The US Senate can improve health reform

The entire behavioral health community is extremely dismayed by the recent vote in the U.S. House (217 to 213) to approve the discredited American Health Care Act (AHCA). This vote was strictly along party lines, with no Democrats supporting the bill. Now, the action moves to the U.S. Senate, where we all sincerely hope that considerably more reasonable decisions will prevail.

To recap the House AHCA:

This bill would reduce Medicaid spending by about $880 billion over 10 years and discontinue premium and care subsidies in favor of much reduced tax subsidies for persons insured under the state health insurance marketplaces. All of this would have the net effect of eliminating needed health insurance for about 24 million Americans, who could no longer afford it.

In the individual market, premiums would skyrocket for those with disabilities and for those who are older, while younger, more healthy individuals would enjoy much reduced premiums. Although the bill makes provision for state-operated, high utilization pools for persons with serious conditions, the federal funding provided would only comprise a very small fraction of what actually would be required to cover these services. Clearly, the AHCA would represent a very huge step backwards.

From a human values point of view, that huge step backwards would lead to an American tragedy. The AHCA does not comport at all with fundamental social justice principles that are an essential part of American culture and history. The vast majority of Americans endorse federal efforts to assist those who are disabled and those who are older. By contrast, the AHCA severely disadvantages these groups in favor of younger persons who are healthy. This perverse inversion does not reflect who we are as Americans or who we want to become in the future. This unfortunate reality is painfully obvious, and it demands urgent action.

Now, we do have an opportunity to take that action to the Senate. Here are a few principles to drive our strategy with the Senate:

1. Modify rather than repeal the Affordable Care Act (ACA). The ACA has reconfigured the fundamental structure and culture of how health insurance operates in the United States. This has resulted in a dramatic and continuing reduction in the number of Americans without insurance. Today, this group represents less than 10% of all Americans.

The state health insurance marketplaces need to be modified to induce insurance companies to enter these markets with less costly insurance packages and reduced copays and deductibles. This can be achieved by altering the metal level insurance packages that are offered. Hence, we can modify rather than repeal the ACA.

2. Maintain the ACA Essential Health Benefits (EHBs). These benefits provide a framework that increases the comparability of insurance packages offered across different communities and states. They also provide a foundational basis for parity of mental health and substance use benefits with medical care benefits.

These EHBs also are helping to transform our health care system from one focused exclusively upon disease to one with a more balanced focus on prevention and care. It will be essential to maintain this structure if we are to continue to bend the cost curve for care so that the entire EHB package remains affordable.

3. Continue Protections for Persons with Pre-existing Conditions. This will require that insurance enrollees have the protections of guaranteed issue and community ratings for premiums. With both of these protections, those with prior conditions could continue to participate in the state health insurance marketplaces.

Without these protections, premiums for those with disabilities and those who are older will skyrocket, thus rendering health insurance unaffordable. Redlining was a very common practice among those with behavioral health conditions before these protections were introduced.

4. Continue the State Medicaid Expansion. A total of 31 states and the District of Columbia have implemented the Medicaid expansion. In these jurisdictions, a very large proportion of those who are too poor to purchase health insurance now have the protection of Medicaid health insurance.

There are two obvious reasons for continuing the Medicaid Expansion. First, those with this coverage can access preventive services and address health conditions before they become catastrophic. Second, those with this coverage are much less likely to seek much more costly emergency services.

5. Continue Medicaid as a Federal-State Entitlement Program. Since its inception in 1965, Medicaid has been a joint federal-state entitlement program that has provided essential services to those with disabilities, needy families, and children. The program was designed so that states with larger populations in poverty receive a larger percentage of reimbursement from the federal government.

All of the proposed alternatives to the federal-state partnership are inadequate because they will either limit services inappropriately, limit the scope of covered populations inappropriately, or both. Hence, they do not really represent viable solutions.

These five principles can help guide Senate action in response to the discredited AHCA. If the Senate can develops equivalent or better solutions that maintain insurance coverage and access to care, we will be very glad to consider them.

I strongly encourage you to become fully engaged in the upcoming Senate debate on these very important questions.