Linda`s List 2017

There’s no doubt 2017 will be a year of pivotal changes. With Donald Trump in the White House and his appointees ready to make fundamental shifts in U.S. priorities, behavioral health leaders are facing an uncertain future with a mixed bag of new challenges.

Linda Rosenberg, president and CEO of the National Council for Behavioral Health, says while she herself tends to be optimistic, this is clearly a year to be more cautious for a number of reasons.

Repeal will impact patients: Rosenberg says any scaling back of care provisions disproportionately affects people with mental health and substance use disorders compared to other illnesses. She cites a January blog on The Hill written by policy experts from Harvard Medical School and New York University that outlines the quantitative impact anticipated for behavioral health if the Affordable Care Act (ACA) is repealed.

In dollar terms, removing ACA mental health and substance use disorder provisions alone would withdraw $5.5 billion annually from treatment services for low-income patients, the authors write. Additionally, 1.2 million people with mental health disorders and 2.8 million with addiction disorders would lose some or all of their insurance coverage.

“And that is very serious,” Rosenberg says.

The populations tend to have more chronic illnesses, and many are receiving ACA subsidies to buy their insurance plans right now.

“This has nothing to do with being a Democrat or a Republican, but it has to do with a lack of understanding of who has benefitted from the ACA,” Rosenberg says. “It’s a combination of the very people who voted for our new president who live a working-class life and are often underemployed and bought health plans on the exchanges, as well as people who benefitted from the expansion of Medicaid.”

Until firm details are in place, providers at the ground level will be challenged to decide how far to continue their efforts related to existing policy while hedging their bets on where new policy might leave them.

Medicaid block grants would likely translate to reduced resources: Rolling Medicaid into a block grant model—as the new administration has proposed—essentially will translate into reduced federal contributions to the program overall. Depending on the fixed amount each state receives, such a model will likely lead to cuts in covered services and/or cuts in eligibility.

The reduction in federal contribution could amount to $1 trillion over 10 years, Rosenberg says, and states will not be able to make up that amount. It’s a significant concern for providers.

“If you look at Medicaid, 25% of all mental health spending and 21% of all addiction care comes from Medicaid,” she says.

She also notes that reduced resources might result in cost shifting to enrollees who can’t afford even modest increases. Bumping up a copay amount by just a few dollars could mean the difference between accessing care and not accessing care for low-income families.

“Cutting Medicaid hurts Medicare, it hurts unborn babies, babies and young children—the very group that those same politicians care a lot about,” she says. “The image of this lazy, shiftless person on Medicaid is not the case. They’re hurting, vulnerable people who because of their illness don’t have the ability to pull themselves up by their bootstraps.”

Many facts are not well understood: Healthcare leaders and other policy watchers have long said that facts about ACA and other health policies are too often lost in impassioned political discussions. For example, some voters erroneously believe that ACA and “Obamacare” are two different policies, while others who are helped by ACA provisions don’t realize that the law made such benefits possible for them.

Rosenberg also believes President Trump has yet to learn the nuances of the U.S. healthcare system and all its interconnected levers. Creating effective health policy has no comparison, she says, and the process should not be regarded as if it were a business deal.

“That goes to the heart of how complex healthcare is,” she says. “It isn’t like making a rocket or flying an airplane. Those things are quite complicated, but healthcare is far more complex.”

Now more than ever, policymakers need the expertise of behavioral health leaders to understand the impact of proposals in the real world. She says educating stakeholders must be on the strategy list in 2017 for providers.

Certified Community Behavioral Health Clinics (CCBHCs): The CCBHC demonstration project aims to create an enhanced care-delivery and payment model, not unlike federally qualified health centers. Eight states now have grant money to test their CCBHC framework with the hope that the most successful models can be implemented nationwide in the future.

“The eight states have designated the organizations that are going to be CCBHCs,” Rosenberg says. “One conundrum is that they all have to deal with the potential for changes [related to the repeal] of the ACA, and they have to concentrate on many things at once. They have small staffs but realize that they are very fortunate to have been selected. They have a chance to protect some people during what will be chaos in healthcare.”

Additionally, it’s important to recognize that if proposed policy changes do occur, more people are going to rely on the safety net, which is exactly where CCBHCs are positioned. Rosenberg says the safety net in behavioral healthcare has been neglected for decades and must be shored up as a priority in 2017.

“For the next several months, protecting access to care has got to be number one,” she says.

All segments are at risk: Federal policy changes are not exclusive to public programs, Rosenberg warns. As the system at large responds to shifting priorities, for-profit providers will likely see downstream effects.

“It paralyzes providers and causes chaos: ‘I don’t know what to invest in. I was going to make an acquisition or do a merger or buy new equipment or invest in a new building,’” she comments. “All of that will come to a standstill. While it’s sorted out, it will be a big economic blow to our country.”

Knowing that healthcare accounts for 18% of the gross domestic product, any slowdowns will be felt for a long time, she says.

Workforce issues remain: “We already have a crisis in the public and private sector to attract and keep workers in healthcare,” Rosenberg says. “Healthcare has been under siege for so many years, and I don’t think it’s regarded as very attractive. Some people are driven by mission, but most have to temper that with realism.”

She is concerned that professionals in the public sector in particular don’t always have salaries adequate enough to keep up with the cost of living, and the situation would be made worse if funding is reduced for organizations that already struggle to meet payroll.

For the future, organizations can look to technology to augment the workforce, both in terms of direct care with telemedicine or coaching and in terms of data analytics that can help enhance care efficacy.

“Every other industry has made changes on the basis of knowing its customer,” Rosenberg says. “We’re just beginning to do that in healthcare.”

Communities are embracing mental health first aid training: Rosenberg says nearly 1 million people in the United States have been trained in mental health first aid, and the National Council’s next goal is to reach 3 million.

Last fall, the International Association of Chiefs of Police called on all police agencies to train 100% of sworn officers and support staff in mental health first aid. The training will help safely de-escalate situations in order to protect both the citizen in crisis and the law enforcement officer.

“I never would have believed eight years ago that people would be so taken with it,” she says. “People have responded to it, and now it’s our obligation to continue to support it.”

Hospital systems, libraries, schools and business leaders are among the other groups leveraging mental health first aid training. It’s taken on a life of its own, Rosenberg says.

Join Us

Behavioral Healthcare Executive will be reporting from the NatCon Conference in Seattle, April 3-5, 2017.