A long-awaited compromise health care reform bill approved by the Senate
Finance Committee last month offers more to psychiatrists and their patients
than did the originally drafted bill. Despite the improvements, APA and other
mental health groups remain concerned because it lacks some coverage
provisions included in other health care overhaul bills.
Senate Finance Committee Chair Max Baucus (D-Mont.) sponsored a health
reform plan estimated to cost over $900 billion in the first 10 years that
aims to provide insurance to most of the millions of Americans who lack health
care coverage. The measure, America's Healthy Future Act, was introduced after
months of negotiations among a small bipartisan group of senators in an
attempt to find a consensus approach to thorny issues.
The initial draft of the legislation drew a variety of responses from
health care advocacy groups. While acknowledging the positive features, some
mental health organizations also voiced concerns about its less-robust
protections for people with psychiatric illness compared with other leading
In a September 18 letter to Baucus, APA Medical Director James H. Scully
Jr., M.D., commended him for including coverage of mental illness, including
substance use disorders, within the basic benefit package that would be
required in all qualified health insurance plans within a proposed insurance
Scully also noted that the bill included other provisions that would be
beneficial for people with psychiatric illness, such as a prohibition on
insurance companies' dropping or denying coverage for people with preexisting
conditions and an end to discrimination based on health status.
The bill also promotes integrated care, especially for individuals with two
or more chronic conditions and expands eligibility for Medicaid—the
largest single payer for mental health services—to people with incomes
up to 133 percent of the federal poverty level.
"These provisions take critical steps in improving access to care for
all Americans across the continuum of care, and especially for individuals
with mental health and substance use disorders," Scully wrote.
However, APA and other mental health advocacy groups also have serious
concerns about the bill and back amendments to address its shortcomings.
The Baucus bill does not require all private insurers to provide parity
mental health benefits—a measure included in the leading House of
Representatives bill (HR 3200), which was unanimously supported by APA's Board
of Trustees last month (see APA Board Takes Stance on Health Reform
APA lobbyists and others in the mental health community sought successfully
to have the bill amended to apply federal parity requirements to insurance
offered for purchase through the health insurance exchanges. While this is a
welcome improvement, the bill—as does the federal parity law—still
exempts small employers. The House bill does not include such an
APA and other advocates also successfully lobbied in support of an
amendment to clarify that patients with severe mental illness are eligible to
receive care in a demonstration project of the increasingly popular
medical-home concept. Such coordinated care projects may help address the
25-year-shorter lifespans of people with serious mental illness by ensuring
that patients get treatment for the nonpsychiatric illnesses that usually kill
"The premature-death data make it clear that people with mental
illness need this kind of support," said William Emmet, director of the
Campaign for Mental Health Reform, in an interview with Psychiatric
The Baucus bill does not eliminate the two-year delay in coverage for
people with severe disabilities waiting to become eligible for Medicare
coverage. Dropping this requirement was a recommendation APA made in meetings
with the White House and also on Capitol Hill.
"With a gap in coverage, individuals forego medical treatments, stop
medications, and otherwise compromise their health," Scully noted.
Mental health advocates also urged Baucus to add a provision eliminating
Medicare's 190-day lifetime limit on psychiatric hospital stays.
The bill also proposes cuts to the budgets of inpatient psychiatric
hospitals. The committee rejected an amendment to restore this funding. The
cuts come as states have drastically cut mental health services during the
ongoing recession. Although national health care funding is difficult to
track, the Center for Budget and Policy Priorities has identified specific
significant cuts in health programs in at least 20 states during the current
"These health cuts have fallen most heavily on areas such as mental
health, public health, and health professionals who serve persons on
Medicaid," Scully wrote in the letter. "While improving access to
insurance will help, greater attention is needed for public psychiatry
The bill also includes a short-term postponement of the pending physician
Medicare fee cuts, which are often called for after the government applies the
required sustainable growth rate (SGR) formula. Physicians are facing a 21.5
percent cut in reimbursement rates on January 1, 2010, unless Congress acts.
The Baucus bill would delay that cut for one year while providing a 0.5
percent increase in payments; the House bill eliminates the cut and provides
for a long-term solution to the flawed SGR formula.
APA's letter expressed concern about the creation of a Medicare Commission
that would develop and submit to Congress proposals aimed at slowing the
growth of Medicare costs. The commission would have the authority to impose
physician payment cuts, among other measures, if Congress did not approve its
own cost-saving measures within a specified time frame. Amendments to repeal
the commission proposal failed. An amendment by Sen. Jay Rockefeller (D-W.Va.)
to strike the sunset provision to end the commission in 2019 passed.
The Finance Committee finished consideration of amendments to the chair's
mark on October 1. An amendment accepted to the mark requires the committee to
receive a preliminary cost analysis from the Congressional Budget Office and
make the amended language public before voting on the package. If the results
of the analysis are unacceptable, Baucus can convene the committee to make
modifications, although this looks unlikely; a vote was expected around press
time. Senate Majority Leader Harry Reid (D-Nev.) is working on combining the
Finance Committee's bill with the version that emerged from the Senate
Committee on Health, Education, Labor, and Pensions. The resulting legislation
may be brought to the floor as early as October 13.
"It's important to recognize that we're dealing with a constantly
moving target in both the House and Senate," Scully said. "That
requires us to continue to be engaged and 'at the table,' which is what our
lobbyists are doing as they work to secure passage of the best possible bill
in the Senate and the House."
Information on the Baucus bill and amendments is posted at<www.finance.senate.gov>.▪