Another Attempt to Weaken the Affordable Care Act

Another Attempt to Weaken the Affordable Care Act?

Grassroots advocacy is making a difference.

As widely reported, there is a new version of Trump care/House Republican efforts to weaken the Affordable Care Act (ACA).  The changes give states additional freedom to eliminate protections for people with pre-existing health conditions. Anyone who has ever received a prescription for an antidepressant or seen a therapist is considered one of those high risk individuals. The new bill also authorizes elimination of 10 essential benefits.  These include behavioral health as well as habilitation and rehabilitation services important to people with behavioral health problems.

All of the Medicaid cuts there were in the original proposal are still there. The changes satisfied the so-called freedom Caucus of extreme conservative Republicans.  On the other hand it has strengthened the opposition of so-called moderate Republicans.  Here is a brief presentation summarizing the status of this effort and other related possible health policy changes. Note especially the charts on pages three and 13.

When the original bill was considered last month all 14 California Republicans were reported to be in support. Now we have heard that Congressman Jeff Denham from the northern San Joaquin Valley is not supporting the bill.  This means that the grassroots efforts of organizations like ours are making a difference. See Sacramento Bee Article.

Unless the bill has been passed by the house before you read this, those of you who provide services in areas represented by Republicans in Congress should redouble your efforts to remind these members of the consequences of cuts in behavioral health services and access to insurance which includes these benefits.

There has never been a time when there’s been so much public attention on how health care systems work. This is the time for all of you to continue to expand your efforts to educate your political leaders and build relationships that will impact policy support beyond this year. These efforts will pay off, even if it doesn’t appear that way in terms of immediate change of position.

Those of you who provide services in areas represented by Republicans in Congress should redouble your efforts to remind these members of the consequences of cuts in behavioral health services and access to insurance which includes these benefits.

The house bill seems short of the votes it needs there.  It is given no chance of passage in the Senate. But we cannot relax as the battle will continue.

Every member of Congress whom we can move from support to opposition makes it harder to pass any of the Medicaid or healthcare cuts that congressional leadership and the president are proposing.

Grassroots pressure seems to be the key-especially as House members start looking to 2018 elections. In recent special elections in Montana and Georgia Democratic candidates did much better than they had done in 2016.

This makes more House Republicans feel vulnerable.  Public opinion polls show that the ACA is more popular than ever and there is little support for Republican proposals to weaken it – outside of a narrowing conservative base.

California has an open primary system which separates it from other states were members of Congress are more concerned about winning the primary election within their own party after which they would have a so-called safe seat.  That is no longer a luxury for any California elected officials.

Accordingly, all of them have to think twice about taking health insurance away from people who now have it and the risks this presents for their political future.

There has never been a time when there’s been so much public attention on how health care systems work. This is the time for all of you to continue to expand your efforts to educate your political leaders and build relationships that will impact policy support beyond this year. These efforts will pay off, even if it doesn’t appear that way in terms of immediate change of position.

Workforce and ACA are connected issues

When the ACA was enacted in 2010, there were many comments about the shortage of doctors and the capacity of healthcare systems to provide the additional care that would be authorized.

Within behavioral health it was estimated that the act would lead to a 30% increase in mental health services and a 50% increase in alcohol and drug services.

I have not seen recent figures to determine how close these estimates have been, but there is no question that the workforce challenge is greater now than at any time in the past.

Increased demand for services is due to many factors besides the ACA.  Federal commercial health plan and Medicare mental health parity laws have increased utilization of services outside of the public mental health system.  The California Department of managed health care has significantly increased its enforcement efforts regarding the parity laws.  The record fine against Kaiser for not providing timely access to mental health services has had a ripple effect across all health plans- but most directly upon Kaiser itself which is increasing its staff and also supplementing its staff by contracting for additional providers.

Similarly the state prison system and county jails are continuing to report increased percentages of prisoners with behavioral health problems.  The largest such facility – LA County’s twin towers – reports that much of the increase is due to methamphetamine cases. These systems are also under legal pressure to provide more services to meet constitutional requirements of ensuring that all prisoners receive appropriate and fully adequate healthcare.

I had the opportunity to briefly attend a workforce summit led by our Santa Clara County Association of providers.  I was impressed by how well attended it was as well as the breadth of discussion of ideas that go well beyond the more obvious solutions of loan forgiveness programs and increased utilization of peers.

Clearly any significant changes that alleviate these problems require participation of commercial health plans, state prisons, and others outside the public mental health system.  The solutions must also include strategies to significantly increase the number of people who seek work in our field- and the actions that must be taken so that work in behavioral health is more attractive than other career options.

As previously reported, the statewide set aside funding under the Mental Health Services Act expires 2017-18. The act leaves it up to each county to determine what to do about workforce as it updates its spending plans.

There is a recognition of the need for statewide leadership on this issue as evidenced by the well attended summit hosted by the mental health planning Council in March.

At  our request the assembly budget subcommittee held a hearing on this issue and we are proposing that the Office of Statewide Health Planning and Development (OSHPD)  be directed to develop an action plan and provide guidance on the state role in addressing this problem which also affects every other state.

I’m hoping to receive the analysis and recommendations from the Santa Clara Summit in time to include those ideas in the direction that the legislature may provide OSHPD.

If other counties or organizations have also looked at this issue and have other ideas now is the time to get them to me so that I can make sure they are part of what the legislature and OSHPD will be  considering.

Are some counties thinking of turning their systems over to managed-care companies?

I recently attended a Didi Hirsch event where I had the opportunity to catch up with recently retired Los Angeles County mental health director Marv Southard.  He stated that there is a new generation of county behavioral health directors and that many of them seem interested in turning their systems over to behavioral health managed-care companies.  I had only been aware of that pattern in relationship to smaller Northern California counties that are part of Partnership Health Plan and only in regard to the new alcohol and drug organized delivery system.

Marv and I both remember how spectacularly unsuccessful San Diego’s experiment with United behavioral health systems was in the 1990s.  We noted that there are fewer and fewer people who remember that experience.

There is a national trend for states to contract through for-profit managed-care companies for behavioral health services in the same way California does for physical health.  In virtually all cases these are movements from a fee-for-service system to managed-care.

California’s County system already is a managed care system so the insertion of an extra layer of a for-profit company is not likely to generate increased efficiency and effectiveness the way it would when converting from a pure fee-for-service system.

There have been many analyses done, most impressively by ACHSA-the Los Angeles Association of our providers. If your County is considering making this change and want help in how to fight this please contact us so we can give you the arguments and resources that may be helpful.

Can counties take over the mild moderate provider networks?

Marv Southard also stated that LA County had gotten local health plan, state and federal approval so that its provider network can become the network for the so-called mild moderate mental health services which are the responsibility of the physical health Medi-Cal managed-care plans.

I noted that this program was initially given to those managed-care plans because they had networks of providers who could provide these very limited services at lower costs because they would not be subject to the full scope County system documentation requirements.

Marv indicated that the approvals LA had received would design these mild moderate services as a different type of program or service with different rates and that he believed the county network could be competitive and not violate federal Medicaid rules about different prices for the same services.

This would seem to be the logical direction for other counties to consider.  It does require collaboration with the Medi-Cal managed-care plans.  But having a single network obviously makes much greater sense as individuals’ needs will vary over time and having to go back and forth between two networks of providers should be avoided if at all possible.

This becomes a greater opportunity and need as counties implement the alcohol and drug organized delivery system which creates the possibility of more comprehensive integration with alcohol and drug providers and mental health providers both becoming comprehensive behavioral health  entities with an integrated contract.

Organized SUDs delivery system implementation back on track in most counties

Earlier in the year it appeared as though only the 18 counties which were fairly far along in their planning or moving forward to implement the organized delivery system, with others waiting to see what happens to the affordable care act and Medicaid expansion.

The failure of the AHCA-the initial house/Trump proposal seems to have gotten just about everyone back on track to move forward.  However, San Diego, Alameda, and Ventura counties are now not sure that they plan to go forward. There seem to be local concerns with a different analytical or political perspective that what is happening throughout most of the state.  My sense is that these concerns will eventually be overcome, as the benefits of the organized delivery system clearly outweigh the risks and I believe the success of the counties already moving forward will prove this. But it does mean more delay in those counties and others that are being hesitant which will undermine integration efforts and those counties for the next year or two.

State failures in getting SAMHSA funding for integration efforts- somewhat similar to CCBHC

The National Council for Behavioral Health has long been the national leader in championing behavioral health integration efforts.  At the state level DHCS has been a leader with the whole person care pilot programs and is taking positive steps to make SBIRT and Depression screening regular parts of primary care.

However, DHCS chose to not even apply for new federal funds to support more physical health behavioral health pilot programs.  Past grants for these programs could be applied for directly by our member agencies or counties.  This new round must go through state agencies and DHCS declined to apply.

They stated that it was not a sufficiently high priority but also commented that the federal rules were not a good fit for California.

Our County-based system is different than nearly all other states. This was clearly a problem in the design of the certified community behavioral Health Center (CCBHC) program. Initially DHCS was not going to apply and only did so after we secured additional funding. However, the verbal assurances I received from federal officials that California’s counties could apply for their entire system were not followed up with written clarifications that the rules would allow this. As a result our applications only for individual providers in small communities in two counties and was not chosen to be one of the pilots.

With the new administration in Washington the future of these programs is very much up in the air. Nonetheless it seems like a good time to evaluate how the federal government designs programs in relationship to California’s system.

These are also among the many issues that frustrate the behavioral health community.  There are questions about how our state leadership decides which issues to take on and whether our current governance structure- one of the few states without its own mental health or behavioral health State Department, is adequate to address all of our needs.

As we begin to anticipate the election of a new governor in 18 months, it seems like a good time to reassess our governance structure to evaluate what improvements can be made.

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