According to the plan offered by the Speaker’s Task Force the eventual closing of the coverage gap is heavily dependent upon the success of the behavioural health component outlined in phase one. The problem is that part of the proposal is fundamentally flawed and unlikely to succeed.
The general plan (Everything is general. Their are no concrete plans. Virtually everything is to “be worked out.”) is based on the idea that people with behavioral health problems are way too expensive and the best way for the state to save money is to make them less expensive. The assumption, the way I understand it, is that if each these 114,000 people have someone in a case manager type role that person is likely to be able to be able to coordinate care, make sure both behavioral health and Medical needs are met, improve health outcomes and save the state money. If this works out after 12-18 months then we are according to the plan to start phase 2 which would cover everyone else.
It is a tremendous oversimplification but the bottom line is really simple. People with mental illness spend a lot of time in the emergency room getting the most expensive care possible and the thought is that if they had insurance that expense would be greatly reduced. If that works then phase one is successful. If it doesn’t then the entire venture will be judged a failure. Very high stakes on a venture much more complicated than they seem to realize.
The first thing to realize is that the Task Force Plan is really not a plan. It is an assurance. Assuring someone that you are going to do something because you have decided to do it is not a plan about how you are going to do it. And despite all the assurances in the world this will rise or fall on the plan.
There are a bunch of problems.
1. The single biggest problem is the assumption that by itself it can work, that ER usage for the mental health population is a function mainly of lack of insurance. It is far more complicated than that. The state of Tennessee does about 20,000 committals a year. For the most part all these committals start in the emergency room. I don’t know the exact figure but I believe that for every mental health emergency that results in committals there are several that don’t. The strong push in the state is not to commit because the state hospital is extremely expensive and all that money comes out of the state budget. The system uses mental health emergencies as an entry point into more intense services. Nothing in this plan is likely to change that.
2. Problems in the lives of those with mental health issues, like all of us, is a function of the context of their lives. The people the task force is talking about serving are disproportionately likely to be very poor, disproportionately unemployed, more likely to have comorbid health problems, be hungry, have substance problems, a history or current reality of ongoing trauma, experience in the criminal justice system etc. Whether or not they are in crisis has a lot to do with things other than insurance. Tenn Care will not be a magic button to make it all go away. No one that I know of thinks of any mental health reform as a 12 month process. Maybe time enough to start the ball rolling. No where close to long enough to be the ball game.
3. One of the few concrete things they do talk about is using the Health Home Tenn Care program. That would be the mechanism for a lot of the coordination this program needs to have to have any chance of success. They hope to put phase one into implementation in 2017. The Health Home Tenn Care program is not even scheduled to go statewide until 2018. It is designed to serve 55,000 people with severe mental illness already in Tenn Care. Their goal is to have 60 percent of primary care providers on board by 2020. The Task Force relies on something that doesn’t exist to do something it couldn’t probably do even if it did. The 114,000 they seek to add would triple the size of a new program trying to get on its feet. Not exactly a recipe for success. Particularly not an overnight (12 months) success.
4. A great deal of the possibility of success in this phase rests in the people in the connecting person case manager kind of a role. As talked about above the Tenn Care Health Home program is unlikely to provide those people. Currently the behavioural health safety net serves about 30,0000 people with behavioral health issues without insurance. The task force plan would add about 85,000 people to the system. Right now most case managers in the mental health system have a case load of 60 – 100 people. You are adding 85,000 people with no money for additional services to the mental health system for a plan that only reimburses at the 65% level for federal funds. It doesn’t sound like conservative principles to me. And it sounds like a whole lot of crossed fingers for success.
It is not that I think giving insurance to uninsured people with mental health issues is a bad idea. It is not. It is a wonderful idea, long overdue. It is the task force use of mental health as a flagship battle that I have a problem with. I don’t think it is the easiest population. I think it is the hardest and most complicated and I don’t think coverage for someone with cancer should be dependent on how well it goes. The plan, such as it is, faces real difficulties. It’s success is anything but sure.
I really think the choice of mental illness and veterans were chosen as much for political reasons as anything else. They are good door openers. They are much more likely to be a political yes.
But there are problems with this mental health option. It goes deeper than what I described above even. It is in some ways like a horse race. Before you bet on the horse to lead you to victory in the race for full coverage you best make sure it is not lame.
If not lame this horse is severely hobbled.
Please let’s make whatever we do something likely to work. We have waited too long.