainthrusts of the Patient Protection and Affordable Care Act as well as the Health Care andEducation Reconciliation Act of 2010 is the expansion of health insurance coverage toabout 32 million Americans. Access is going to be expanded in several different waysincluding the extension of coverage to dependents until the age of 26 (very important giventhat many significant mental health conditions are often diagnosed by this age), theabolishment of pre-existing conditions (often a significant concern for those with mentalhealth conditions) and by the creation of health insurance “exchanges”. An exchange isgoing to be a place (or website) that an individuals or an employer can go to for thepurpose of purchasing health insurance. Each state can choose whether to create and runtheir own exchange or to have the federal government create and run the exchange forthem. While the exchanges are currently under development, the exchanges will have tostandardize the language in the plan offerings so that the consumers (YOU!) can look at theplans offered and make good comparisons. All plans sold in the exchange must include 10essential benefits, which will include coverage (and this is significant) of mental healthservices and substance disorder services. *The Affordable Care Act will extend Medicaid eligibility if a state elects to extend coverage.For those who might not be as familiar with what Medicaid actually is, Medicaid is a statebased program that provides health coverage to lower income people, families withchildren, the elderly and people with disabilities. One disappointing (my opinion only)portion of the Supreme Court ruling last summer was that the Supreme Court ruled that the
  4. 4. federal government couldn’t restrict Medicaid funds if a state decided not to expandMedicaid coverage. This means that each state can decide whether they want to expandMedicaid or not. The map before you shows what each state is leaning towards doing as ofa week ago.If your state is expanding, that means that more people will be covered under Medicaid asthe Affordable Care Act extends Medicaid to those with incomes below 138% of the federalpoverty guidelines. Over 15 million uninsured adults could become newly eligible forMedicaid across all states. *This is where the news gets (I think) really good. Remember the Dominici & WellstoneMental Health Parity Act? It still stands. It’s now paired with the Affordable Care Act. Soall those mental health services need to be on par with, as good as medical conditions. Thevery act that many described as “toothless”, “worthless” and “useless” because at the time itdidn’t mandate mental health coverage is predicted in combination with the Affordablecare Act to bring truly bring mental health parity to millions of Americans. That’s becausenow mental health care services are mandated to be covered as the part of the 10 essentialservices and because of the mental health parity act, the coverage will have to be on parwith all other coverage *The Affordable Care Act also aims to improve and increase community and home basedservices for people with disabilities under Medicaid. Community First Choice Optionprovides assistance for people with significant disabilities who need assistance in theirdaily lives. Now with mental health parity – significant psychiatric disabilities must beincluded as well. Another Medicaid state option created by the Affordable Care Act thatmay be of great benefit to those with psychiatric disabilities is the option to fund a “healthhome” - programs that provide comprehensive care coordination and other supportiveservices for people with chronic health conditions. These are options that states can seekto expand and fund services for their Medicaid clients. *I want to conclude today’s keynote discussion with ethics and notions about what we valueand who we are as a society. There are many who still believe that mental illnesses are notmedical conditions that should be accorded the same treatment that one could expect for aphysiologic condition such as appendicitis or cancer. However, growing research indicatesthat there is a physiologic component to many mental illnesses. Mental illness actuallyresults in more fatalities per year than HIV/AIDS. Increased costs of providing coveragewould most likely be offset within several years by increased productivity and decreasedusage of other medical services *Given the Affordable Care Act’s complexity and scope, it will likely take some years as allthe provisions become interpreted and implemented. In conclusion, I would argue that weare entering a new era with guarded optimism for how we envision the funding andprovision of mental health services in this country. While there certainly is much to bedetermined in the coming years, including funding of provisions of the Affordable HealthCare Act, the status of mental health care funding in this country has never looked better.
  5. 5. This is not to say that there is not a lot of work to be done. However, great strides are beingmade in the areas of expansion of coverage, mental health parity and provision of services.There is great reason to be hopeful.I’ve included a list of references for this talk as well as some helpful websites. Please don’thesitate to contact me should you have any questions. Thank you for your kind attentionduring today’s presentation!References:Krisberg, K. (2012). Health Law Raising U.S. Mental Health Parity to the Next Level.TheNation’s Health.Sept. 2012.Mauldin, J. (2011). All Smoke and No Fire? Analyzing the Potential Effects of the MentalHealth Parity and Addiction Equity Act of 2008. Law and Psychology Review 35; 193-207.Mechanic, D. (2011). Behavioral Health and Health Care Reform. Journal of HealthPolitics, Policy & Law 36 (3): 527-531.Siegwarth, A. &Koyanagi, C. (2011). The New Health Care Reform Act and Medicaid:New Opportunities for Psychiatric Rehabilitation. Psychiatric Rehabilitation Journal 34(4); 277-284.Smith, D., Lee, D. & Davidson, L. (2010). Health Care Equality and Parity for Treatmentof Addictive Disease. Journal of Psychoactive Drugs 42 (2); 121-126.Helpful websites:• http://www.healthcare.gov/law/• http://www.healthcare.gov/using-insurance/low-cost-care/medicaid/• http://www.cbpp.org/cms/index.cfm?fa=view&id=3819• http://www.oecd.org/

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