On July 9, the mental health and substance use care fields scored a major victory when the Senate passed by a margin of 69 to 30 (1 not voting) the Medicare Improvements for Patients and Providers Act of 2008. The House passed an identical bill (HR 6331) on June 24 by a margin of 355 to 59 (20 not voting). President Bush subsequently vetoed the bill. However, on July 15 the Congress overrode the veto by larger margins than the original vote: 383 to 41 in the House and 70 to 26 in the Senate. This action sustains very important gains for the mental health and substance use care fields.
The legislation phases out the discriminatory 50% co-pay for mental health ambulatory care under Medicare Part B over 6 years. After this period, the mental health co-pay will be 20%, the same as for all other illnesses. National data show that the discriminatory co-pay has driven many consumers into expensive inpatient care, into primary care, or away from mental healthcare entirely. Unlike most issues, the data supporting this legislation are very clear—allowing for a slam-dunk victory for the field.
The legislation also postpones scheduled cuts in Medicare funding to providers. This is important because cuts in provider payments drive providers away from serving the population covered by Medicare, about 44 million elderly and disabled persons. This number is expected to grow by about 35 million over the next 20 years. (An estimated 10,000 persons will reach age 65 each day over the next 10 years.)
In addition, the legislation recommends the development of integrated mental health/primary care systems for rural areas. The New Freedom Commission and the Institute of Medicine have called for integrated care.
The effort to eliminate the discriminatory 50% co-pay was long and arduous. In May 2003, I had the honor of briefing Senate and House staff on national Medicare data I had acquired from CMS for a long-term SAMHSA financing project. In 2007, the House Ways and Means Committee's Subcommittee on Health, chaired by Rep. Pete Stark (D-Calif.), held a hearing at which testimony and data were presented in support of reform (See my June 2007 commentary on “Making the case for parity and Medicare reform”). At the same time, 17 national mental health and substance use care organizations formed a coalition to advocate for this specific reform. Subsequently, Stark attached the co-pay reform to the SCHIP bill, which was vetoed by President Bush.
This year Medicare co-pay reform was included in HR 6331. In April, Mental Health America held a briefing for Senate staff, and members of the reform coalition visited senior senators. I expect that this legislation's passage is the opening round of a much larger debate on national healthcare reform, particularly as we move closer to this year's presidential and congressional elections. Sen. Ted Kennedy (D-Mass.) already has requested that his staff begin holding meetings to start formulating strategies on universal health insurance coverage. Clearly, the mental health and substance use care fields will need to engage this issue as it unfolds over the next several months. We also are anticipating the next step for federal parity legislation, which has passed both houses and is in a conference committee.
The environment for national healthcare reform will be much different now, compared to the Clintons' healthcare reform effort in 1993. Since then, our healthcare expenditures have skyrocketed; the number of uninsured persons has increased dramatically; and states such as Massachusetts and Minnesota have undertaken major universal health insurance reform efforts. When you add in the dramatic increases in the cost of fuel, our faltering housing market, and the malaise of our overall economy, it seems clear that national healthcare reform likely will be more complex and difficult for us now.
Our hats are off to all who worked so hard on Medicare co-pay reform: Mental Health America, particularly Kirsten Beronio, who organized the coalition; the National Council for Community Behavioral Healthcare; the American Psychiatric Association; the Whole Health Campaign and its member organizations; the 17 member organizations of the reform coalition; and all who testified or participated in briefings. Joint action clearly can be successful and produce a positive social outcome!
Ronald W. Manderscheid, PhD, currently Director of Mental Health and Substance Use Programs at the consulting firm SRA International, Inc., worked for more than 30 years in the federal government on behavioral health research and policy. He is a member of Behavioral Healthcare's Editorial Board. Behavioral Healthcare 2008 August;28(8):37