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I got mental health parity for Christmas! Why do I feel so disappointed?

Posted By Ben Miller, Thursday, December 31, 2009
Updated: Friday, May 27, 2011

Yes, it is that time of year to look back on what we have accomplished in 2009 and begin to consider what we are going to do differently in 2010 that we didn't do in 2009 (for a real treat, read how much foreign policy has changed in the past 10 years). And we did accomplish a lot. Healthcare made it out of the House alive and out of the Senate on life support. Partisan politics showed us again why political ideologies trump the American public's views on what should be done in healthcare. Let's be honest, it is ultimately about reelection, right? But something had to be done as people are dying from lack of insurance and costs are skyrocketing!

Consider two studies that show the burden of healthcare costs on our pocket books. Most recently, there is a wonderful article in NEJM, but I still prefer the 2005 Graham Center "one-pager" that asks the question "Who will have health insurance in 2025?" The answer, not surprisingly, is "almost no one" as the average healthcare premiums will be more than the average household income. Let me say that again, by 2025, the average healthcare premiums will be more than the average household income. OK, so maybe this is why I am still excited that Congress got healthcare to a point where we can move forward. There are still a few things to watch for, but the next steps are exciting!

We should all prepare to enact our New Year's Resolutions - let's just hope dropping the public option is not a Congressional resolution!

Deep Breath: Let's drill down into where collaborative care fits into all this. As described in apreviouspost, I have been trying to figure out the connection between current policy initiatives and collaborative care. With the dawn of a new year, I still don't know where "we" stand in terms of collaborative care policy and current health reform efforts. I have a few idea though, which when I really think about them begin to give me a better sense of where we are heading.

  1. Mental Health Parity Begins January 1, 2010: It's here, now what? What does parity really mean? How about "parity in reimbursement by private health insurance plans that cover mental health and substance abuse services". This is significant as it will modify the rate of out-of-pocket spending (traditionally higher for mental health than for other medical conditions) and decrease the limits of treatment scope and duration. But is this enough? Parity will reduce some barriers, but not all.
  2. Secretary of HHS, Kathleen Sebelius, is not afraid of using the word integrated: If you have not seen the speech Secretary Sebelius gave on December 16th to a crowd in Maryland, click here. I see this as more significant than mental health parity that the Secretary is talking about "integrated care". What? Who? How? I know, I was equally as surprised that the person uttering these words was not one of the collaborative care faithful. She even names our good friends at Cherokee, Intermountain, and the VA as examples. Something here? Only time will tell.
  3. Both the House and Senate Bills still dichotomize mental health and physical health: There are examples out there of how the House and Senate bills treat mental health. See here for more detail (PDF). Who knows where the final bill will land with what it wants to do with mental health, but a few things we can tell Congress thinks about mental health:
    a. Mental health services should be required in benefits packages;
    b. Insurers shouldn't discriminate against mental health conditions;
    c. Medicaid should be expanded;
    d. Education is important (increase in funds for higher ed and loan repayment programs);
    e. Substance use is a problem (SBIRT not bad)

Unfortunately nothing like:

    a) Services will be paid for regardless of if they are classified as mental or physical;
    b) Primary care will be compensated for treating mental health (i.e., depression screening and treatment); mental health will be compensated for treating physical health (i.e., health behaviors);
    c) There is no such thing as mental and physical health- "It's about the health, stupid!" (if this doesn't make you laugh, read the context).

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Comments on this post...

r says...
Posted Friday, July 08, 2011
BEN, Americans simply aren't ready for the healthcare reform you envision. Yes, the public option has traditionally polled well, but that is in the abstract. When it comes down to the taxes, governmental oversight, and regulation of actual legislation, people who already have high-dollar insurance lose their stomach for it. This especially true in the face of an effective media campaign from conservatives and healthcare lobbyists against it.



Still, the late Senator Kennedy would have led the charge to support this bill. It is very much in-line with his incremental approach. Even with large Democratic majorities in the House and Senate, this is the best that was going to happen this year. And, with 2010 already being an election year, it is very unclear if waiting would have brought along anything better. Beyond 2010, if the Democrats maintain a majority in both houses, it will be slim. It is now or never.



As for the collaborative care implications of all this, I didn't read the actual bills, but I believe that most of the primary-care incentives didn't make the final cut. For me, that was the biggest loss. Something needs to be done to create better parity between the reimbursement that is paid to specialists vs. generalists for providing the same service.



I did follow your link to Secretary Sebelius' Maryland speech. It is excellent news that someone at her level has tuned in to the collaborative care signal. It would be a huge coup to get her and/or Surgeon General Regina Benjamin for the Louisville CFHA Conference's summit or plenary.
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Tattiana Romo says...
Posted Friday, July 08, 2011
Yesterday I came home to an angry father and worried mother...They (whoever they is) increased the cost of insurance, dad noticed they deducted $1500 from his check. What does this mean for my parents and 15 year old sister? No more health insurance because its too expensive. They cant afford to have health insurance! hmmm do they keep their health insurance and move to an apartment or get rid of health insurance and keep their home? Better cross my fingers that my parents live long healthy lives so I dont get stuck with their medical bills after they die right (sorry for my sarcasm cant help it)?



No wonder many purposely settle for low income lives...so they can qualify for some type of assistance with health care.
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