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Revitalize strategy and business planning for population health in a time of uncertainty

April 6, 2017
by Patrick Gauthier
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When I began writing this blog entry, the American Health Care Act (AHCA), the Republicans’ proposed replacement for the Affordable Care Act (ACA), was still on the table. As we all know now, President Trump is moving on to focus on other issues.

So where does that leave us? We are still in the same state of uncertainty. With the failure of the AHCA, we are left not knowing what exactly the healthcare landscape will look like in Trump’s presidency. But, we can still be sure it will change.

I’ll use this blog to discuss the likely eventual changes to federal healthcare law in regard to Medicaid, and what you can do to prepare for them.

Medicaid expansion is not likely to last

Much of the push for the reform of the ACA came from GOP governors and Congressional leaders who were opposed to Medicaid expansion. Seema Verma, the new administrator of the Centers for Medicare and Medicaid Services (CMS), was the chief architect of Indiana’s Medicaid plan: The Healthy Indiana Plan. Considering Vice President Mike Pence is the former governor of Indiana and Verma is in the top spot at CMS, it’s safe to assume that the Trump Administration will likely deliver greater state control over Medicaid spending and rules. These will probably include work requirements and copays. The AHCA proposed a full repeal of Medicaid expansion by 2018. While the timeline may have changed, we can probably count on Medicaid expansion being on the chopping block in the future.

What are the risks of Medicaid reform?

Medicaid reform could spell big losses for the people we serve—those with complex behavioral health and medical conditions, and those with poor social determinants of health, such as unstable housing and limited access to providers. If the AHCA is any indication, two major changes may come to the behavioral health field. First, the essential health benefits (EBH) provision of the ACA may disappear under reform or repeal of the act. Put simply, this means that plans won’t be required to provide coverage of mental health and substance use treatment services. As such, state’s may choose not to cover behavioral health services in their Medicaid plans.

The second major risk is the possibility of losing progress on the Medicaid IMD exclusion. You may remember that the IMD exclusion prohibits states from covering treatment in inpatient facilities or institutions with more than 16 beds. This rule forced many people with major mental illnesses onto the streets, emergency rooms, and jails. IMD exclusion waivers have allowed states to use Medicaid money to cover stays in previously excluded settings for certain individuals and certain time frames, providing much-needed treatment.  

What you can do about it now

There are some things you can do immediately to benefit the people you serve. Consider the following:

1. Speak up and advocate. Contact your state legislators and other decision-makers to let them know how important parity, EHBs, and the IMD exclusion waivers are to individuals with mental health and substance use disorders in your state. Ask your colleagues, friends, and other providers to do the same. Work with your provider and consumer associations and contact your local media.

2. Plan now for state managed care plans similar to Indiana’s. Think about how your program or organization can help people who will need to meet employment or cost sharing requirements. For example:




As a now recently retired Primary Physician for 40 years, our mal-adaptive healthcare industry is paralyzed by its excessive cost within our nation's economy. Within our national economy, our nation's healthcare industry requires 18.3%. ALL of the other developed nations spend less than 13.0% of their economy on their healthcare. For our economy, the excess between 13 and 18% represents $800 Billion annually. AND, all of these developed nations have better health. The precise reasons for the excess are complex and currently unyielding to our nation's current healthcare reform strategies.
Given this observation, it seems that the locally driven, social determinants of a person's health increasingly contribute to the unique problems of each community. I have often wondered what it would take to mobilize a community wide commitment for enhancing its Social Capital asset as means to improve the resiliency of each community's Common Good. I have written one possible approach to this strategy. If you have a minute or two, See:

Clearly, the excess cost of healthcare has marginalized our ability to serve the emotional needs of our citizens. The blog has a unique definition for HEALTH. You can find it on the Rationale Page of the Blog site.


Patrick Gauthier

Director of AHP Healthcare Solutions

Patrick Gauthier

Patrick Gauthier, BA, is the director of AHP Healthcare Solutions and an expert on the...

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