Growing Washington bipartisanship on many issues gives hope for healthcare future, but everything is still at risk.

Last week the US Senate began hearings on a bipartisan effort to provide greater short-term or moderate term stability to the health benefit exchanges which depend upon federal subsidies to provide affordable health insurance to individuals who do not qualify for Medicaid or employer insurance.

These exchanges also depend upon the mandate that everyone must pay at least part of their health insurance if they have above Medicaid incomes, which is the single part of the Affordable Care Act that Republicans have most strongly campaigned to eliminate.

The fact that a significant number of Republicans are now accepting that at least for the short term this mandate will remain and are open to negotiations with Democrats to stabilize these health benefit exchanges is obviously a very encouraging sign that could extend to other related issues, especially in light of other similar developments.

  • In a well-publicized action also last week the president chose a proposal from Democratic congressional leaders over proposals from Republican leaders on how to give immediate aid for areas damaged by hurricane Harvey in Texas and to raise the federal debt ceiling.
  • Less well-publicized is the fact that there is also a bipartisan group in the House of Representatives now meeting to also consider healthcare market stabilization.
  • Also not so widely reported is the fact that congressional budget committees rejected the Trump administration proposal to reduce mental health block grant by 25%. This is a relatively small grant. The administration proposal would have meant about a $12 million reduction for California, so the overall dollars are not that significant but keeping it from being cut at all is a strong signal of federal support for mental health.
  • Not coincidentally a moderate group of House Republicans known as the Main Street group and the “Problem Solvers Caucus” is reported to be growing in size.

These are all very hopeful signs. Nonetheless we can’t lose sight of the fact that congressional leaders are still very attached to the idea of making significant cuts in Medicaid which could become a major part of discussion in developing the federal budget or tax reform – both of which are likely to be taken up in the next few weeks.

AB 1250 amended with minor clarifications on September 12. will change anyone’s view of the bill

At this stage I assume everyone is familiar with this bill which is a union sponsored proposal that makes it impossible in nearly every instance for counties to contract out for mental health substance use disorders child welfare health or really any other program.  The implications of having to rely only on County directly operated programs in areas where the overwhelming majority of current programs and demonstrated success is with private providers will almost certainly lead to much greater costs, much less efficiency and effectiveness and an inevitable reduction in the availability of services since revenues are not likely to be increased for these programs commensurate with these added costs.

Tuesday, September 12 winds up being the unofficial deadline for having amendments to legislation in print and available online for legislators and the public to review if a bill is going to be voted on this year before the Legislature is required to adjourn on September 15. The bill was amended that day but the amendments provide minor clarifications of the same amendments that were adopted on September 5.

This is a new deadline that was put into law by constitutional amendment passed by the voters in 2016. In previous years the legislature had the authority to waive the rules requiring amendments to be in print and available online in advance of the vote.

The shared amendments were not integrated into the bill; that means that the bill can only be voted upon in its current version. It cannot be further amended this year.  When it was heard in the Senate Appropriations Committee, three Democrats (Scott Weiner of San Francisco, Jim Beall of Santa Clara and Jerry Hill of San Mateo), all of whom are former county supervisors, expressed concerns about this current version of the bill and were hoping it could be amended to make it more acceptable to them.

This doesn’t guarantee that they will vote against it, so it is still critical in these last few days for all supporters of health mental health substance use disorders, child welfare and other programs which depend upon county contracts, to be contacting their legislators and informing them of the devastating impact the passage of this legislation could have.

Here is our most recent letter as well as a template for provider organizations and others to use to develop their own opposition letters to fax or email.

Workplace Mental Health Summit meeting brings this key component of a comprehensive prevention and early intervention system out in the open.

In 2014 I wrote this white paper  on prevention and early intervention (PEI), identifying four pillars or core programs around which most of our PEI efforts should be focused. These four components consist of school (at all levels from preschool through college), primary care and other healthcare entry points such as emergency rooms, the Internet and workplace.  I also identified early psychosis programs as an additional essential component.

Since that time there has been a lot of discussion and effort about the need for bidirectional integration and coordination of physical healthcare and behavioral health care.  The best model for this was incorporated into the coordinated care initiative – a program for people with both Medi-Cal and Medicare. That same concept was made part of the proposed 2015 Medicaid waiver submitted to CMS with shared savings between counties the state and health plans but it did not receive federal approval.

There are many successful local programs built around this concept and it will be a public policy priority for us in 2018 to present it again to the state, since we believe it should produce net state savings even without federal financial participation.

Similarly there been many advances in school mental health. Legislative approval to start a program for community colleges and oversight and accountability commission approval for a K-12 pilot program is expected soon to expand and complement the hundreds of County PEI funded school efforts.

The use of the Internet and smart phone based technology applications such as “7 cups” continues to grow and there is significant interest in partnerships between technology companies and county and state leaders reflected in the success of AB 1315 (Mullin) which creates an entity to receive private matching funds which have been promised by several Silicon Valley companies.

Early psychosis programs now in operation or development in nearly every county.  But the one area in which we have not seen any significant activity is the workplace.

As I wrote in 2014, the median age for onset of schizophrenia and bipolar disorder is 22 or 23 – an age at which most people are in the workplace. Moreover it has been well documented for decades that untreated depression costs California employers tens of billions of dollars annually in lost productivity, absenteeism, and disability.

It always seemed to me that someone in the workplace should be able to recognize when something’s not right for an employee and be able to steer them to getting the help that they need. It would also seem that these types of programs should eventually pay for themselves by reducing these other employer costs.

There was a three-year program (Wellness Works!) funded by Cal MHSA under which Mental Health America of California (MHAC) sought to establish workplace programs built on a model developed in Canada. That Cal MHSA program was part of its stigma reduction efforts with an emphasis on providing support for people with mental illness in the workplace.

As that program ended, Sutter Health (a large healthcare system in Northern and Central California which includes 29 hospitals in 16 counties) decided to promote workplace mental health for its system led by John Boyd, Sutter CEO for mental health services. Boyd also serves on the state Mental Health Services Oversight and Accountability Commission as well as the Board of Directors of the Steinberg Institute.

These three organizations are participating in a summit on workplace mental health being hosted by the Staglin family winery in the Napa Valley which has been famous for nearly 20 years for its mental health wine and music Festival that annually raises several million dollars in one weekend for mental health research and advances to promote earlier care-especially for people who may become diagnosed with schizophrenia.

The two-day meeting, bringing together experts from across the country and many participating corporations, would appear to be the boost that this subject area needs in order for it to gain the attention and statewide interest that the other core programs I wrote about have already been receiving.

For now it appears as though each of these four core programs is being developed as an innovation with pilot testing of concepts or small grant funded programs that are not designed as sustainable system reforms.

I am hoping that the day will come soon when we will know enough about the key approaches in each of these areas so that counties can build comprehensive PEI systems around these core programs.  That is a necessity if our PEI programs are going to achieve their primary purpose – which is to make early identification and treatment of behavioral health problems the norm.  In so doing we should have the financial success we need of reducing the number of people who reached a very expensive long-term service needs often required when a mental health or substance use disorder is untreated and allowed to worsen for several years – as usually happens under our current fail first models that have existed for decades.

I also note that since 2014 another emerging core program like early psychosis programs should be youth centers – drop in places where young people ages 12 to 30 can go for any type of health or behavioral health problem – since we know that this population is the least likely to use the health care system, and is the most vulnerable and important to reach for PEI.

The model was first developed as “Headspace” in Australia, where there are now 100 centers and replicated as “Jigsaw” in Ireland, and as “Foundry” in British Columbia, Canada, and is soon to be an innovation program in Santa Clara County. These efforts have been led by Stanford professor Steve Adelsheim, who has written extensively through a Robert Wood Johnson grant on how to adopt this program for the United States.  Here there are challenges with our several different ways of financing behavioral health care and physical healthcare to make them available in the same place for people with both public and private insurance.

Over the next several years we will see expansion in all of these areas with promising evidence that most of them only require one time investments of new money and expectations that they can be sustained over time due to the savings they generate across health care education in the workplace.

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