Our Health Policy Matters

Where our nation's mental health is concerned, disparity, not parity, rules. Mental Health America released a new report today.  It's entitled Parity or Disparity: The State of Mental Health in America, 2015 .  The report offers the first cumulative ranking of mental health status and access to services for all fifty states and the District of Columbia. Source:  Data from www.mhascreening.org The report includes measures of mental health status and access for adults and children, drawn from national databases that are regularly updated.  Altogether, they paint a very interesting picture of how states measure up to one another in protecting the mental health of their people. The best states for your mental health?  Massachusetts leads the list, followed by Vermont, Maine, North Dakota, and Delaware.  Rounding out the top ten are Minnesota, Maryland, New Jersey, South Dakota, and Nebraska. There are traditionally liberal and traditionally conservative states in the to

I was sitting at my desk at Mental Health America when the news broke on Friday afternoon that a fifteen year old student at Marysville-Pilchuck High School in Washington had opened fire in the school cafeteria, killing at least one other student before taking his own life as well. Another fourteen year old who was shot died over the weekend, bringing the death toll to three – all young teenagers. It is hard to know what to make of these kinds of tragedies, because we don’t really understand them.    The shooter, Jaylen Fryberg, was said to be popular and well-liked.  The victims – two of whom remain in critical condition – were his family and friends.  Some form of bullying may have been involved, but no one had any reason to believe that when he walked into school on Friday he intended anyone harm. In recent years, shootings – whether or not they are related to a mental illness in the shooter (and most frequently they are not) – have shone a bright light on how po

By now, everyone has heard the news from Ferguson, Missouri.  An unarmed 18 year old named Michael Brown was shot and killed by a police officer.  Michael Brown was black. Some of the events surrounding the shooting are in dispute.  But what isn’t in dispute is that for the past two weeks, a community has been torn apart by race – a community that until recently was best known for its proximity to St. Louis and its designation as a Playful City, USA . Picture credit: Health Affairs Media reports since the August 9 th shooting have focused almost entirely on one angle – race relations.  We’ve heard about unrest in the city, the National Guard, police in riot gear, and danger in the streets.  We’ve heard about the District Attorney’s ties to law enforcement, and concerns that a too-white Grand Jury may be racially motivated not to indict the police officer involved in the deadly shooting. But the media have been strangely silent about a different angle – this comm

Losing Tim: How Our Health and Education Systems Failed My Son with Schizophrenia  is now in the Columbia University Press catalog. Cover Photo Credit: Hartford Courant, Shana Sureck You can find it using this link:  http://cup.columbia.edu/book/978-0-231-16828-1/losing-tim It will be available in the Fall of 2014.  It is a story of how the mental health policies of the last generation of policymakers (of which I was a member) failed my son, and how the policies of this generation of policymakers continue to fail him, and so many like him. I can't say that I hope you will enjoy it, but I do hope you will find it moving.   And that it will help move us all - including the next generation of policymakers - to action.  It is long past the time we could pretend that neglect is a synonym for common sense and compassion.

I started writing Our Health Policy Matters three and a half years ago, right after the 2010 mid-term elections. Since then, I have written about two policy areas about which I am passionate – public health and mental health.  As I explain below, I am about to change my professional focus.  And while I will be speaking about one more than the other in the future, for me these two areas are related. Let me explain why. Mental health and public health are first and foremost about wellness.  They are about identifying risk factors for disease and eliminating or mitigating them. Many of the same environmental risk factors contribute to poor health, especially poor mental health.  These include poverty, violence, abuse, and neglect.  When we address or mitigate these risk factors, we improve our nation’s health and mental health together. We often place the burden of responsibility for maintaining one’s health squarely on the shoulders of individuals.  But this is a too

A different kind of climate change was in the news this week, as Gallup reported that the percentage of people who are uninsured declined rapidly from 17.1 percent to 15.9 percent in just three months. That is a pretty substantial drop, and one that began when people started signing up for Obamacare. According to Gallup and others, it translates into an additional 3 million people who now have health insurance, consistent with the numbers of people signing up for Affordable Care Act coverage. That’s good news for Obamacare – perhaps.  One of the more interesting – and sometimes frustrating – things about health policy is that like climate change it unfolds slowly over time, and so it is often difficult to see the change in climate while it is happening. For one thing, there are always other variables.  For example, the unemployment rate has also gone down during this period, from 7.2 percent last October to 6.7 percent today . It is possible that some of these 3

It sometimes seems like policymakers go out of their way these days to pick on people with mental illness. According to a report released last week by the American Mental Health Counselors Association , 3.7 million people with mental illness will remain uninsured because of the decisions of states not to expand Medicaid.  And if you believe some earlier data from the Kaiser Family Foundation  about the total number of people who will be left uninsured because of states' failures to expand Medicaid, then you can only conclude people with mental illnesses account for nearly 80 percent of all those who are being denied insurance coverage in non-expanding states. This includes 652,000 in Texas and 535,000 in Florida, and around 200,000 each in Pennsylvania, Indiana, Georgia, North Carolina, South Carolina, Tennessee, and Louisiana. The association characterizes this as “dashed hopes” and “broken promises.” You might also call it a national disgrace. For thos

A single health policy issue will decide who controls Congress after the 2014 election.  Here’s why. You may have noticed the relative dearth of partisanship emanating from Washington over the past couple of months.  Congress approved a budget with little fanfare and passed a debt ceiling increase with no hint of strings attached. There is a reason for this newfound spirit of bipartisanship, and it is not what you think.  Congress isn’t suddenly taking to heart its relentlessly low approval ratings in 2013.  And it hasn’t just become aware of how unproductive it has been. Barring an unforeseen catastrophe like 9/11, Katrina, or Sandy, it’s just that members of Congress already know which issue will swing the upcoming election.  And they are not interested in muddying the waters at this relatively late date.  The Democrats know that they have an advantage in the improving economy, their stand on women’s issues, and their strong support among minorities. T

I was asked recently why I didn’t actively seek out a specialized school setting many years ago in which to educate my son. My son has a serious mental illness, one which first manifested when he was a child.  I’ve written about this before in Health Affairs and will write about it again in a book scheduled for publication later this year. The argument is this.  If you put children with a special condition – such as serious mental illness – into a classroom with other children with the same condition, then you can adjust your educational services to meet the needs of those children all at the same time – and you will get better outcomes. That’s essentially how our health care delivery system has often been built, too.  Through most of the twentieth century, people with mental illnesses were treated in one set of hospitals (usually state hospitals). And people with most physical conditions were treated in a different set of hospitals. I wrote “most” above becau

Obamacare will insure 2 million fewer people in 2014 than previously reported.  That number is in a new report just released by the Congressional Budget Office (CBO). That may come as a surprise to you.  But it isn’t the biggest surprise in the report for me.  I’ll explain why later.  First, let’s review the new numbers. Last May, the CBO estimated that seven million people would sign up for insurance through exchanges this year.  That number is not a surprise – it has been reported widely in the media. It also estimated that nine million previously uninsured people would be enrolled in Medicaid or CHIP.  In other words, a total of 16 million people would obtain coverage this year through Obamacare. But last week, CBO released updated estimates .  It now says that only 6 million will sign up through the exchanges this year, and only 8 million will enroll in Medicaid or CHIP.  Because some of the people who would have signed up are already insured, that means

It is never easy to absorb unpleasant information. And when I was a policymaker, if someone told me that my decisions were going to cost innocent people their lives, then I usually chalked it up either to hyper-sensationalism or hyperbole.  After all, would passing a small increase in a business tax really force an employer to imperil workers by cutting corners on safety?  Would gun registration really leave a homeowner defenseless in the case of a break-in? Would cutting back welfare a few dollars actually result in a choice between eating or heating in the winter? In most instances, it was hard to see the direct connection. But the more I learned about health issues, the more I understood that there really were some decisions that were a matter of life and death.  These were the issues that taught me humility.  These were the issues that taught me that I needed to set aside my political ideology and embrace both theology and hard data whenever they stared me in

The President focused on income inequality in his State of the Union speech.  This is an important issue; as the gap widens between those rich and poor. But income inequality is built into our public policy at so many levels – and even at the lowest ends of the economic spectrum sometimes the “wealthier” individuals receive better benefits than those who may need them even more.  A case in point is how the insurance subsidies work in the Affordable Care Act in the aftermath of the Supreme Court ruling of 2012. In these, the poorest individuals and families – those living below poverty level – fare the worst. This is an inequality that could be repaired easily and immediately. Here’s how this particular inequality works.  If you are a single person earning $11,375 per year, you pay the highest percentage of your income for insurance as anyone in any income bracket .  An example:  If you want to buy “silver plan” health insurance on the open market, it will cos

It was good news when Congress recently agreed on a budget for the first time in forever.  It was the product of compromise, and everyone expected to give at least a little.  But when the details came out last week, it turned out that some had to give more than others.  And the ones who probably gave up the most were the people who have saved the greatest number of lives over the past century – the public health and prevention community. Last week, the House introduced the FY2014 Omnibus Labor, Health, Human Services, and Education bill – one of twelve appropriations bills that will implement the FY2014 budget.  As the bill summary noted, the legislation includes $156.8 billion in discretionary federal spending for all these important areas combined. That is a big number, and comes to around $500 per person.  By comparison, Defense – which is often considered to be the other “big” area of discretionary spending – will get around $1500 per person. But the disappointi

Last week, I was talking with a new acquaintance about health and mental health policy. He was a successful businessperson, smart, very well educated, and well-informed about public policy.  Like most of us, he follows the news about Obamacare closely.  And he has strong opinions about it.  But I realized as we talked that there were things he thought he knew about Obamacare that were not actually true.  But we both had heard them many times before. So here are five often-repeated “facts” about Obamacare that you, too, have probably heard, and happen to be wrong. 1.  The Affordable Care Act was supposed to reduce health care costs significantly.  Untrue – when the Affordable Care Act was passed, the Congressional Budget Office projected that it would cost more than $1.2 trillion over ten years.  After the Supreme Court decision in 2012, CBO lowered its projection to under $1.2 trillion.  (When these numbers were updated in 2013 , they did not change dramatica

Now that 2014 and Obamacare are both here, there will be plenty of stories about Affordable Care Act implementation.  Some will be newsworthy; but others will just be history.  Last week, we got our first history story characterized as exploding news. The Washington Post reported on a newly-released Harvard study that analyzed the impact of the 2008 Oregon Medicaid expansion on hospital emergency department visits.  The study found that there was a 40 percent increase in the number of emergency department visits made by the new Medicaid enrollees. For the Post article, an MIT health economist (I guess no Harvard ones were available!) commented  that he viewed it “as part of a broader set of evidence that covering people with health insurance doesn’t save money,” something he went on to characterize as a “misleading motivator for the Affordable Care Act.” And Forbes went farther, claiming the study results are “ undermining [the] central rationale ” for ACA. But