Before the Congressional recess: Before the Congress left Washington for their summer recess, I reported on the partisan battle over additional funding to combat a potential ZIKA virus public health crisis (SSCI HeLP line for June 2016). Recall that the Obama Administration requested $1.9 billion in new emergency funding, and the Congress worked that number down to a $1.1 billion funding request by removing funds not directly related to the ZIKA crisis. Unfortunately, Congress was not able to pass the Senate compromise bill, despite a 52-48 vote in favor of the bill–recall that to advance through the Senate, a bill must receive 60 votes in favor of the bill. I also wrote that as much as $622 million of unused Ebola appropriations could be repurposed to support ZIKA eradication and research. This is about half the amount contained in the compromise bill that was defeated in the Senate, but it is still a great deal of money to initiate action on this emerging public crisis.
Current status of ZIKA expenditures: The Obama Administration and the CDC have repurposed successfully over $600 million to be used to combat ZIKA. However, the Administration has disbursed only about one-half of its reprogramed dollars or about $201 million. Similarly, the CDC has released a little more than $100 million (again about one-half) of its available funds. As of early August, the Executive branch Office of Management and Budget confirmed that $385 million of repurposed funding is available for the Administration to allocate to the fight against a potential ZIKA outbreak. If the public health situation is dire, and if the funding need is urgent, how is it that the Administration is not disbursing all of the available funds rather than just half? This is as lot of money, hundreds of millions! In the August 3 editorial page of the Wall Street Journal, the editorial writers assert that the Department of Health and Human Services spokesman Bill Hall attributed the delay of disbursing available funds to combat this urgent public health crisis to “bureaucratic federal procurement regulations”. Is it unconscionable, or not, that the Administration cannot manage to allocate hundreds of millions of dollars already in its accounts to combat this emerging ZIKA outbreak because of “bureaucratic federal procurement regulations”? How can the President berate the Congress for going on recess and not doing its job, when the Administration is not doing its job either! This partisan political story just gets worse and worse while a public health emergency festers. In fact, the CDC recently issued its first ever travel alert in the US for parts of Miami concerning the increased risk of ZIKA infection, especially for pregnant women.
Government fails us: The Congress has failed to appropriate what the Administration asserts is the necessary funding to combat an emerging ZIKA public health crisis. The Administration has failed to disburse the hundreds of millions of dollars languishing in OMB accounts. Sounds to me like the gridlock in Congressional is being matched now by bureaucratic ineptitude in the Executive branch. This has to be the quintessential example of the government and our elected officials failing us, their constituents! Perhaps after a crisis develops, Congress will pass a bill with any needed additional funds. Perhaps if a crisis develops, the President will sign the bill and then instruct his executive departments to disburse the funds appropriately and expeditiously. Of course, each branch of our government will blame the other branch for their public health failure! Will the public’s health suffer because the ZIKA issue has become a “political football” in the midst of a major election year where the parties seem to be focused on scoring political points rather than on serving the public’s health?
The Senate Committee on Health, Education, Labor, and Pensions (HELP Committee) unanimously, and therefore with full bipartisan support, passed legislation to reform the provision of “mental health” care.
Goals of the legislation: The goals include efforts to increase access to “mental health” care; improve training for those who care for people with “mental illness”; and promote better enforcement of existing “mental health” parity laws—making insurance companies reimburse for “mental health” treatment the same as for “physical health” treatment. The bill is composed of six titles. For example, Title III proposes support for state responses to “mental health” and substance abuse disorder needs. Title IV promotes access to “mental health” and substance abuse care, and Title V does the same explicitly for children and adolescents. The bill authorizes (not appropriates—do you understand the difference) block grants to states for “mental health” services and for prevention and treatment of substance abuse disorders.
Limitations: Foremost is the fact that the HELP committee lacks jurisdiction over funding. Stated differently, the committee that passed the legislation cannot actually appropriate funds to support implementation of the legislation. The Congressional Budget Office (CBO) scored the bill and estimates that it would cost between $40 to $80 billion dollars over 10 years—a new appropriation that would have to be offset with cuts elsewhere to maintain overall budget neutrality. Nonetheless, the bill could move to the Senate floor as early as next week to debate funding and to entertain any amendments.
Amendments on the Senate floor: What happens next is not readily predictable. For example, Senator Collins lamented that “exclusions of reimbursement for certain residential mental health services is a concern.” The Senator might offer amendments to repeal the current prohibition on Medicaid paying for inpatient care for anyone over age 21years or under age 65 who resides in an institution for “mental disease” (IMD). Removal of this so-called IMD exclusion would be very costly even though it would remove a major barrier to treatment of “mental illnesses”. Other Senators are “concerned also about Medicaid’s prohibition against reimbursements to hospitals and facilities larger than 16 beds for mental health and substance abuse treatment.” These are difficult issues, especially concerning funding decisions. Given the harsh reality of the current budget deficit crisis, this bill may fail to gain any appropriations in the ensuing Senate debates.
Does all this make sense to you? One additional comment from Senator Collins caught my attention. She lamented, “It is stunning to me that in this day and age we do not treat mental illness in the same way that we treat physical illness.” Her observation has veracity, of course. However, physical diseases are never lumped under a label of “physical illness” the way that we lump diseases of the mind under a label of “mental illness.” I remain puzzled by the labeling of some diseases that affect the mind as “mental illnesses” while others are labelled as diseases of the brain. (Feussner JR. When diseases of the brain become diseases of the mind: A new frontier for clinical research. US Medicine 39:9, November 2000.) For example, Alzheimer’s disease has devastating effects on personality, cognition, and memory. Is Alzheimer’s disease a disease of the brain or a “mental illness”? A brain tumor, or a temporal lobe seizure disorder, can affect one’s cognition or personality—are these diseases of the brain or “mental illnesses”? Alternatively, depression is likely to be labeled as a “mental illness” despite studies demonstrating a neuro-chemical basis for depression. Are schizophrenia or bipolar disorder diseases of the brain or “mental illnesses”? Does our profession inadvertently contribute to the lack of equitable reimbursement for “mental” as opposed to “physical” illnesses in part because of our labelling practices? Perhaps all those treating these patients can change our nomenclature in the future–just stop labelling patients as “mentally ill” and stop using the catch-all phrase “mental illness” altogether. Stay tuned!
Also see: www.congress.gov/bill/114th-congress/senate-bill/2680
SSCI HeLP Line
Update on the Patient Protection and Affordable Care Act (PPACA): Good and bad.
What was the base state before passage of PPACA in 2010?
Before considering the current state of health care after passage of PPACA, it is important to define the “base state”. Fortunately, baseline data are available from the 2010 national census concerning the health insurance status of Americans. According to the 2010 census, 16.3% of Americans had no health insurance, nearly 50 (49.9) million Americans! In 2010, Americans receiving health insurance from government increased slightly from prior years to 31%, 95 million Americans. That same year, Americans covered by employee-based health insurance decreased to 55%, 169 million Americans. These data represent the “base state” from the same year PPACA passed but before implementation. Physicians and scientists know how important it is to have such robust “before” data. As with any new law, there are “good” features that are very popular, and “bad” features that are not so popular.
THE GOOD. Although the naysayers will not admit it, there are very good provisions within PPACA. What are some of them? For a start, the PPACA broadens health insurance coverage for adults with pre-existing conditions and eliminates pre-existing conditions for children. Resolving this “pre-existing conditions” issue is long overdue! In addition, PPACA allows dependent children to remain on parents plan until age 26, an almost universally popular provision. The PPACA also ends rescissions, that is, insurance coverage cannot be cancelled because of a new illness. Now, there is also no lifetime dollar limit on coverage. Finally, the PPACA begins to address closure of the so-called Medicare drug donut hole. All of these changes are very positive improvements for many Americans. Importantly, there are now many more Americans with health insurance than before passage of PPACA—nearly 12 million more! These are some of the most positive changes resulting from implementation of PPACA.
THE BAD. Of course, no law is perfect. If you compare the 2016 census data with the numbers of newly insured Americans, there are at least 35 million Americans still without health insurance. Furthermore, in 2016, the penalty for not having health insurance increases significantly–to the higher of either $625/adult or 2.5% of household incomes. This is a potent penalty for those not complying with the PPACA provisions. According to CMS actuaries, health expenditures increased in 2014. Notably, the costs of hospital care, physicians’ services, prescription drugs and especially insurance premiums have all gone up. BUT the most striking increase is in the cost of government administration for health care—up 5-fold. More recently, from 2015 to 2016 insurance premiums on the ACA exchanges rose on average 9%. In 29 States, the average premium increases were in double digits and in one third of States the average premiums increased 20% or more. In addition to premium increases, there are increases in insurance deductibles. Silver plans, the most popular in the health care exchanges, now have an average deductible of nearly $3000 in 2016. Then there is the performance of the so-called “Obama care exchanges”. Fully 12 of the 23 cooperatives failed and are defunct. Of the remaining 11 cooperatives, 8 are under enhanced federal oversight or are on a corrective action plan. None of this is good news for Americans who counted on the cooperatives as a vehicle to sign up for health insurance. What does all this mean for patients wishing to use their health insurance? Can these patients really afford routine primary care or access to care for management of chronic disease? There are issues also of access to health care. Within PPACA, there was no plan to address the physician workforce, especially the ongoing shortage of primary care providers. For practicing physicians worried about medical malpractice, the PPACA failed to address tort reform in any meaningful way.
So there you have it—the mixed bag that is PPACA, both the good and the bad! Is it possible to keep the good while diminishing the bad? We shall see what the congress and new administration might propose after the elections in November. Stay tuned!
The new year is off to a most positive start with passage of a $1.1 trillion omnibus spending bill by the 114th Congress, and recently signed by the President. This new spending bill increases funding for biomedical research substantially. Funding for the National Institutes of Health (NIH) will increase by about $2 billion, and the new NIH appropriation will total about $32 billion. This exceptionally good news is not to be taken lightly. In 2009, at the beginning of the current administration, the NIH budget was $29.5 billion. From 2009 to 2015, the NIH budget stagnated, and actually lost ground in terms of inflation-adjusted dollars. In 2015, the NIH budget was a modest (only by Washington, DC standards) $30.1 billion. One only need to compare that budget with the 2009 budget to deduce that neither the previous Congresses, nor the current administration, was able to navigate a divisive political atmosphere to continue supporting the country’s critical investment in biomedical research. Fortunately, the 114th Congress gets it! The current increase is highly positive and ends an unfortunate sustained lack of federal investment in research. However positive, the current increase is just a beginning, and the Congress and the next administration must embrace the pragmatic need to keep the country’s investments in medical research ongoing and increasing in a predictable manner. If you recall, HR-6, the 21st Century Cures Act suggested just that. The 21st Century Cures Act recommended a multi-year, incremental investment in biomedical research funding to put the NIH on more stable footing, with the ability to fund research knowing what the out year budgets might be. While the 21st Century Cures Act was passed overwhelmingly in the House, it continues to languish in the Senate.
And what about everyone else?
In addition to the increase in the NIH budget to about $32 billion (a 6.6% increase, largest increase in 12 years) other entities supporting medical research also received increased budget appropriations. The NSF will see a 1.6% increase ($119 million) to a new budget of $7.46 billion. The research appropriation for the VA’s Office of Research and Development will see a 7% increase in its research budget to $631 million, its largest budget ever. Only the AHRQ will experience a budget decrease, of 8% from $364 million to $334 million, (this could be viewed as progress as HR-6, the 21st Century Cures Act, proposed to terminate all funding for the AHRQ). Let’s hope that congressional support for further investment in medically focused research continues for the next period of time, providing the academic enterprise, and its research faculty, some stability and the assurance that this most critical academic mission in not again shortchanged or caught up in partisan bickering. The only remaining concern is that despite being passed by Congress and signed by the President, report language—what the Congress expects the funded departments or agencies to do with the increased revenues from the new budget agreement–is still not available for this Omnibus spending bill.
For additional information, see also news.sciencemag.org 12/18/2015
Coming next: Update on the Patient Protection and Affordable Care Act (PPACA): Good and bad.