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Preserving our moral values in healthcare reform

April 6, 2017
by Ron Manderscheid, PhD, Executive Director, NACBHDD and NARMH
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Almost a fortnight ago, brief, blissful respite from our national healthcare struggles seemed to be upon us. The White House and the House GOP leadership had capitulated and agreed that the disastrous American Health Care Act (AHCA) could not even garner enough Republican votes to pass the House.  Early on a Friday evening, this was wonderful news for all Americans,  including those with behavioral health and ID/DD conditions.

Now, like a sphinx rising from its own ashes, an even more draconian version of the AHCA is being crafted by the White House and the House GOP. As before, the White House is negotiating with moderate Republican House members and with the ultra-right American Freedom Caucus. Disingenuously, the White House appears to be telling these two groups somewhat different things.

Stated in overly simple terms, the White House is trying a sleight of hand to reduce insurance premiums for those who are young and healthy at the expense of other less-advantaged groups. The areas of skirmish this week are  community ratings, guaranteed issue, and essential health benefits.

Community ratings

Community ratings were put in place by the Affordable Care Act (ACA) to prevent any groups from becoming disadvantaged in their health insurance premiums. If community ratings were removed, then persons with disabilities, persons who are older, or even males could be forced to pay much higher insurance premiums because they are at risk of higher healthcare costs.

The White House would like to narrow the applicability of community ratings, either by allowing states to opt out, except for gender (which they apparently told the American Freedom Caucus), or only to opt out of age (which they apparently told moderate Republicans). Neither approach is sound: the former would put much greater financial burden on persons with disabilities; the latter, on persons who are older. Neither would achieve the goal of protecting persons with pre-existing conditions or persons who currently are ill. In fact, by contrast, both approaches would create financial advantage  for the young and healthy.

Guaranteed issue

Another topic under discussion is guaranteed issue, the ACA rule that requires insurance companies to insure everyone. The White House apparently told the House conservatives that guaranteed issue would be removed, yet told the moderates that it would be retained. Clearly, everyone deserves this protection, and it must be retained. Further, attempting to move persons with disabilities to high risk pools, where they will be at great risk of much higher insurance premiums, even if subsidy funds are provided, should not be construed as a meaningful substitute for guaranteed issue. It definitely isn't. It would advantage the young and healthy.

Essential health benefits

A third topic under discussion is removing "essential" from the ACA essential health benefits, and giving states the option to include or exclude specific benefits. If developed, this proposal could put  the mental health and substance use benefit at risk, and also potentially endanger efforts to guarantee parity of these benefits. The current ACA essential health benefit helps to assure that people in different states and different locales in the United States have access to a similar package of good insurance benefits.This is a very important protection that should not be removed. Again, the young and healthy would benefit at the expense of other key groups.




A very large, population health study appeared in an April edition of JAMA. The authors collected de-identified longevity records for all census tracts from their death certificates. They also obtained poverty level records for these census tracts from data at the IRS. The data covered 15 years. The analysis confirmed the relationship between poverty and longevity. The relationship occurred in most census tracts, BUT not all of them. The authors reported the evaluation of several statistics to characterize these outlier census tracts. The only observation that prominently occurred was a higher prevalence of college educated adults in the related census tract with NO relationship between longevity and poverty. The original research paper and 1 of 3 editorial COMMENTARIES used the concept of 'social capital' as the basis for an explanation.
It is likely that the local determinants of a person's health are increasingly prevalent as a basis for a substantial portion of our nation's excess cost of healthcare. All of the other developed nations of the world use 13.1% OR less of their nation's economy for their healthcare. For our USA, it is 18.3%. The difference between 13% and 18% last year, as a measure of its excess cost for our economy, was $988 Billion. Using 2005 dollars, it represented the cost of fighting " 9 " Iraq/Afghanistan wars simultaneously. It is unlikely that a reform strategy based only on payment systems will change this.
The longevity study is just one of many that indicate that the amelioration of the determinants of population health are best managed through a community by community commitment to enhance its 'social capital' asset for the Common Good of their community. The Design Principles for managing a common-pool resource already exist and have been validated. Professor Elinor Ostrom (Nobel Prize 2009) among many colleagues have long studied these principles. For healthcare, the common-pool resource is the portion of our nation's economy allocated to healthcare. Remember, ten of the 30 OECD nation's have better out comes for population health than the USA.
The disruptive events for each citizen involving cognitive dissonance are increasingly intense. Along with our increasingly fragile extended families and their inability to maintain strong family traditions, the root cause of root causes must be managed through a nationally committed effort to mobilize locally committed stakeholders and resources, community by community. These community's collective thrust initiatives should comprise @ 400,000 citizens each, for @800 nationally. With NO connection to the funding of direct healthcare, the national effort could be funded by a Federal commitment to $1.00 per citizen per year. The funding would primarily offer technical support and training to each of the local "Community HEALTH Forums."
Eventually, Primary Healthcare should be well funded by capitation to include on-site mental health capability. This level of Primary Healthcare should also be funded through risk-sharing agreements with the sources of Complex Healthcare that are stop-loss protected by the primary payers and secondarily by their State and Federal level of payers.


Ron Manderscheid

Exec. Dir., NACBHDD and NARMH

Ron Manderscheid


Ron Manderscheid, Ph.D., serves as the Executive Director of the National Association of County...

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