MHW Looks at 2017 Advocacy Wins, 2018 Challenges

NYAPRS Note: The following piece in today’s Mental Health Weekly underscores the critically important work of behavioral and physical health and disability advocates last year to protect Medicaid and Medicare. It also points to the momentous impact of the new federal Interdepartmental Serious Mental Illness Coordinating Committee, led by new HHS Assistant Secretary for Mental Health and Substance Use Dr. Elinore McCance-Katz. 
Two things you can do today:

1. Contribute to the Bazelon Center’s vital advocacy efforts at
 Reserve April 19-20 on your calendars to hear Dr. McCance-Katz and a panel of ISMICC members and advocates lead off this year’s NYAPRS Executive Seminar in Albany entitled “New Strategies and Partnerships to Support our Most Challenged New Yorkers: The Way Forward.” Look for details in the coming few weeks.


Year In Review: 2017 Marked By Fight To Preserve Key Protections In ACAMental Health Weekly January 2, 2018

The mental health community witnessed some defeats and some wins in 2017. Preserving key protections in the health care law for people with mental illness and substance use disorders dominated the field in 2017. Following the advent of a new administration protections afforded by the Affordable Care Act (ACA) had been threatened by a number of bills to repeal and replace the health care program.

Over the past year, the field fought tirelessly to preserve the Medicaid expansion, along with protections for people with pre-existing conditions — which would have been lost if Congress had succeeded in overhauling health care reform.

The field sounded the alarm over the reform bills urging Congress to reject the legislation that would overhaul Medicaid and leave millions without insurance coverage. A number of organizations asked their respective members to urge lawmakers to improve the current law in a bipartisan fashion (see MHW, Feb. 27, May 29, Sept. 25, 2017).

House lawmakers introduced the American Health Care Act March 6, which would have changed Medicaid to a per capita payment system, a big concern for the field (see MHW, March 13, 2017). The per capita cap would have placed a cap on what the federal government would pay each state for its Medicaid enrollees, essentially ending the 50-plus-year federal guarantee of matching each state’s actual Medicaid spending and replacing it with a capped, preset amount and preset growth rate. Other bills followed, such as the “skinny repeal” of the ACA and the Better Care Reconciliation Act.

On the evening of Dec. 21, 2017, the Senate passed a short-term Continuing Resolution, by a vote of 66 to 32, that includes a three-month funding extension for the Children’s Health Insurance Program (CHIP).

The year concluded with an overhaul of the country’s tax code. The Tax Cuts and Jobs Act, signed into law on Dec. 22, 2017, repealed the ACA’s individual mandate, and will have other ramifications for health care. The National Council for Behavioral Health released a statement, saying, “It is disturbing that with virtually no input from the people who depend on entitlement programs like Medicaid, Medicare and Social Security, the bill cuts the federal revenue necessary to care for millions of Americans living with mental illnesses and addictions.”

‘Difficult Year’
“It was a difficult year for people with mental illnesses,” Jennifer Mathis, deputy legal director and di- rector of policy and legal advocacy for the Bazelon Center for Mental Health Law, told MHW. In looking at legislative actions that took place over the past year, the field has witnessed some significant victories, including the defeat of some potentially “disastrous” legislation, she said. “The legislation would have gutted the Medicaid program, and most of the advances brought by the ACA for people with disabilities, including psychiatric disabilities,” she said.

Mathis added that preserving the ACA was a significant victory. “Obviously, some of the damage will be done by the [provision] in the tax bill because it repeals the individual mandate — a core part of the ACA and one of the pieces that made protections of the ACA possible,” she said.

According to the Congressional Budget Office, repealing the individual mandate will increase the number of uninsured people by 4 million in 2019 and 13 million in 2027.

Premiums are expected to go up as young and healthy people exit the insurance pool, Mathis noted. In addition to repealing the individual mandate, the new tax law has impacted other programs as well, she said. “Creating that deficit will trigger automatic cuts to other programs, including Medicare, Temporary Assistance for Needy Families, and rehabilitation services and social services,” she noted. “These are significant cuts triggered by the whole sequestration.”

The Bazelon Center is very concerned about CHIP, which was allowed to expire at the end of September 2017, said Mathis. Some states are expected to run out of funding in January, she said. CHIP provides low-cost health insurance to 9 million children. “That’s significant for kids with disabilities and kids not covered by Medicaid,” she said. “That’s very concerning and the reason I say it’s been a very difficult year.”

Other issues include workplace privacy protections for people with disabilities, which are being eliminated under the Americans with Disabilities Act (ADA), said Mathis. H.R. 1313, which preserves employee wellness programs, has stalled, she said. “If Congress starts weakening the [bill], that doesn’t bode well for people with mental illness,” she said. “We’ve been monitoring and advocating for that as well. These are some of the main actions we’re watching in Congress.”

ISMICC report
The field hailed the release of the first report to Congress by the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) on Dec. 14, 2017. “The Way Forward: Federal Action for a System That Works for All People Living with SMI and SED and Their Families and Caregivers” provides a roadmap for improving mental health services for adults living with serious mental illness (SMI) and children and youth who experience serious emotional disturbances (SEDs).

The report’s area of focus included increasing access to care and developing financial strategies that increase the availability and affordability of care. It also calls attention to screening and early intervention across all primary care settings and in schools (see MHW, Dec. 18, 2017).

The ISMICC, chaired by Elinore F. McCance-Katz, M.D., Ph.D., U.S. Health and Human Services (HHS) assistant secretary, is charged with making specific recommendations for actions that federal departments can take to better coordinate the administration of mental health services for adults with SMI or children with SEDs. Its inaugural meeting was held Aug. 31 (see MHW, Sept. 11, 2017).

Maintaining Protections
“Congress was not successful in repealing the ACA,” Laurel Stine, J.D., director of congressional affairs for the American Psychological Association Practice Organization, told MHW. “We wrote several letters this year predominantly on the ACA,” Stine said of the Mental Health Liaison Group, which she co-chairs. Defending the Medicaid expansion was critical, she said, particularly in light of the number of bills that “at- tacked” the ACA in one way or another, she said.

Marketplace protections are also strong, she noted. However, the major attack on the ACA was the repeal of the individual mandate, a “devastating blow to the ACA,” she said.

“The big issue in 2017 is advocates keeping the ACA as strong as it is,” said Stine. The Medicaid expansion and other consumer protections still exist, she noted. “The ACA is still the law of the land,” said Stine. “It’s still a victory in and of itself.” ACA enrollment is also at its highest, she noted. A recent poll revealed the ACA received a 56 percent approval rating, Stine said. “It’s another thing advocates can hail,” she said. “Those are victories. The ACA still remains strong and that’s our message.”

Last year represented the first time Congress had bipartisan bills in both chambers involving the Health Information Technology for Economic and Clinical Health (HITECH) Act, said Stine. Sens. Sheldon White- house (D-Rhode Island) and Rob Portman (R-Ohio) and former Rep. Tim Murphy (R-Pennsylvania) all had bills to include behavioral health providers in the HITECH Act. Additionally, Reps. Doris Matsui (D-California) and Lynn Jenkins (R-Kansas) have also introduced legislation.

“We’re very excited about these bills, particularly because the legislation would help psychologists, community mental health centers, psychiatric hospitals, social workers, [all of whom had been] initially left out of the HITECH Act,” Stine said.

The HITECH Act provides HHS with the authority to establish pro- grams to improve health care quality, safety and efficiency through the promotion of health IT, including electronic health records and a private and secure electronic health information exchange.

Stine also pointed to a letter prepared by Sens. Whitehouse and Portman and Reps. Matsui and Jenkins to Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma on Nov. 17, 2017. The letter urged the CMS to build financial incentives for adoption and use of health information technology by mental health and substance use treatment providers into new models the agency plans to pursue for behavioral health.

“The overarching issue is that the ACA remains strong despite GOP-led acts on the ACA, which would have undermined Medicaid expansion and other hallmark provisions within the ACA,” said Stine.

Vulnerable Populations
2017 has been a year of significant change, Mark Covall, president and CEO of the National Association of Psychiatric Health Systems (NAPHS), told MHW. The organization’s first mandate was to ensure that health insurance coverage continued to be available for all Americans with mental health and addiction disorders. “Our priority was to maintain coverage for the most vulnerable population,” he said.

Another main focus in 2017 was keeping parity protections, said Covall. A very important message had been sent to Congress, he noted: Patient protections are essential and critical and need to be maintained.

“That’s our main message around recovery and parity,” he said. The ACA was a bipartisan deal, he added.

NAPHS is also very involved in addressing the opioid crisis and in trying to obtain additional resources, Covall said. The Medicaid expansion was key for addiction treatment, and wasn’t available previously, he said. Medicaid is the largest funder of mental health services and a significant funder of addiction treatment, said Covall. “That program continues to be there,” he added.

Covall said it’s been a huge disappointment to the field that CHIP was not extended for an additional five years. “Nine million children are on the program, many with mental health and addiction problems,” he said. “That is a safety net for them.” States will experience difficulty continuing the program, he said. It’s still unknown what the long-term impact will be, said Covall.

“One thing everyone agrees on is the growing consensus about the real need to deal with barriers to accessing care called the IMD [the Medicaid Institutions for Mental Dis- eases] exclusion,” he said. It’s one issue that continues to receive sup- port from Democrats and Republicans, he noted.

The CMS is looking at different waiver opportunities for the IMD exclusion, including a specific waiver for substance use disorders, Covall said. “We have a legislative fix,” he said. “We’re getting close to an ultimate remedy for this long-standing, discriminatory practice.”