Health Reform Opponents May Undo MH Access Expansion

A public that is still split over the Democrat-led health care law and the increase in Republican members of Congress after the November elections could endanger provisions of the law that benefit people with psychiatric disorders, say mental health advocates.

These advocates, including APA, are nervously watching congressional Republicans for indications of how they will target the wide-ranging health care law enacted in March. Since the bill passed without support from any Republicans in Congress, members of that party have declared their intent to “repeal and replace” the law with more limited “market-based reforms.”

Mental health advocates are especially concerned that provisions considered critical to expanding access to treatment for people with mental illness will be those targeted for repeal.

“Regardless of the party in charge in Congress or media narrative, APA is always concerned about defending the advances in mental health treatment and coverage that have been enacted into law,” said Matthew Sturm, an associate director of APA's Department of Government Relations, in an interview with Psychiatric News.

Beyond Republicans' announced intentions to target some or all of the law for repeal, supporters of various provisions of the law are concerned that their efforts to protect it could be complicated by problems such as insurers' dropping coverage for certain populations. Several insurers have dropped their individual, child-only, or Medicare Advantage policies, including Harvard Pilgrim Health Care in New England, which ended its Medicare Advantage plan for 22,000 seniors over concerns about “the long-term viability” of the plan in light of the health care law's changes.

Additionally, the Kaiser Family Foundation's September tracking poll of public opinion found likely voters equally divided at about 45 percent each on whether they supported or opposed the law, percentages that have changed little in the past six months. The poll results have been disappointing to President Obama and congressional leaders who were hopeful that the legislation would quickly gain popularity after its passage.

The law's defenders also face challenges from unexpected implementation complications. For instance, about 30 companies providing limited-coverage policies to 1 million employees have received one-year exemptions from the Department of Health and Human Services to the law's coverage mandates after the companies found their policies would not meet the law's minimum coverage requirements. The exemptions angered health care reform advocates who were concerned that the move weakened the law.

These factors could feed Republican efforts to push through repeals of some provisions of the law—possibly even with the support of some Democrats, according to advocates.

Short of a repeal of the entire health care law, it remains unclear what provisions the GOP will target first. One of the most likely approaches could entail cutting off funding for the federal agencies or departments, such as Health and Human Services, that are responsible for implementing the law's provisions, according to advocates. Such a move worries advocates because it could affect the implementation of the law's state-based insurance exchanges—or marketplaces—which require part icipating insurers to provide mental health care coverage at parity with that for other types of medical care.

Republicans would likely have the support of insurers if they moved to roll back the requirement for parity coverage within those state exchanges, said Andrew Sperling, director of federal legislative advocacy for the National Alliance on Mental Illness, in an interview with Psychiatric News. Insurers have long opposed various parity-law requirements over concerns that they will raise the cost of the policies that the companies sell.

The best indication of other likely Republican targets in the health law may be provisions they have already targeted for repeal in the current Congress. For instance, in September the Senate came within four votes of approving an amendment to tax legislation that would have eliminated funding for the federal health care law's $11 billion Prevention and Public Health Fund. The fund was needed, according to a letter APA and other health care advocates sent to members of Congress, to pay for local health departments' illness-prevention programs, such as those that provide immunizations.

The nonprofit Center on Budget and Policy Priorities estimated that the amendment would have cut the number of people gaining insurance under the law by 2 million and would have increased premiums by as much as 4 percent for people with coverage through the new health insurance exchanges—due to the smaller number of healthy people being included in insurance pools.

Another likely target for Republican repeal efforts is the Community Living Assistance Services and Supports (CLASS) Act, a voluntary long-term-care insurance program that will provide cash benefits to help cover the cost of nursing-home care, a home-care attendant, equipment and supplies, and home improvements to aid disabled beneficiaries. Mental health advocates said the program is needed to keep the soaring cost of long-term services from wiping out the savings of people who are disabled. However, it likely will be targeted because critics believe it will add billions of dollars annually to the federal budget.

Not all Republican health care initiatives may be opposed by APA. For instance, APA is likely to join other physician groups in supporting Republicans' stated plans to pursue tort reform. A typical package of tort-reform proposals would produce $54 billion in net government savings, in part, through a reduction in medical tests used for defensive medicine by physicians worried about lawsuits and reimbursed by federally funded health insurance programs, according to the Congressional Budget Office, which is the nonpartisan accounting arm of Congress.

Although psychiatrists have one of the lowest malpractice lawsuit rates in medicine, malpractice reform remains an important APA priority. APA has stood with the AMA and allied medical specialty societies in supporting tort-reform proposals. These include caps on noneconomic damages and the use of health courts to lower the cost burden for physicians and to cut the cost of defensive medicine.

A copy of the APA letter about the prevention fund is posted at <http://healthyamericans.org/assets/files/Johanns%20Sign%20On.pdf>.