Legislature seeks health care reform prescription

Mental health, Medicaid expansion at top of list
The Colorado Statesman

State lawmakers agree that a simple Band-Aid fix is not enough to address health care reform. But how to go about expanding Medicaid and mental health services, launching a health benefits exchange and discussing women’s health care rights is proving to be a difficult and divisive task.

There is consensus that the state needs to make advancements in mental health, but advocates are fearful that connecting the conversation to recent incidents of gun violence will only add to negative stigmas.

Lawmakers are proposing:

• Making it easier for physicians to seek involuntary mental health commitments;

• Delivering mental health history in real-time to the Colorado Bureau of Investigation for background checks on firearms purchases;

• Ensuring that behavioral health and substance-abuse treatment is part of all health care coverage;

• Enabling small group insurance carriers to report mental health claims to the all-payer claims database; and

• Easing requirements for mental health professionals to treat patients.

As of Jan. 24, only the small carrier bill and the measure easing mandates for practitioners had been introduced.

Rep. Tracy Kraft-Tharp, D-Arvada, has introduced House Bill 1015, which would allow insurers to share mental health information for people who have small group health plans, including employers with 50 or fewer employees. That information is currently shared only for individuals and larger pools.

“We can look at where are we spending our health care dollars and where are we not spending our health care dollars. I think this is the key,” explained Kraft-Tharp. “People complain about health care reform… But we have to know where our dollars are going, we have to know where our dollars are not going…”

Michael Lott-Manier, a public policy analyst with Mental Health America of Colorado, agreed that it is important to share mental health data across all carrier levels.

“It’s helping people make better decisions about the value of their health care dollar, and it’s also improving the strength of the all-payer claims database, which is a powerful tool for policymakers to analyze how money is getting spent on health care in Colorado,” he said.

Kraft-Tharp has also introduced House Bill 1104, which would eliminate a requirement that physicians disclose to patients certain information related to their visit both orally and in writing. The measure would remove the oral requirement. It would also require that a licensing fee mental health professionals pay to fund the costs of the Mental Health Professional Peer Health Assistance Program be annually reassessed and capped at $25.

Meanwhile, Gov. John Hickenlooper, a Democrat, has also unveiled an ambitious mental health agenda that includes $18.5 million for:

• Establishing a mental health crisis hotline along with five 24/7 walk-in crisis centers;

• Expanding hospital capacity to include a 20-bed jail restoration program;

• Developing transitional housing for people with a mental illness who leave institutional care; and

• Developing peer support programs.

State leaders have made it clear that their plans come in the wake of the Aurora movie theater massacre that claimed 12 lives and injured 58 others in July, as well as the Sandy Hook Elementary School shooting that left 20 children and six staff members dead last month.

President Barack Obama has also announced executive orders aimed at keeping guns out of the hands of people who are suffering from a mental illness and making it easier for them to find treatment.

In the Aurora incident, accused gunman James Holmes had been seeing a psychiatrist. Victims of the senseless massacre are suing because the psychiatrist failed to seek an involuntary commitment.

If lawmakers are to lower the bar for a therapist to seek involuntary commitment, it would have to be carefully defined, explained Dr. Carl Clark, chief executive of the Mental Health Center of Denver. Currently, a physician must determine that a person is “imminently dangerous” in order to seek acommitment. But Clark explained that often people, who don’t think they have an illness, or are incapable of realizing that they have a mental health condition, fall through the cracks.

“You’re taking somebody’s fundamental right to make a decision about their health care away from them. You should have a really high criteria for when you do that, which is what we have now,” said Clark. “The problem is there is that group that really falls through the cracks… It’s not an easy thing to solve.”

He believes that if lawmakers do not make it easier for physicians to seek an involuntary commitment, then the legislature should re-examine immunity laws to protect therapists from civil lawsuits.

“The danger is that if the immunity statutes aren’t really clear… you could have practitioners who are saying, ‘You know, you have a criminal background, and yes, you need treatment, but I’m not willing to take you into treatment because of my risk of liability,’” lamented Clark.

Requiring that mental health history be transferred to the CBI in real-time for firearms background checks is also a troubling proposition. Currently, it takes as long as six months for that information to be distributed, which means an individual with a mental health flag could buy a weapon.

But Clark is concerned about connecting the mental health discussion to the highly volatile gun control debate.

“You can have a hunter who is a responsible gun owner his whole life who suffers from depression. He gets treated for the depression, and then he hears this conversation going on about how people with mental illnesses can’t have access to guns,” described Clark. “He’s thinking, ‘No way, I’m not going to talk about this. I enjoy hunting.’ So, that’s where it kind of gets a little blurred.”

Lott-Manier agreed, suggesting, “We urge people not to equate gun violence with mental illness, or even addiction.”

“Focusing on one risk factor like that, especially one that has to do with such a narrow segment of people who actually are confirmed of committing these violent crimes, is not going to be effective in dealing with the issue, and we see gun violence as a public health issue,” added Lott-Manier.

Kraft-Tharp, who has a background as a social worker, said she understands the catch-22. On the one hand, the recent violence is bringing mental health to the forefront; on the other hand, mental health and gun violence are being directly connected.

Kraft-Tharp hosted a town hall on Jan. 19 in Arvada focused on mental health issues. The meeting saw an overflow crowd and included families of suicide victims who cried as they recalled their experiences, according to Kraft-Tharp.

“That’s something that the mental health field really struggles with,” she acknowledged. “We want to reduce the stigma, we want to make it OK for people to be able to get the help that they need, but mental health becomes a focus during tragic events.”

A final mental health issue that lawmakers will likely address is on so-called “parity,” or including behavioral health and substance abuse treatment as part of overall health care coverage. Federal law mandates that mental health conditions be considered equally to physical ailments. Obama said parity rules would be released next month. Even though Colorado already has a parity law, state lawmakers are expected to codify state statute with federal rules.

“Historically, insurance carriers placed harsher restrictions on paying for mental health services than they did for physical health services…” said Lott-Manier. “We’re looking forward to making sure that [parity] is generally honored by people here in Colorado.”

Medicaid expansion

Mental health issues aren’t the only explosive health care topics facing lawmakers this year. Medicaid expansion is also developing into a controversial debate.

Sen. Irene Aguilar, D-Denver, has offered to take up Hickenlooper’s commitment to expanding Medicaid. The proposal calls for extending the subsidized medical program to 133 percent of the poverty level in 2014, representing an estimated 160,000 new adult Medicaid clients. The governor has said the expansion can be paid for with a $280-million savings in Medicaid spending over 10 years.

Aguilar, a physician, said the Medicaid bill would be introduced in the next two to three weeks, adding that the holdup has been narrowing 26 different eligibility categories down to four.

Republicans do not believe that the expansion can be paid for, even with the savings. They have introduced a bill to fight growing the federal program in Colorado.

Senate Bill 6, sponsored by Sen. David Balmer, R-Centennial, would protect K-12 education funding if the state were to run out of general fund dollars to pay for the Medicaid expansion.

“My bill is making sure that Colorado continues to keep K-12 education as our top priority,” said Balmer. “The governor has said that he’s not going to be using any general fund money with the Medicaid expansion, so if that’s the case, then he should not be opposed to my bill.”

Aguilar, however, said the measure was introduced simply to pander to conservative political interests.

“I’m sorry that some of our local Republicans are not willing to listen to where the people are at,” she said.

Dr. Jan Kief, president of the Colorado Medical Society, agrees that the majority of Coloradans would like to see the program expanded. Her organization, which represents physicians across the state, has voted to back expanding Medicaid.

“The Colorado Medical Society has had a long-standing goal of achieving health care coverage for all Coloradans,” she said. “It’s the right place, the right time and the right value.”

Her organization, however, does not support an idea that is being floated to diminish medical liability protection in Colorado. Lawmakers have been discussing adjusting the liability cap to increase a physician’s responsibility.

Kief said that if the state is to expand Medicaid, it should not be making life harder for doctors: “Now is not the time to impose much more liability restraints on our nurses and physicians.”

Another fight over health care expansion is likely to be generated by universal health care. Aguilar has proposed a referred initiative that would ask voters to back a constitutional amendment to create a health care cooperative. The co-op would provide health insurance to all Coloradans. She must receive two-thirds support from both the House and Senate to place the question on the ballot. Aguilar acknowledged she has an uphill battle, but she still plans on introducing the bill in the next few weeks.

Health benefit exchange

Similar to the Medicaid fight, Republicans this year are also taking aim at the health benefit exchange, which would offer an online marketplace for consumers to compare and purchase health insurance. It is expected to open in October.

Even though the exchange was established in 2011 with legislation sponsored by Republican heavyweight Rep. Amy Stephens, R-Monument, many of her Republican colleagues are opposed to the exchange.

Sen. Ted Harvey, R-Highlands Ranch, is co-sponsoring House Bill 1078 with Rep. Janak Joshi, R-Colorado Springs, which would repeal the exchange. Concerns have been raised over the sustainability of the exchange. And since part of its purpose is to connect uninsured and underinsured Coloradans with subsidies, the
program is expected to inflate Medicaid rolls.

“There are many states across the country that have chosen not to participate in the program, and I think they are doing so because it’s going to be more expensive for the states to do it than to not do it,” said Harvey. “It’s bad public policy.”

Stephens was traveling in Hong Kong this week and was unable to comment. But Gretchen Hammer, chairwoman of the exchange board, has told The Colorado Statesman that there are long-term sustainability plans in place.

Women’s health care

Perhaps even more polarizing than discussions over traditional health care are the conversations taking place again this year at the legislature on women’s health care. Last year was dubbed a “war on women” as the
focus both in Colorado and across the nation turned to abortion and keeping public dollars away from funding female contraception. It became a major wedge issue in the presidential election.

Similar discussions are taking place again this year, which is flabbergasting to women’s health care advocates such as Planned Parenthood after Colorado voters elected Obama and a Democratic-controlled state legislature. The contention is surfacing as the nation this month celebrated the 40th anniversary of Roe v. Wade.

“A majority of Americans oppose efforts to overturn Roe v. Wade, and in November they voted to protect a woman’s ability to make her own personal medical decision without interference from politicians,” said Vicki Cowart, president and chief executive of Planned Parenthood of the Rocky Mountains. “Legislators who continue to interfere with a woman’s access to safe and legal abortion do so against the will of their constituents.”

Republicans, however, are moving forward with bills that would either ban abortion outright, or limit the practice. The measures include:

• Senate Bill 66, sponsored by Sen. Owen Hill, R-Colorado Springs, which would prohibit public dollars to go to anyone who “directly or indirectly” performs, advocates for, or provides referrals for induced abortions;

• House Bill 1033, sponsored by Rep. Steve Humphrey, R-Severance, which would outlaw abortion, even in the cases of rape and incest;

• House Bill 1032, sponsored by Joshi, which would establish a so-called “fetal homicide” law, enabling prosecutors to charge a person who commits a crime that causes an unborn fetus to die. Critics have said the measure would create “personhood,” which would assign constitutional rights to the unborn, thereby banning abortion; and

• Senate Bill 56, sponsored by Harvey, along with House Bill 1131, sponsored by Rep. Lori Saine, R-Dacono, which both would ban sex-selection abortions.

Hill disagrees with his critics, suggesting that opposition to pro-life measures is mounting simply for political reasons. He believes issues surrounding abortion remain important to Coloradans.

“It says in our constitution that if we’re going to be a rule of law state we have to do this,” Hill said of his measure. “If they want to throw up their hands and say laws don’t mean anything and the constitution doesn’t mean anything anymore, they’re welcome to say that. However, the people have spoken and if they want the people to say something different, then get it out of the constitution.”