Tag Archives: Affordable Care Act

Serious Brain Illnesses and the ACA: No Relief for the Weary


As a pediatrician whose patients and their families sometimes develop serious mental illnesses, and as a family member and caregiver, I can tell you the word “serious” is a euphemism, a polite understatement.  I have a friend with stage IV cancer who has received life-saving treatment for many years—she is able to work, care for her family, and enjoy her life despite the fatigue and side effects.  If she were to stop treatment she would likely die quickly.  Her illness is serious.  Treated, illnesses like schizophrenia and bipolar with psychosis settle to the level of serious.  They are not really “mental” either, which sounds as if we are speaking about nebulous, abstract, idea-based problems —they are brain illnesses.  Let’s call them what they are.  Untreated, these brain illnesses are not serious—they are devastating, catastrophic, and deadly.   Those who do not die wind up far too often in prisons unprepared to care for them or homeless, living—if one can call it living—under bridges and in doorways. 

 

Brain illness care has long been the red-headed stepchild of medicine—barely funded when required by law, and far too often, not even then.  For decades, advocates have worked towards parity, the equal treatment of brain and other body illnesses by insurance, only to witness seemingly solid legislation morph into a sieve of loopholes.  Anyone who has watched can testify to the creative genius of private insurers, against whom no legal barrier to patient abuse has so far succeeded.  Prohibit annual or lifetime payment caps and they limit the number of visits allowed.  Require inpatient hospital coverage and see new categories like “partial hospitalization” that don’t count.  Require outpatient coverage and get provider networks at payment rates so low hardly any doctors sign up.  Will the Affordable Care Act (ACA) along with the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 do any better?  My short answer is “no.”  For the long version, read on.

 

 

Under the recently released final rules for parity, effective for plan years that begin after July 1, 2014, most private insurances (except for grandfathered small group policies) will have to provide some brain illness coverage.  The exact services covered will vary between states, because of the way the Department of Health and Human Services interpreted the ACA.  By making Essential Health Benefits depend on prior insurance offerings in each state, the word “essential” is stripped of any semblance of ordinary meaning and varies when we step over the state line between Alabama and Georgia.

 

The final parity rules removed an earlier stipulation for insurers to use clinically accepted standards of care for brain illness treatment authorization. If a treatment is recommended by national experts and advised by your own doctor, the insurer does not have to use the same guidelines and can deny payment.  Although plans are supposed to use similar methods to develop provider panels for psychiatric and other medical care, the parity rule discussion says disparate results in the composition of those panels don’t prove there is a problem.  So if your plan does not include sufficient psychiatrists on the panel accepting new patients (a common issue) but has plenty of other types of specialists, you may not have grounds to protest if the insurer can figure out an excuse.  If insurers are only providing certain elements of brain illness treatment in order to satisfy the ACA, they don’t also have to meet the full requirements of parity otherwise. 

 

There may be some relief to states and patients for coverage of court-ordered brain illness treatment, because insurances can’t restrict such coverage if they don’t restrict it for other court-ordered medical services.  For example, if a court-ordered blood transfusion for a child would be covered, then services provided during a court-ordered psychiatric hold should be covered as well.  I am uncertain if insurers will be permitted to exclude the entire category of all court-ordered treatments to evade this element—I do not see reference to this in the ACA itself.  If that is an available loophole, we will certainly see it used.

 

If insurers cover a certain type of care for medical illnesses, such as outpatient rehabilitation or residential treatment, they must now also cover it for psychiatric illnesses.  That sounds good on the face of it— funding is greatly needed for day treatment programs and other levels of supervised care.  Unfortunately, the option is still wide open for insurers to deny or limit authorization for such services based on… well, whatever they want to base it on, absent any requirement for using accepted standards of care.  I expect we will have services mainly in theory, denied in practice by some set of arbitrary criteria.

 

In a particularly odd arrangement, insurers that can demonstrate a 2% or more increase in costs during the first year of parity can request exemption from parity the next year, and afterwards a 1% cost rise gets them a one year exemption.  Potentially, subscribers could have brain illness coverage every other year.  If my friend with cancer got her chemotherapy only every other year, what do you suppose would have happened by now?

 

The point-of-service cost-sharing barriers are substantial under the ACA.  For those with lower incomes who don’t qualify for Medicaid and have subsidized plans, a $30 co-pay might as well be $300 if they don’t have it.  A $2000 deductible or out of pocket limit?  Unimaginably out of reach.  People affected by serious brain illness are more likely to have lower incomes and thus likely to forgo necessary care at a lower level of up-front cost.

 

Some with serious brain illnesses who have not been able to get private insurance due to their pre-existing conditions may now get private policies.  Those under 26 can now stay on parent plans—but will these newly covered persons have access to care?  Having an insurance card is not at all the same thing as being able to get treatment.  At the onset of illness, many already had private insurance that failed to meet their needs.  I have seen no improvement at all in access for my privately insured patients to appropriate care for brain illnesses.

 

For long-standing serious brain illnesses, partly because treatment barriers and gaps have contributed to loss of function, public insurance is common—either Medicaid, for those with SSI Disability, or Medicare for those with SSDI.  I do not see the kind of changes in either of these programs that would be needed to prevent care gaps.  The “donut hole” for Medicare prescription coverage is closing, but there remains substantial out of pocket cost.  There is no parity requirement for payment of psychiatrists in Medicare and payment is low compared to other outpatient services.  Consequently, finding a psychiatrist who accepts Medicare isn’t easy.  In my city, the only option is the county Mental Health Center, already overloaded.

 

Medicaid appears to be affected by parity only if it is administered through Managed Care Organizations or Alternative Benefit Plans.  The Medicaid Expansion, in states that adopt it, will add some with brain illnesses who have not been able to get disability benefits.  The main barriers to care for those with Medicaid are funding, generally severely inadequate at the state level, and commitment laws that hinder timely treatment when the patient is sick enough to be unaware of the illness (anosognosia).   When it comes to strokes and heart attacks, we hear “time is tissue”—the rush is on to treat patients urgently, conscious and asking for help or not.  With serious psychosis, just as damaging to brain tissue if untreated, we bizarrely decide the ill person, unable to make rational decisions, does not want help.   Staffing at Mental Health Centers is limited, wait times are lengthy, and necessary community supports are minimal to absent. There is no move towards building a serious brain illness treatment infrastructure in the ACA.  If care is affordable but not available, patients are left behind just the same.

 

Although Medicaid pays for residential care of those with intellectual disabilities, there is an “IMD exclusion” prohibiting federal matching funds for care in a psychiatric hospital.  This has helped cause deteriorating service quality at state hospitals and made it appear cheaper for states to put those with serious brain illness in jail than to hospitalize them.  The ACA includes a “demonstration project” to pay private psychiatric hospitals with Medicaid funds to provide emergency services in some states. Because private hospitals have higher administrative overhead, proportionately less money may be used for actual patient care than in lower overhead public facilities.  The demonstration project funds are not available for public psychiatric hospitals, although the money is public in origin. Why not use those funds to improve state hospital care and coordinated transition of care to communities?

 

Because milder brain illnesses are more common and seem to garner more popular sympathy than serious cases, I am also concerned about wise use of scarce resources. The ACA does nothing to ensure that priority will be given to those most severely affected, both in terms of initiating treatment and maintaining it.  The spectrum of brain illness is broad, just as for other medical illness.  It is being absurdly stretched to include non-illness ordinary frustrations of life so providers can be paid for their preferred “patients.”   

 

I would not begrudge a person with a mild brain illness appropriate treatment any more than I would a person with a mild asthma flare-up.  Mild problems can become serious without good care.  At the same time, I would not leave a person in my waiting room gasping for breath to see one with a head cold.  I would not stop insulin for my patients with diabetes just because they “look good right now” in order to counsel basically healthy people on how to eat more vegetables.  And that is the sort of mindlessness happening in brain illness care right now—priority is given to the worried well.   

 

Although we have no cure for the most devastating brain illnesses, we most certainly do have multiple proven interventions that can, much of the time, bring those affected to the level of the merely seriously ill.  Treatment reduces the risk of relapse and allows many to have meaningful lives in their communities.  Just as with cancer, brain illness can sometimes worsen even during treatment so that the care plan needs to be adjusted—this can only be effective when care is continuous and frequent enough to catch the early signs of trouble.  Each relapse not treated quickly and skillfully may cause cumulative, permanent, unrepairable damage to the brain.  Treatment gaps in a system full of cost and access barriers can mean death. 

 

Any reform of healthcare that fails to address the needs of people with serious brain illnesses, including their critical need for continuous care with no loopholes or gaps, is a sham, a travesty, and a parody of reform.  I am weary of seeing tragic headlines about those we have failed, when I know we already have the knowledge and tools to do better.  My grade for the ACA on brain illness?  Fail.

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Filed under HHS rules on ACA, Medicaid, mental health

The ACA stands: Poor People Left in the Dust


 I’ve written most of this in advance of the expected Supreme Court ruling on the Affordable Care Act (ACA).  Instead of going into great detail about what the ACA will do (been there, done that), here’s my synopsis:  the ACA, after being riddled in the womb with bullet holes by Republicans and Corporate Interests, had its best part amputated shortly after birth by the Court. 

The Justices said they didn’t read the whole thing, but they must know the law has a deadly infection—private for-profit health insurance.  No matter what else is in it, we can’t save healthcare reform until that infection is cured.  So they found a way to let it live, including all the elements that profit the insurers, but they cut out the only part that would have helped poor adults get desperately needed care—the Medicaid Expansion. 

That was the only version of the ruling I hadn’t prepared for, ironically.  I should have known.  States can still participate and get the federal money, but they won’t be required to do so.  This is especially bad news for Alabama, with our long-standing habit of leaving federal Medicaid dollars on the table so we can give tax breaks to the rich corporations.  Will we take it during the initial period, when it is fully federally funded?  I have my doubts but hope I’m wrong.

 President Obama once wanted something better.    I believe in my heart our President still dreams of a day when we will have real healthcare reform—quality, affordable medical care for every one of us.

We can’t afford to take much time for regrets.  We need to push, harder and more effectively, for Expanded, Improved Medicare for All.   How can we learn from this experience, quickly, to do better next time?  I have a few lessons to suggest.

Votes Count.  Even though we didn’t get to directly vote for constitutionality or for the Justices, we did elect the Presidents who appointed them and the Legislators who confirmed them.  We had a part to play in letting the ACA stand and in this blow to the poor.  The Republicans have a number of ways to continue finishing off the rest, and you can be sure they’ll do their darndest.  We are only going to get as good as we vote for.  For Court appointees, our votes can affect what happens to our country for decades to come.  There is no excuse for taking your right to vote lightly.  Contrary to the Randian/ Libertarian fear about being made to support the public good at the “point of a gun” and despite serious corporate influence on policy-making, we the voters still have a say.  Use it.

Emergency relief measures are not a substitute for real reform, but they matter.  It may still take us awhile to get the national health insurance program we need.  In the meantime, it is the right and decent thing to enact some stop-gap help for those in the worst straits.  The ACA has a few of those left, mainly coverage of young adults and prescription coverage for Medicare.  But to cut out mandatory coverage for the poorest poor adults is a travesty.  If the Court could finagle around to change the “penalty” for the individual mandate to say it really meant a “tax”, they could have found a way to save this part.  We didn’t have to wait for a more comprehensive solution to do this basic act of humanity.  We wouldn’t wait to give pain medicine until after a broken leg is fixed.  At the same time, we should not get confused and think pain medicine will repair the problem.

Unless we get conservative buy-in, we will fail.  We aren’t likely to have a Democrat controlled Congress in the near future, even if we re-elect Obama as I hope.  If we did, and we rammed a single payer bill down the opposition’s throat, they might not notice their lot had improved in time to prevent sabotage of a new system.  We need to spend more time studying how to enlist the good parts of conservativism – decisiveness and unyielding dedication to a cause, for instance (thank you, Chris Mooney), and communicate with our brethren in their own language.  We can help bring out their better natures, and they have some skills we need.

Quit Compromising.  Surprised, after what I just said?  We have made a huge error in confusing persuasion with negotiation. We need bipartisan buy-in at the grassroots level, not a bipartisan solution in Congress.  Unless we become fiercely devoted to the goal of real healthcare reform, to the point we will absolutely not compromise our principles, we are always going to wind up being the patsy.  My husband loves the Bible quote “because you are lukewarm, and neither hot nor cold, I will spit you out of my mouth”. Come on, people!  Get some fire.  We can do this.

Remember why it matters.  I haven’t got much choice here—I see the consequences of our current healthcare system right in my office, every day, in ways that range from frustrating to tragic.  The father who quit bringing his children for checkups because he knew he had a deductible  in his grandfathered policy and was too embarrassed to say he couldn’t pay. The child who suffered terrible itching for weeks from eczema, waiting for insurance to authorize his prescriptions, because they insisted he try the things that had already failed before he could get what had already worked before. The working and uninsured mom who chose to spend her limited funds on her family’s food and shelter, who would have qualified for the Medicaid expansion.  Who, when  I asked “are you ok?” broke down sobbing because she was so tired of pain, for months, but it couldn’t be cured in a trip to the ER and the free clinic here didn’t have a specialist to help her. 

All the numbers you hear about have faces.  Remember that.  We cannot forget why, whether we are tired of working on this or whether we really have time to do it, we have to keep going.  Until we fix the problem.

 It will be tempting to get caught in a sort of righteous jubilation  here—it looks like we won something big.  I would have had more sympathy for that if the poor hadn’t been shamefully hung out to dry.  Let’s don’t go there!  We have work to do.  Medicare for All or bust!

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Filed under citizen responsibility, Healthcare reform, SCOTUS Ruling on ACA

Waiting for the Verdict: Healthcare Reform and Political Philosophy, Take Two


We are still waiting for the Court to rule on the ACA—they’re going to drag it out to the last minute.   I’ve got 4 versions of a post in response, so while we’re waiting, I’ll use one I’ve been thinking about and fiddling with for awhile. I was trying last year to work out a personal political philosophy.  My first stab at that didn’t hold up very well—a few people accused me of being Libertarian after reading it, and I knew that wasn’t true.  I think those elements stood out because I was trying to imagine myself in others’ shoes and looking for a way to be more inclusive.

 

So here’s take two.  I had the thought maybe my problem was the way I equated Government with The People.  I get tired of hearing “The Government this” and “The Government that”, as if we have nothing really to do with it—us and them.  It actually works out better, though, if I separate the two concepts.

If we define the Government as an abstract thing, not as specific people or jobs, we don’t have to give it moral content.  Let’s just say corporations aren’t people and neither are governments.  Only actual human beings should really be counted as persons.  To be democratic, a government must only be able to accommodate a content assigned to it by voters.  So the only features it has to have are reversibility and responsiveness to the people.

 

That has nothing to do with big or small government, freedom of speech, civil rights, marriage or anything specific. Lots of different democracy formats are out there —our founders picked a representative republic.  It avoids responsiveness turning into random flailing.  Too bad we left holes for corporations to interfere so badly with responsiveness, but we could fix that.

What about content?  Laws can’t really make us good or protect us from massive badness.  They work best as a formal commitment to ideals we already have.  They are supposed to help us weed out the “cheaters” in the system—they don’t help much when too many of us are cheaters.  Without the spirit, letters of the law fail. 

We could pass the most wonderful healthcare reform law in the world, perhaps with another brief Democrat controlled government, but it would never work as intended without the majority of us wanting it to function.  It would wind up full of red tape and so hard to use it would get thrown out after the next election.  That’s what happened even to the ACA, no matter what the Court decides—it was ruined from the get go because we didn’t commit to the purpose of insuring everyone.

 

This is one area the Randians and Libertarians have gone off course.  If we monitor our government structure so that it remains responsive, all that stuff about being made to do something “at the point of a gun” is malarkey.  Poor Ayn never really did completely understand the point of a representative democracy, which is not a gun but a ballot—perhaps she was too scarred by her experience in the former USSR.    If we vote to do something and we don’t like it afterwards, guess what?  We can change it.  If we try single payer health care—really try it, with our very best whole-hearted effort from all political corners—and we hate it, we can go back to what we had.  I’m sure it wouldn’t take any time at all for those insurance companies to regroup.  They are like the sand monster in Spiderman.  But we won’t want to change. 

 

It’s also where the Democrats have gone off—no number of laws will help if we can’t get the hearts of the people to endorse them.  It’s not that we shouldn’t codify our intentions.  It’s that laws and rights need to emerge from a solid ground in our own morality or they’ll always be perverted.  Failing to understand that makes us pile on ever more complicated, expensively enforced rules that continue to be broken.   It annoys conservatives to the point they don’t want to talk to us and have a horror of any new plan we come up with.

Government doesn’t need to get bigger any more than it needs to be drowned in a bathtub.  What needs to get bigger?  We do.

We have two jobs—protect the reversibility and responsiveness of our system, and help each other be better people.  All the good things we could do, using our government—giving each other the most freedom possible (in areas ranging from speech to livelihood to marriage and more), respecting privacy, educating ourselves, building safe and healthy communities to live in, caring for the poor and disabled while honoring their work, stewarding our environmental resources, taking part in global humanitarian and peace efforts, pooling our resources for quality healthcare—are not really part of government itself but reflections of who we are. If you look in that mirror and don’t like what you see us becoming, you have work to do.

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Filed under citizen responsibility, Healthcare reform