Obama-2: Fulfilling the Agenda

As we clear away the confetti from the recent Presidential Election, we are left to speculate what Obama-2 will look like. The observations made here proceed from the assumption that many balls already are up in the air (no pun intended), and that Obama-2 will have a major task to bring them safely over the goal line. The observations focus principally on healthcare, including prevention and promotion.

We can expect the following major actions from Obama-2:

Implement the Affordable Care Act (ACA). The law requires and efforts are well underway to implement the Medicaid Expansion and to build Affordable Insurance Exchanges by 2014 that will provide insurance coverage to 32 million more Americans. At the same time, well-funded efforts will be undertaken to build health homes that offer integrated care.

Behavioral healthcare will experience considerable opportunity as a result of the insurance expansion (11 million enrollees will already have a behavioral health condition) and, at the same time, considerable stress as many behavioral health providers become part of accountable care organizations that operate health homes.

Implement Parity Regulations. The long-awaited federal regulations on mental health and substance use service parity under the 2008 Wellstone-Domenici legislation and under the ACA will be released in Obama-2. We will need to help implement these regulations in the context of the ACA. For example, we will need to consider how parity will work when a health benefit is integrated rather than carved out; how parity will work with a performance-adjusted case rate; etc. A little reflection will suggest that the concept of parity may be different under the ACA than it has been in the past.

Reform Medicare, Medicaid, and Social Security. As a result of the “fiscal cliff” due to federal deficits and debt, and the threat of sequestration, Obama-2 will undertake reform of Medicare, Medicaid, and Social Security. Only three options are available: alter revenue streams; alter covered populations; or alter benefits. Solutions offered will be broad-based ideas with potential impact upon everyone—raise the retirement age for Social Security and Medicare enrollment; increase payroll deductions for these programs; remove payment caps; cap annual Medicare and Medicaid benefits, etc. Because the effort will be designed to apply universally, very careful attention will need to be paid to anticipated impacts on persons with mental illness, substance use, and I/DD conditions.

Obama-2 also will help us step up our nascent efforts at disease prevention and health promotion, as well as efforts to alter negative social and physical determinants that can harm future health status. A better financial outlook for health care will depend upon the success of these upstream efforts and upon care delivery models that reward results rather than unlimited care.

Reform Government. Obama-1 already had the stated goal of federal reform—remove duplication, reduce the number of agencies, consolidate programs, etc. Such efforts can be expected to continue in Obama-2, driven in part by productivity concerns and in part by our fiscal crisis. For behavioral healthcare, a continued federal focus on services and training will be essential. Field advocacy will need to be fully unified on this issue, once it arises.

Our hope is that Obama-2 will continue and expand efforts to promote social justice for all Americans in each of these four domains. This means that efforts will need to continue to reduce disparities and promote equity in each of the domains, particularly around health concerns. An important principle here is that equity does not mean distributing resources equally. It means distributing resources according to actual need.

Clearly, we will have major tasks going forward to work effectively with Obama-2 in each of the four domains. To do this effectively, we will need to organize ourselves now, so that we have a clear, agreed-upon agenda going forward. Our agenda will need to have broad-based support across all stakeholders in our field.

Obame-2 started the day after the Presidential Election. Let us start today.