“…the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; those who are in the shadows of life; the sick, the needy and the handicapped. “ ~ Last Speech of Hubert H. Humphrey

When people think of Qbamacare, they think of the insurance aspect. A lot of the law, however, was  designed to deal with a health care system in crisis. No aspect of our healthcare system was more in crisis than the care of our seriously mentally ill. One reason is a lack of private insurance (many folks with serious mental illness can’t hold down steady jobs, which is how America distributes its private health care dollars). Secondly, if these folks had coverage it tended to be Medicaid, and Medicaid is known to be a poor payer, so poor that many general med-surg hospitals closed their in-patient psychiatric units in an effort to limit their “exposure.” Thirdly, through a quirk in the Medicaid enabling legislation, freestanding psychiatric hospitals were not allowed to bill Medicaid for services even if the folks were admitted to their hospital. (50 years ago, state and local hospitals provided such care, and Congress did not want to shift that expense to a federal program.)

The Obamacare act was designed to right many wrongs, and included was a effort to fix this problem. In a section called the Medicaid Emergence Funding Demonstration Act, it provided funding to freestanding psychiatric hospitals to:

provide $75 million to the new demonstration to determine whether it will improve access to psychiatric treatment, lower costs, and reduce crowding in general hospital emergency departments (EDs). At the end of the 3-year trial period, the CMS will make recommendations to the US Congress about the feasibility of offering the program nationwide.

Alabama applied for and received funding to do just this and the community mental health center in Mobile (Alta Pointe) took the money and opened many more beds to help relieve the congestion. The next thing that happened following the demonstration in Alabama? The slicing of the state mental health budget by 25% and the closing of acute crisis beds at several state hospitals. Thanks Obama!

The difference between Obamacare and other programs was the inclusion of evaluation and outcome measures in these pilots. This particular program is being looked at and so far has been found wanting.

So what’s the status? CMS reported on MEPD progress at the end of one year in a mandated report to Congress (see CMS Report To Congress On The Evaluation Of The Medicaid Emergency Psychiatric Demonstration). CMS’ endorsement was tepid – it stated it did not have enough data to recommend expanding the demonstration, but that it supported allowing the demonstration to continue through the end of its authorization in 2015.

At a year, though overall hospital costs were down, length of stay was the same, as was the rate of discharge to the home environment. In other words, the care by the measures agreed upon was the same. Anecdotally, though many benefited, in Alabama care delivery was not improved. In the words of a spokesperson from the Alabama Hospital Association:

“Most of the hospitals feel that the number of patients in departments continues to increase and the length of time it takes to get people into beds is increasing,” Blackmon said.

The national evaluators apparently felt that there were more comprehensive ways to provide care, so this program will likely not be reported favorably to congress and will end.

Which brings us to yesterday’s news story. Alta Pointe, which opened a hospital in response and is now the effective state facility of the seriously mental ill in Alabama (though with little state money), has been using this “demonstration” funding to provide services previously paid for by the state. Now that the demonstration is going away, they will likely close their 100 beds, leaving only 34 crisis beds for approximately 2,000,000 people. Congress has an opportunity to pass a stand alone to continue the program but, given the outcome and the mood in congress, this is unlikely. Alabama has the opportunity to replace the money with state dollars. Given that they are looking to cut half a billion from existing programs and didn’t budget for this expense, not likely either. Don’t think the citizens of lower Alabama are in the mood to pony up an extra $2,000,000 annually in donations, either.

In the words of one al.com commenter:

Let’s look for Al.com’s isolated sob stories to make our hearts heavy and give in to another tax hike. Nonsense. Cut the programs. Cut the departments. Cut the government in half.

So what will happen? Fortunately, space under the bridges is available and serves the dual purpose of allowing the non-afflicted to get to where they want to go. If it gets too cold, those with serious mental illness can commit crimes. Alabamians are always willing to pay for jail cells..