Public Health, Mental Health, and Health Policy in a Post-ACA World

Now that the ACA decision is behind us, what’s on the horizon in the world of public health, mental health, and health policy?

The truth is that ACA was essentially neutral with respect to prevention and public health.  3% of our nation’s health funding went to these services last year, and 3% will continue to go to these services with or without ACA.

That won’t stop the assault on public health.  Federal, state, and local governments have all cut public health services in recent years and, unless we have a public health crisis, may well cut further.

And Chief Justice Roberts took a swipe at public health programs in his majority decision, when he wrote on page 22 and 23:

“To consider a different example in the health care market, many Americans do not eat a balanced diet. That group makes up a larger percentage of the total population than those without health insurance…. The failure of that group to have a healthy diet increases health care costs, to a greater extent than the failure of the uninsured to pur­chase insurance.… Under the Gov­ernment’s theory, Congress could address the diet problem by ordering everyone to buy vegetables.”

In other words, the majority went out of its way to raise a question about how far it will let health promotion programs can go in the future.

ACA still points the way toward some of the most promising strategies for improving our nation’s health.

It created:

• A new $16 billion prevention fund (that has already been raided for other purposes).
• A “community transformation grants” program to promote individual and community health and prevent or reduce the incidence of chronic diseases associated with obesity, tobacco use, or mental illness.
• A primary care extension program to train primary care providers about evidence-based therapies in preventive medicine, health promotion, chronic disease management, and mental health.

Why is it so hard to fund public health and prevention?  Simply put, because when prevention works, nothing bad happens.  So prevention develops no new constituencies over time.

Mental disorders also directly get about 3% of our nation’s total health expenditures, but people with mental illnesses gained much more through ACA, and had more at stake in the Court debate. 

These gains included:

• Guaranteed access to health insurance, regardless of pre-existing conditions. 
• Coverage for mental health services as part of the basic benefits package in health insurance.
• The right of children who develop mental illnesses to remain on parents’ insurance policies until the age of 26.
• Beginning in 2014, guaranteed Medicaid and Medicare Part D coverage for benzodiazepines (such as xanax and valium), barbiturates, and smoking cessation drugs.
• A mandatory 3-year, 8-state demonstration project to reimburse inpatient and residential treatment facilities for services to adult Medicaid beneficiaries in need of medical assistance to stabilize a psychiatric emergency.  
• Grants to states to prevent and manage co-morbid chronic conditions in the Medicaid population; grants to organizations to co-locate and integrate health and behavioral health services; and grants to educational institutions for the development or enhancement of behavioral health training programs in the areas of child and adolescent behavioral health.

These initiatives now all move forward.  The challenge of protecting them from future Congressional assault will fall to the families and advocates of the one in four people with a mental illness each year and, especially, the one in twenty with a serious one.

Looking toward future health policy in general, there are two things about health care that neither ACA nor the Supreme Court’s ruling changed.

First, health care costs will continue to rise.  Keep in mind the number 5.7%.  That’s the average annual increase that CMS analysts project over the next ten years – far above the rate of inflation. 

Second, health care costs will rise not just because of new drugs, new technology, and higher labor costs, but for a much simpler reason, too – because policy leaders give altogether too much attention to how we pay for health and mental health services after we get sick, and too little attention to how we protect health and mental health in the first place.

Keeping people out of the health care delivery system whenever we can is by far the wisest health care cost containment strategy we can pursue.

It’s the one thing everyone wants, no matter whether they are liberal or conservative, Republican or Democrat, rich or poor.

In the post-ACA political world, this at least should be possible.

This is the fifth in a series of five OHPM columns on the impact of the Supreme Court decision on the Affordable Care Act.