A massive spending and tax-relief stimulus law designed to cut
unemployment, aid struggling families, and boost a sliding economy includes
numerous provisions urged by APA and other mental health advocates.
The American Recovery and Reinvestment Act of 2009 (ARRA, PL 111-5), signed
by President Barack Obama on February 17, includes a large funding increase
for state Medicaid plans and further delays implementation of Medicaid
regulations that are opposed by APA.
These provisions are extremely timely because "states are desperate
for more money because revenues are down and their Medicaid costs are constant
or rising," said Lizbet Boroughs, associate director of APA's Department
of Government Relations.
The law includes a temporary $87 billion increase in the Federal Medical
Assistance Percentage, which means that the federal share of Medicaid costs
will rise, helping states avoid program cuts. Medicaid is dually funded by
states and the federal government. The law provides a 6.2 percent
across-the-board increase to each state's Medicaid program and extra funding
for states with the highest unemployment rates.
The lack of a specific line item for mental health care in the new Medicaid
funding concerns mental health advocates, including David Shern, president and
CEO of Mental Health America. His organization—and APA—lobbied for
such an addition so people with psychiatric conditions would not lose out to
other programs as states tinker with Medicaid programs.
Also on the Medicaid front, a moratorium set to expire next month on
regulations promulgated by the Bush administration and related to Medicaid
targeted case management (TCM) was extended until the end of June. APA opposed
the tightening of TCM regulations—intended as a money-saving
measure—because it could sever a critical coordinating service that
benefits many mentally ill people who receive Medicaid benefits
(Psychiatric News, August 1, 2008).
Another measure aimed primarily at the public-health sector is the creation
of the $1 billion Prevention and Wellness Fund to support evidence-based
clinical and community-based prevention and wellness strategies. Among the
largest provisions in the fund is $500 million designated for bolstering the
general- and public-health workforces.
Mental health advocates said the funding measure could save or create
20,000 public-health jobs, including some of those of the 11,000 such workers
already terminated in the recession. Retaining and rehiring public health
workers is an important step to ensuring the availability of health care
services for the unemployed, uninsured, and underinsured during the recession,
according to mental health advocates.
Health workers also could benefit from $500 million that the law allocates
to the Health Resources and Services Administration for health profession
development through scholarships, loan-repayment help, and training grants.
The funds can also be used to coordinate cross-state telemedicine
Psychiatrists are among those designated in ARRA as eligible for
scholarships, loan-repayment help, and grants through the National Health
Service Corps. The corps aims to boost the number of clinicians in rural and
other "medically underserved" areas of the country.
Another significant aspect of ARRA for physicians is the inclusion of $19
billion to invest in health information technology, including efforts to
ensure patient-privacy protections (see Incentive Payment Will Go to M.D.s Who
Adopt Electronic Records).
Additional funding is directed to the National Institutes of Health, whose
Fiscal 2009 budget was increased by 34 percent over 2008, from $29 billion to
$39 billion. The allocation of ARRA funds will direct about $1 billion in
total to the National Institute on Drug Abuse, National Institute on Alcohol
Abuse and Alcoholism, and National Institute on Mental Health.
The 34 percent boost dwarfs NIH's 1.5 percent increase in the last budget
"Hundreds of grant applications scored high enough to be funded last
year, but [NIH] ran out of money before they could be funded," Boroughs
said. The hope is that the additional funding will lead to more psychiatric
research receiving support.
In addition, the law includes $1.1 billion for "comparative
effectiveness research" through NIH and the Agency for Healthcare
Research and Quality that compares two or more therapies for a given medical
condition. The funds also may be used to analyze existing studies, including
NIMH-sponsored trials of treatments for schizophrenia, bipolar disorder, and
Other provisions of the law aim to ensure that comparative effectiveness
research is conducted and findings disseminated in a way that ensures that
clinical effectiveness and quality outcomes are promoted. This approach aims
to counter the use of research designed only to promote least-expensive
treatment options. Mental health advocates, including the National Alliance on
Mental Illness, opposed language in early versions of the measure that
emphasized cost savings over clinical effectiveness and federal government
restrictions on funding for treatments based on studies with limited efficacy
Privately insured people also could benefit from a 65 percent premium
subsidy for nine months of coverage under the COBRA law—the federal law
that allows many workers to continue in their employer's group health
insurance plan for a defined period after they leave a job. The measure, aimed
at people terminated between September 1, 2008, and December 31, 2009, will
help provide continuity of health care, especially for psychiatric conditions
that are sensitive to disruptions in prescribed medications.
The impact of the COBRA change could be significant because fewer than 1 in
10 eligible workers opted for continuing insurance coverage under the law in
2007, due to high cost. COBRA requires workers to pay the entire
premium—including the share typically paid for by employers—plus a
2 percent administrative fee. The average cost of COBRA coverage for a family
of four is $13,000 a year, according to government statistics.
Numerous aspects of ARRA remain unclear, including how many of the
provisions will be implemented. While, for example, the Prevention and
Wellness Fund will invest in evidence-backed, community-based prevention
programs that directly improve the health of Americans, the law tasks
officials at the Department of Health and Human Services (HHS) with
determining which programs meet the goals of this huge investment, and many
senior positions at HHS have yet to be filled.
Even when the HHS positions are fully staffed, the wide latitude given to
administrators to implement the law's provisions will require careful scrutiny
and feedback by mental health and other advocates.
"You can bet we are going to be in there every day trying to
influence how these provisions are being implemented," Boroughs