Tag Archives: Obamacare

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.


Filed under HHS rules on ACA, Medicaid, mental health

Robamacare, Obomneycare, or Medicare for All?

Mitt Romney’s choice of Paul Ryan for running mate has set off a flurry of campaign excitement.  This could be the best news for Medicare in a long time—Ryan’s not-so-subtle Medicare killing plans might turn 2012 into the “Medicare Election” after all.  If so, privatizing Medicare could become a new 3rd rail no politician will dare to even glance towards any time in the near future.  This is a great time for people in both parties to take a strong position on Medicare—we need to let folks know we are NOT willing to let granny get shoved off the cliff. 


It’s important for Dems not to get too lulled by their own campaign ads, though.  There are other ways to ease granny off that cliff.  Some are sneaky enough that we might not be able to haul her back up by the time we realize she’s rolling.


It ought to be pretty easy to see the risks in converting Medicare to a voucher or “premium support” system, where rising costs could easily render our elderly either uninsured or unable to afford to use their insurance.  Interestingly, the idea is very similar to what the ACA does in the upcoming “exchanges”, and we will see the same problems there.  Low income families are highly likely to forgo needed care and leave that brand new insurance card in their wallets, because of the still daunting co-pays.  If you doubt that, come hang out with me at work for a few days and listen to the parents with minimum wage jobs who have employer-provided insurance.


There are FaceBook memes popping up on the pages of my intelligent friends saying Obama is using the Medicare cuts to save Medicare—that this money was cut by reducing fraud and excess payments to Medicare Advantage plans (private insurers who cover Medicare patients at higher cost than traditional Medicare), whereas the Romney/ Ryan plan would line corporate pockets.  Not exactly!  Some of the ACA cut is to hospitals, in the form of DSH reductions and value-based payment cuts to hospitals that serve the uninsured.  It is true that the ACA cut Medicare Advantage payments, which should have been just eliminated.  Then Obama’s administration (not Congress, mind you—this was an executive action) turned right around and began handing the money back as rewards to Medicare Advantage plans with only average performance.  Corporate pocket-lining is a bipartisan effort.


The ACA generally works to direct more money into the private insurance system, including taxpayer subsidy of pricey overheads.  For those who believe the ACA clearly benefits some specific groups and so is a step in the right direction, I have thought of a better metaphor than steps.  It is like global warming.  Sure, there are some chilly areas that will benefit from temperatures rising—more tourists, longer growing seasons.  The net effect is detrimental.


I have been mulling over partisanship a lot in the last few weeks.  I was raised a Democrat and even though I knew the party had problems, I made some unquestioned assumptions I now believe were incorrect.  I have decided to join the Green Party.


Between the two major parties, there are some clear differences.  The Republicans yearn to undo Roe v. Wade, bring back sexual repression, and rein in women/ minorities to their liking. They would love to end critical scientific and historical education, because the particular biases of the far right are unstable in an educated public. They worship guns and encourage the bizarre belief of some right-wingers that it would be possible to fight off an out-of-control government (complete with weapons of mass destruction) by personal armaments. The Democrats don’t so much offer improvements in those areas as they do a little more security in the status quo.


Both parties, however, have the same underlying primary purpose—to protect the interests of big money.  I doubt if this is a conscious purpose on the part of all involved—I’m not that cynical.  But in practice, in history, it doesn’t matter, because that’s what happens. The Republicans serve big money by trying to lower regulation and by cutting the “social wage” (the provision of a floor for fundamental human needs like food, shelter and medical care), so that the poor are forced into jobs they might not otherwise accept and are kept so busy scrambling for their lives that they don’t have time or energy to organize an opposition. To their base, they frame it as Personal Responsibility.


The Democrats serve money by increasing regulation to stabilize and rescue corporations when they are at risk of collapsing from their excesses and by increasing the social wages when public destabilization looms.  To their base, they frame it as a Safety Net.  The party appears to be more socially evolved for a few reasons—it is partly because they needed the progressive, socially generous block of voters (the ones Republicans bypassed in favor of Randians and religious fundamentalists).  It is also partly because some of those social policies serve particular corporate interests better, and partly because the appearance of social responsibility attracts candidates who really do believe we have a social duty to each other (even though they find, once in office, that they can’t do nearly what they hoped for).


Besides serving the interests of big money, both parties have more in common than either side would like to believe, in terms of aggression and erosions of civil liberties.  Worse, they are both creating an inexorable trend towards loss of democratic functioning in our government.  They are both making our votes count for less and less, by subverting orderly representative and judicial processes.


Most of you probably already know this—I’m saying it mainly to lay some groundwork for the rest of this post.  There are some very different possible responses to seeing this sad scenario.  One option is to say we should work within the Democratic party itself, to turn it in a better direction. This was why I stayed in the party so long.  It’s a little better reasoning than the old story that ends “with all this shit in here, there must be a pony”—and it goes like this:  “with all these great progressives in the tent, there must be hope for this party.”


After arguing this point with a new email friend, where I vigorously took the side of the Democrats, I read a book this friend recommended, and I have changed my mind.  It isn’t the repeated offenses of the Democrats, or the examples proving it is just as much a corporate party as the other, because like you, I knew that.  What got me was the history of progressive movements.  Time after time, when progressives have allowed themselves to be folded in, they lost their battles.  The only times they won any major ground—Civil Rights, for instance—were because of intense independent grassroots pressure.  I didn’t want to believe that and tried to find an exception the author forgot.  I couldn’t.  Can you?


Being scientifically minded, I just can’t ignore empirical evidence.  You should read the book—it is like watching Lucy pull the football away from Charlie Brown way too many times. 


We can’t do the significant things we need to do by working within the two party system. If we want big deal changes like real healthcare reform, not just rolling off the cliff instead of being thrown off, we need to take this seriously.  By staying under the big Democratic tent, we give those elected an easy out—they know we are terrified of the openly vicious alternative and will generally forgive them by blaming their failures on the other party, so our vote is in the bag.  This means they only have to please their corporate masters.


I saw this in action just last week, when a Democrat friend of mine heard me say some true but unpleasant things about the ACA.  She said she agreed, but that we should be careful NOT to report any of those things until after November 6, because it would give ammunition to the other side. Think hard.  If you have to lie to others or yourself to support a party, there’s a problem.


One way a third party can influence policy is by threatening or throwing elections in swing states—that could get us some important things and possibly even a change as significant as single payer health insurance.   But only if we don’t wuss out and throw darts at Ralph Nader for doing the right thing.  Another way would be if folks stuck with it and didn’t go back to the Democrats every time a small point was won, allowing the US to gradually build a true third party free of corporate control.  The time to start is now.  If we wait until it looks like an independent party can do something substantial, we will never start.  That’s an idealist point of view, I know, but it isn’t impossible.  All other developed democratic countries have some form of Labor party except us.


To succeed, we have to focus on one central objective—attaining responsive representation in government, so big money can’t rule the day.  Without that, it doesn’t really matter about the rest, because once we’ve fully lost the power of our votes, we will have only as much civil liberty as suits the most powerful big money interests.  We have to keep our focus on representation, the same way meditators deal with distractions.  If we get stronger, the efforts to distract us will intensify—be ready for it.  They’ll wave gay marriage at us, reproductive rights, maybe even changes in drug policy—don’t bite unless it comes attached to democracy.


Some folks, like Morris Berman, believe it is already too late and no road forward is possible for the United States.  If he is right, my Dem friends are probably doing the best thing.  Either one should expatriate, as Berman did, or one should at least hang with the party who won’t rape us with ultrasound probes.  It is not unreasonable, if one must go off the cliff, to choose being rolled over being thrown.


If it is NOT too late, there is only one real choice for progressives.  We must refuse to serve as arm candy that makes the Democratic party look safe.  We must stop letting Lucy hold the football.  We must stay out, and we must do our best to gather a coalition of others who will challenge the powers that be. 


Filed under Healthcare reform, Politics