Election Over . . . Now What?

Wow is this country divided!!! California voters approved four statewide tax extensions or increases and many local property taxes and strengthened the already total Democratic Party control of the legislature while at the same time the majority of states gave Republicans the White House and re-affirmed their control of both houses of Congress.

So what will this mean for community behavioral health care in California?

The results in California assure that we will move forward in a positive direction with more state funds, especially for substance use disorders based upon the passage of Proposition 64. That measure – which legalizes recreational marijuana – creates about $1 Billion in new taxes (wide ranging estimates from $700 million to $1.2 Billion or more) with 60% earmarked for “Education, Prevention, Early Intervention, and Treatment for Youth” “Youth” age is not defined and the legislature could extend it to 25). The services are for substance use disorders and related conditions including mental health and also for family members.

CCCBHA is well positioned to work with state and county officials and other substance use disorder providers and advocacy groups, as well as education and criminal justice leaders, to shape this legislation – probably the most significant new law since Proposition 63.

Passage of Proposition 64 should start a planning effort to develop strategies to close gaps in the continuum of care and to coordinate and integrate efforts with Proposition 63. It should also lead to integrated prevention and early intervention and comprehensive youth policies and programs, including school programs and integrated criminal justice and hospital diversion programs.

These efforts are further strengthened by the passage of several local housing bond measures generating several billion dollars from the City of Los Angeles and several bay area counties. These were property tax increases that required a 2/3 vote and all included funds for housing for homeless individuals and families.

These measures will significantly improve the “leveraging” value of the No Place Like Home MHSA housing program.   That in turn means that the cost per unit of housing from Proposition 63/MHSA funds will be much less and means that the value of that measure will be greater. That in turn means that the MHSA will be able to serve more people.

At the same time the state budget got boosts from the passage of a tobacco tax (Proposition 56) which will provide over $1 billion in funding for MediCal. Similarly, Proposition 52 preserves a hospital tax that generates $2 Billion in additional federal funds for MediCal while Proposition 55 extends a tax on high income earners that will increase state general fund revenues by $4 to $9 Billion starting in 2019.

But what about the federal government and federal support for our programs?

That is, of course, the big unknown and we have to assume that there will be efforts to scale back federal support just as we saw during the Bush administration.

However, the circumstances are quite different than they were during those years.

  • First and foremost is that the Affordable Care Act gave health insurance to 20 million people who otherwise would not have it. Never in history has congress taken action to take a major entitlement away from people who already have it. Secondly, while the term Obamacare is not popular, its central provision of preventing insurers from denying coverage to people based upon pre-existing conditions is very popular. That feature does not work unless insurers have a broad pool of healthy people also insured to reduce overall costs. There are very few options other than keeping most of the law intact that makes that work. I have no idea exactly what will happen but know that it won’t be that easy to just repeal the law and go back to what we had before it. I don’t see that happening.
  • The support in Congress for behavioral health is much stronger now than it was ten years ago. Mental Health Parity was passed in 2008 on a bipartisan basis and signed into law by a Republican President. The Certified Community Behavioral Health Centers pilot program has bi-partisan support in both houses with all four of its co-authors still in office. It is likely to be shown to reduce overall health care costs and could be expanded. And legislation to recognize the underfunding and importance of mental health and taking steps toward more comprehensive support seems ready to be enacted by both houses of congress.
  • Finally our advocacy leaders, the National Council for Behavioral Health are in a much stronger position than they were when George W. Bush was elected. In fact, it was his administration’s efforts to weaken Medicaid that led to the leadership changes at the National council bringing in Linda Rosenberg and her team of talented people to position us to be more successful on Capitol Hill.

Putting this all together I think we should expect a continuation of most recent trends. There will be efforts at the federal level to shift financial risk to states and to give states more flexibility. It will probably be even more important to look at payment reform and to position our membership to do business with for profit managed care companies.

There is a risk of losing some level of federal financial support but I doubt that it will be that substantial as applied to behavioral health, especially in states like California which are not likely to use increased flexibility to reduce Medicaid benefits.

Within the state there will be continued support for closing gaps – especially for substance use disorders, housing and developing jail and hospital diversion programs and alternative crisis care systems.

There will be expanded efforts to support on-campus prevention and early intervention behavioral programs for students of all ages, requiring better coordination between behavioral health and schools and colleges.

Perhaps I am being overly optimistic (as I often am) but I really think we are in a much stronger position (both in California and Washington) than we were from 2001-2006, the last time there was total Republican control in Washington.

That, of course, does not mean we should be complacent. However, I think that those who want to simply repeal Obamacare and reduce Medicaid benefits and funding will encounter a lot more resistance (including many Republicans) than it sounds like on the campaign trail.

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