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Mission not accomplished

October 23, 2012
by Dennis Grantham, Editor-in-Chief
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Are you - and those you serve - better off than they were four years ago?

Are you better off today than you were four years ago? 

Ronald Reagan famously asked this question in one of his debates with President Jimmy Carter in 1979, a time when many Americans wondered whether the nation was headed down the drain. 
When I heard the same question asked by Mitt Romney, I couldn’t help but think back. Of course, an incredible amount has changed, and not always for the better. One of the biggest economic changes that has occurred since then has been the increasingly large impact of healthcare and health insurance costs on the budgets of governments, businesses, and households nationwide. While we’ve always had uninsured—at least until Medicare eligibility at age 65—we’ve never had so many—some 45 million, including many working people. 
For this reason, I can’t fault the President or Congress for getting on with the business of healthcare reform, even in the midst of the Great Recession. To me, the development and passage of the Affordable Care Act (ACA) will, in 2014, represent a big boost to the health and hopes of many Americans:
  • It will put healthcare insurance in reach for some 32 million of our 45 million uninsured, including 11 million with untreated behavioral health problems. That's a feat that no business, no entrepreneur, and no amount of private investment could accomplish.  
  • It will put in place a set of essential health benefits (EHB) to ensure that all insurance plans offer a common array of services, including mental health and substance use treatment benefits that are at “parity” with medical benefits.
  • It will lend a hand to middle- and lower-class workers who must pay for health insurance, which, according to current figures from the Kaiser Family Foundation, now costs more than $15,700 for family coverage—of which employees typically pay about 1/3, plus copays, rising deductibles, and increasing prescription costs. The self-employed and those with health conditions pay all of those costs—and far more.
  • It, along with a range of new approaches and payment reforms, will offer new ways to exercise control over healthcare costs. Some of these changes are already emerging—integrated behavioral and primary care programs, coordinated care programs for “dual eligibles,” and more. Any of these efforts are far superior to the previous approach—doing nothing—or asking the poor or voiceless to endure draconian Medicaid cuts.   
Those who champion the Affordable Care Act are quick to say that the ACA makes us better off as a nation. I agree, because this major, multi-year legislative effort is the only one we’ve got that will put practical, long-term reforms in place.  But when I said so recently, I caught a face-full from several readers who said in no uncertain terms, “We are not better off!”
And it’s true. For those providers and service recipients who still bear the brunt of massive, recession-driven state funding cuts; for those over age 26 who are unemployed and uninsured; for adults with pre-existing conditions; and those in states that stand against the Medicaid expansion, the ACA has, of yet, delivered precious little.  And it will not deliver anything really substantive to these people until 2014 or, in some states, later than that. 
Hearing the criticisms of readers made me realize that the ACA—the signature accomplishment of the Obama Administration—may be seen, even by many of its supporters, as the promise of a promise that has yet to be fulfilled. And, as recent history teaches, there is political danger if voters perceive that, in their lives, a President's "accomplishment" is more promise than fact. 
So, are we as a nation, and in the field of behavioral health, better off now than we were four years ago? From a health policy standpoint, there’s no question about it—the ACA provides an ambitious and focused agenda for needed reforms. But from the standpoint of our fellow citizens,  there are years of work ahead before they will consider the ACA as a “mission accomplished.”
Dennis G. Grantham, Editor-in-Chief