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 reform bills.

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 marketplace.

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 Proposals).

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 exemption.

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 them.

"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 News.

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 recession.

"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 services."

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>.▪