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Health Care Reform Legislation Advances in Congress

November 19, 2009

After months of anticipation, the U.S. Senate is expected to begin debate later this week on legislation to reform our nation’s health care system.  This follows passage of legislation by the House Nov. 7 by a vote of 220-215.  The Senate bill includes the merger of separate bills that cleared the Finance and Health, Education and Labor (HELP) Committees earlier this year.  Senate Majority Leader Harry Reid (D-Nev.) is expected to press the Senate move forward on debate throughout December and move for final passage before the Christmas holidays.

Like the Senate bill, the House bill (known as the Affordable Health Care for America Act, HR 3962), contains a number of critical coverage expansions and improvements critical for people living with mental illness.  Among these are:

  1. Expanded Medicaid eligibility for low-income childless adults, including individuals living with serious mental illness who currently do not qualify for Medicaid coverage in their state.   The expansion is up to 150 percent of the federal poverty level in the House bill (about $16,200 for an individual) and 133 percent in the Senate bill.  These childless adults living with serious mental illness are currently more likely to be uninsured and most likely to be without any health care insurance coverage at all.
  2. Expanded coverage for the uninsured through a new national health insurance "Exchange" would be required to have mental health benefits and cover those benefits at parity. This would expand the 2008 federal parity law into the individual and small group market in many states.
  3. New protections for individuals that already have insurance coverage or are at risk of losing coverage. Insurance reforms included in both bills would ensure that people with mental illness could not be denied health insurance benefits on the basis of a preexisting condition or could not be dropped from existing coverage due to their medical condition.

How Will Reform Impact Consumers and Families?

It is important to note that NAMI’s engagement in the health care reform debate this year has not been limited to those provisions in the legislation that impact exclusively on mental illness treatment.  NAMI members know from personal experience how children and adults living with mental illness face enormous challenges accessing not just specialty mental health care, but also primary and specialty care.  Adults living with mental illness are disproportionately represented in both the uninsured and underinsured populations.  Many of these uninsured Americans living with mental illness fall just beyond eligibility criteria for programs such as Medicare and Medicaid, while others are employed intermittently or in low wage service sector jobs that do not offer employer sponsored coverage.

It is also the case that people living with serious mental illness are among the least healthy Americans.  Data compiled by the National Association of State Mental Health Program Directors (NASMHPD) in 2006 reveals that adults with serious mental illness have a life expectancy that averages 25 years below the general population.  This NASMHPD study found significantly higher rates of medical co-morbidities such as diabetes, heart disease, pulmonary disease, asthma and cancer, as well as poor access to basic primary care services.   

In short, people living with serious mental illness have the most to gain from comprehensive health care reform legislation as they are more likely to be uninsured or underinsured and more likely to experience poor health outcomes as a result of the complexity in treating mental illness and co-occurring medical conditions.

Click here to view NAMI’s letter in support of HR 3962, as well as the principles that NAMI has been using to guide advocacy on this important legislation.

Key NAMI Priorities in Health Care Reform

Among the key provisions in the House and Senate bills that will expand access to coverage and improve health care for people with mental illness are:

1) Insurance Market Reforms

Both bills contain a full range of reforms to the current health insurance market.  These changes are critically important to people living with serious mental illness excluded from coverage on the basis of pre-existing medical conditions.  Among these important new protections are:

  • Requirements for guaranteed issue and guaranteed renewal of coverage in the individual and small group markets;
  • A prohibition of pre-existing health condition exclusions as well as restrictions to severely limit the use of health status in determining premium rates;
  • A prohibition on the application of annual and lifetime insurance caps and limits on out-of-pocket spending; and
  • Creation of a high-risk pool to provide immediate assistance to those currently uninsured with pre-existing conditions before insurance market reforms go into effect. 

2) Inclusion and Equitable Coverage of Mental Health and Substance Abuse Benefits

A key goal for NAMI in health reform has been ensuring that all expanded health coverage for the uninsured BOTH includes coverage for mental illness and substance use treatment AND does so in compliance with the new Wellstone-Domenici parity law.  It is critical that all plans offered through the Exchange—whether purchased through the individual or small group market—comply with this important new law.  Both the House and Senate bills accomplish these goals by including mental health coverage in the required basic benefits package and referencing the parity law in a separate non-discrimination standard for all plans offered through the Exchange.  The House bill would also significantly erode the individual market and small employer (50 and under) exemptions to the parity law that we were forced to accept in 2008. 

3) Medicaid Expansion

The House bill includes the largest expansion of Medicaid eligibility since 1965, requiring states to cover individuals and families up to 150 percent of the federal poverty level (about $16,200 for an individual).  The Senate bill expands eligibility up to 133 of the federal poverty level.  This change alone is the largest coverage expansion ever for childless adults living with mental illness—especially for those unable to qualify for SSI, who work intermittently and do not qualify for Medicaid in their state.  This coverage expansion begins in 2013 and 2014 with a 100 percent federal match rate, declining to 91 percent in 2015 and beyond.   In addition, the House bill extends higher federal match rates for the states under the current economic recovery program through July 2011.

The House and Senate bills also contains a proposal drafted by Senator Olympia Snowe (R-Maine) and Representative Bart Gordon (D-Tenn.) authorizing a new Medicaid demonstration program for emergency psychiatric services (lifting the Medicaid IMD Exclusion for acute care in free-standing psychiatric hospitals).  Finally, the House bill adds a new requirement for state Medicaid programs to cover preventive services without cost sharing.

4) Improvements to Medicare

The largest changes to Medicare relate to the Part D prescription drug benefit, including filling the so-called “doughnut hole” coverage gap—initially with a 50 percent discount on brand name drugs and eventually closing the gap entirely by 2019.  Both bills also expand the Low-Income Subsidy (LIS) program (e.g., increasing the asset test) and adds new protections for dual eligible beneficiaries (e.g., minimizing disruption from annual switching between plans). 

In addition, the bill eliminates cost sharing for preventive services under Medicare and authorizes a new Medicare “medical home” pilot program to provide more coordinated and comprehensive care for beneficiaries with multiple medical co-morbidities.

5) Comparative Effectiveness Research (CER)

The House bill improves provisions from the Energy and Commerce Committee bill setting forth structure and oversight to guide implementation of comparative effectiveness research (CER).  This provision in the bill sets forth oversight and structure for federally funded research designed to compare two or more treatments for a particular disease or medical condition.  NAMI supports investment in CER to improve quality and better inform treatment decisions.  At the same time, NAMI also wants to ensure that CER studies are well designed and reflective of real world treatment settings (e.g., differences among racial and ethnic minorities, complexity of medical co-morbidities, etc.). 

Changes contained in HR 3962 will help ensure that the differences among ethnic and minority subpopulations are more accurately measured in CER.  New language will also ensure that CER is not used to inappropriately mandate payment, coverage or reimbursement policies.  NAMI is urging further improvements such as those put forward by Senators Kent Conrad (D-N.D.) and Max Baucus (D-Mont.) in the Senate bill to ensure that CER is overseen, disseminated and implemented by an independent, non-governmental institute that genuinely represents the interests of patients, researchers and providers and reflective of how CER can best be used in real world treatment settings.

6) Community Living Assistance Services and Supports (CLASS) Act

NAMI is extremely pleased that HR 3962 includes the late Senator Edward Kennedy’s CLASS Act, a new voluntary, public, long-term care insurance program to help support people with significant functional limitations, including serious mental illness.  After a contribution period, individuals determined to need assistance as a result of functional limitations would qualify to receive assistance to purchase services to maintain personal and financial independence.  CLASS Act assistance would supplement, and not supplant, other long-term care assistance such as Medicaid. 

7) New Standards for Federally Qualified Behavioral Health Centers (FQBHCs)

HR 3962 authorized the Health Resources and Services Administration (HRSA) to establish new standards for Federally Qualified Behavioral Health Centers (FQBHCs) under the Public Health Service Act (Section 2513).   These new standards include outpatient mental illness treatment services, targeted case management, crisis intervention services, family psychoeducation, peer support and family supports.  NAMI is extremely grateful to Representative Doris Matsui (D-Calif.) for her efforts to get this provision added to the House bill.