Are you better off? An election-year question that still looms large | Behavioral Healthcare Executive Skip to content Skip to navigation

Are you better off? An election-year question that still looms large

September 6, 2012
by Dennis Grantham, Editor-in-Chief
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I was just 18 when I first heard this question, but even then, in the context of the late days of the Carter Administration, it registered with me as a first-time voter, and, I know, with my parents and older relatives during a Reagan/Carter debate in 1980:

“Are you better off now than you were four years ago?”

In the context of those years, everyone knew what Reagan’s question meant—and people—regardless of political leanings, responded to it. Inflation was high, energy prices had soared, interest rates neared 20 percent, and our 52 hostages had been held for nearly a year in Iran. President Carter’s own description of “a national malaise” seemed apt, though I've never bought the idea that he or any other President is entirely responsible for every national circumstance.    

When I heard the same question asked by Mitt Romney in his recent address to the Republican National Convention, I had to think a little longer, because the economic and political equations had changed so much.  Let’s see . . . just refinanced at around 5%, energy is expensive but our car gets good mileage (Carter's administration set up the first auto mileage standards), economy is rough but improving.

With the possible exception of college tuition, the one really enormous economic change from the first time that I considered the ‘are you better off?’ question 32 years ago is the incredible impact of healthcare and health insurance cost increases on the budgets of governments, businesses, and households nationwide. Compared to 1979, the ability of those under 65 who do not qualify for Medicaid to afford appropriate healthcare can only be measured in our nation's incredible rate of 45 million uninsured, including a growing number who no longer receive healthcare benefits at work. 

Though some criticize President Obama for putting healthcare reform “ahead of jobs,” I can’t fault either him or Congress for getting on with the business of healthcare reform. To me, the development and passage of the Affordable Care Act represents a huge boost to the health and economic circumstances of many, many Americans. And, while its major provisions won’t be in place until 2014, it has set in place a series of positive changes:

·         It puts 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.  Come 2014, these folks are definitely better off, though perhaps not today.

·         It puts in place a set of essential health benefits that will ensure that all plans offer an array of services that includes mental health and substance use care benefits that are at “parity” with medical benefits.  While neither the EHB or parity regulations are perfect, they definitely represent progress made in the past four years.  Definitely better off.




I think this is very nicely analyzed and presented. Thank you.

I do not know which country you live in, but here in the USA Mental Health/Behavioral Health care is much worse than it was four years ago. Funding has been cut drastically. The overall economy and umemployment are bad. Gas prices have doubled and those cars with great gas mileage - who can afford to buy one?

I'm in the same country as you and I see your point. My point is this--imagine the situation if we had all of the negatives--the funding cuts, the recession, the unemployment over these past four years, with none of the work that's taken place on parity regulations, essential health benefits, or the ACA?

Hey, I know that a lot of people are struggling and if you're one of them, it is really awful. I guess that my point is that struggling with everything when you will soon have improved access to insurance and care is better than struggling with everything when you've got no hope and no prospects for health coverage.

I think that the funding cuts of recent years have been awful--but there's little anyone can do to require better care for people without something like the ACA. I agree that it is amazing that when the going got tough, the voiceless and vulnerable were absolutely the first in line to get hurt by cuts.

Well, I will have to say in all honesty. We have to remember who inherited the White House prior to the last 4 years. Now,the thoughts of the 8 years,before this last 4 years has not been given a full opportunity. How did we get to this crisis in the first place. I would like to think it just didn't start in the last 4 years. Yes, of course the cut may have been needed, but that is only to see where the "hog" is and what he has been doing with all the surplus.Ask yourself this question has he been eating all the surplus or sharing it? This question is for the prior 8 years and not the last for years. The last 4 years has been spent uncovering the professional experts downfalls. Why didn't the prior 8 years secure all this drama??

In theory all you say may be true… practice its not the reality.
We have seen our title XIX eligibility cut from 100% FPL to 38% THOUSANDS have LOST their health coverage. That drops the eligibles, which drops the capitation rates.. so those that remain are now facing 15 -30% cutbacks in services This has been a nightmare and nothing to celebrate WE WERE much better off four years ago, but then again no one speaks up for the poor.
Rather we ballance the budget on their backs and TALK about how better it is....well here in the real world its not.

At a couple of places in my piece, I suggested that some would not be better off before 2014--when the changes are scheduled to kick in under the Affordable Care Act. Part of that is the Medicaid Expansion, which is scheduled for 2014.

The Supreme Court decision in June said that states would have the option to go with the Medicaid expansion in 2014--instead of requiring states to go ahead, as was said in the ACA. If states go ahead with that expansion, the feds would pay nearly all of the cost to cover all of a state's residents up to 133% of FPL, which would address the "nightmare" cut you're referring to.

It sounds like you are describing a state funding cut that has taken eligibility from 100% of the poverty level to just 38%, probably due to the recession. I think that is awful--but it remains a state decision--and obviously someone doesn't think you'll express your opinion and vote. If you and others who need services can get your state to say yes to the Medicaid expansion, then you'll get some help to address your situation--though it will be in 2014, not now.

I don't blame you for being angry--I'd be angry too.


Certainly the recipients of behavioral health services are not better off. As layer after bureaucratic layer has been laid on a system which is nearly paralyzed from funding cuts, managed care arbitrariness, health homes and the like, I rarely hear one of my patients comment on feeling better off. One would think that would be a no-brainer of a goal. If truly it is we have indeed dropped the ball.

As a citizen and part of the shrinking base of taxpayers which is now its own minority, I would contend that the legislated redistribution of wealth as in ACA is bound to cause more long term harm than good. No one would argue that healthcare reform is essential. Yet if we diligently review the content of ACA including the deals, riders, controversial mini-policies and pure pork for lack of a better word, few would ever sign their name to its numerous inclusions.

One further consideration is the notion of a government writing checks for all sorts of wonderful sounding causes while the account balance has maxed out its overdraft. If we as a people burden future generations with severe economic hardship, where do you think the funding of behavioral health will be? I would think in the dark ages.

I can't say I or my clients are better off either. The blogger's argument that additional healthcare coverage justifies the rest of the hardship is nonsense. Someone would rather suffer some form of economic hardship knowing their healthcare was taken care of? Seriously? This is a government decision? Who is the person making these choices for me? The whole healthcare mess can be traced back to government intervention. Health insurance became an employer's benefit option to circumvent government imposed salary caps during WWII. More government is not the answer. I had a friend who worked for a medicare supplemental insurance company who had a hospital refuse to contract with them as their income would decrease due to insurance companies providing stricter oversight of billing then the government - an example of waste, fraud, and abuse when government involved. The add-ons to the ACA are another example. As far as which country? I live in the U.S.A. which was founded on the principle of individual (not collectivized) freedoms protected from governmental intrusion by our Constitution.

I don't think that I'm arguing that the ACA "justifies the rest of the hardship," because I don't see it as some sort of trade. But if that's what you read, so be it.

The hardships (recession, job losses, reduced incomes) that we have today are a separate issue from the ACA, in my opinion. With or without the recession, those things have been going on for a long time and hurting a lot of people as industries change and people lose income and insurance.

My thought was that the ACA would help, especially for those facing hardships, when it comes into full effect in 2014 by helping to take care of worry about healthcare costs. It won't get them a job, but it would ensure that they could get a doctor's appointment.

One thing to consider--many of the benefits added under the ACA will be administered by insurance companies, either through Medicaid managed care programs (for those up to 133% of FPL) or through the expansion of private insurance due to the "mandate."

Presumably, this private sector involvement will provide the level of oversight that you don't believe that government is providing.

But then, if you don't believe that government is doing the right thing to start with, then I'm just blowing hot air, right?

Thanks for writing in--if I'm writing "nonsense," somebody's got to put me straight.


A few thoughts:

1) I agree that the system is incredibly underfunded.

2) I disagree that the ACA is a legislated redistribution of wealth. The insurance subsidies are no different than the earned income tax credit or any other tax break. The Medicaid expansion could help save some money by keeping people out of ERs and getting them going to primary care docs instead.

3) Your comments about the ACA legislation remind me of a thought once shared with me by a tall Texan:

"There are two things that women and children should never see--the making of law and the making of sausage."

4) You make some great points. But until someone has a better idea, the ACA is the only approach available. As legislation, it is "not pretty," but it is on the books. And if it leads to a better approach, an improved reform effort, then I'll join you in rooting for that, too.

5) This is one issue on which I wish Mitt Romney would have run on, not from, his record. He made healthcare reform work in Massachusetts--if he was in support of the ACA, he'd be just the guy to run it.

You make a tough case. Good arguments.



Dennis Grantham

Dennis Grantham


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