just about any decision is possible from the Supreme Court, 1 of 3 outcomes is
Uphold the entire law,
Uphold the law except the individual mandate,
Strike the entire law.
are the collaborative care ramifications for each?
1) SCOTUS Upholds the
Entire Law. For proponents of
collaborative care, there is a lot to love about PPACA. First we have the
wondrous notion of health insurance expansion. For anyone who has worked in
primary care, one of the biggest psychosocial barriers many of our patients
face is that of not having health insurance that can help cover services
whether they are physical health or mental health. Second, we have the issue of
access that comes along with coverage. If more patients have access to
services, there is an increased likelihood that more patients can be seen in
collaborative care settings. While there are other provisions of PPACA that
address "integration” of behavioral health (section 5604 and 2703 as an
example), it is not likely that the SCOTUS decision will impact these as it
does the coverage and access issue.
2) SCOTUS Strikes the Individual
interesting is that Massachusetts,
the "canary in the coal mine" for much of what we are seeing unfold
nationally with health reform is doing quite well with healthcare. First,
residents of the Commonwealth are quite supportive of the Massachusetts individual
mandate law. Jonathan
Cohn has written extensively about Massachusetts
and the mandate before. One key point he makes is that the individual mandate
would likely have less of an impact on folks than most people are aware:
"Perhaps more important, the mandate didn’t actually change life
for most people in Massachusetts,
at least in ways they could perceive. Most people already had insurance that
satisfied the requirement. And while nationally the proportion of people with
insurance is lower than it has been in Massachusetts,
overall the same basic truth holds: The majority of people already have
insurance that would satisfy the mandate."
"The vast majority of Americans already gets insurance from their
employers, Medicaid, Medicare, the individual market, or other sources of
coverage, and will essentially automatically comply with the mandate once it
goes into effect in 2014. The Congressional Budget Office (CBO)projects
that about 80% of the 272 million non-elderly people in 2014 would be insured
even in the absence of the ACA and would therefore already fulfill the
much of what we hear in the media about the individual mandate is noise. Since
this is the most "controversial" piece of the legislation before
SCOTUS, let's just pretend that this piece of the legislation is "struck
down," what will we do? What will this mean? I would encourage those
interested to read the brilliant post by Sarah
Kliff and Ezra Klein from the Washington Post on this topic.
3) SCOTUS Strikes the
Entire Law. Let
me be somewhat controversial for a second and posit that even without PPACA,
the good work happening on the ground, the innovation, will continue
regardless. Let's be honest, even with a fully supported (financially and
politically) PPACA (including the mandate), there are still major hurdles that
must be addresses in healthcare. Does PPACA truly defragment healthcare and
make it the system we all want? Not really, but it does help.
demonstrate my point, let me offer a case study on behavioral health.
written about extensively before, the separation
of behavioral health from the larger healthcare system is an inefficient and often
ineffective model of comprehensive healthcare. Despite decades worth of research highlighting this
inseparability, we still have a bifurcated system (mental/physical) that has a
tough time taking care of the whole person. Policy barriers, primarily
financial policies, make sustaining integration efforts a challenging
proposition; however, integration efforts do not stop just because policy has
not changed to accommodate their innovation.
Health's Integration Program
Behavioral Health Project
Advancing Care Together practices
Alaska's Southcentral Foundation
the list goes on and on. Despite policies that may make their integration
efforts challenging, they keep going.
we think about the implications of major policy decisions on much of our work,
sometimes these decisions help and sometimes they hurt our efforts; regardless
of the decision, practices in our communities continue to innovate.
innovation can be defined as "the intentional introduction and application
within a role, group, or organisation, of ideas, processes, products or
procedures, new to the relevant unit of adoption, designed to significantly
benefit the individual, the group, or wider society."
policies can support or hinder the adoption of these innovations, the benefits
that the community receives far outweighs whether or not it is supported by
someone, somewhere in healthcare policy land.
behavioral health and healthcare is a truly unique opportunity to demonstrate
as well as influence
such important policy issues like the "triple
let's imagine that next week SCOTUS knocks down PPACA in its entirety. What
will we do? Will we hide away worried that policy is no longer in our favor?
Will we decide that all our efforts are for naught?
answer is simple: No! We will do what we must to continue to create a high
performing and effective system we all deserve. Regardless of the ruling, you
cannot stop the innovation in our communities. We will wake up, have our
coffee, see the outcome of the decision and continue going back into the
trenches working towards a comprehensive whole person system. We will see this
ruling as just another bump in the road and keep on moving towards change.
towards change and continued innovation!
is the President of CFHA and hosts the CFHA Game On blog. He is also the founder of the Occupy Healtcare movement. He is an Assistant Professor in the
Department of Family Medicine at the University of Colorado Denver School of Medicine where
he is responsible for integrating mental health across all three of the
Department’s core mission areas: clinical, education, and research.|