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Healthcare is almost 20% of our economy. A future President Clinton or a future President Trump will, through executive action, have a lot to say about how that money is spent. Commonwealth fund (found here) has an exceptional comparison of the two candidates’ proposals and how they would effect the budget. If you care about fiscal responsibility, for the record, the balance sheet is found below:


So, the Trump plan is not, despite what he claimed in the debate, the way to fiscal solvency.

Kaiser Family Foundation has put together a specific list of issues (found here) that folks appear interested in and has evaluated each camp’s claims.  The Cliff’s notes version is as follows:

Health insurance coverage and cost – Issues include overarching reform of health system remains unpopular in a partisan manner. Affordability hampered by a glitch where family coverage became more expensive, “cost sharing” was not controlled by the law, enrollment was not implemented well, and transparency provisions not implemented. Market place competition is limited, especially in rural areas.

  • Clinton
    • supports policies to maintain and build upon the ACA.
    • increase premium subsidies in the marketplace so no participant is required to pay more than 8.5% of income for coverage.
    • fix the “family glitch” and allow people to buy coverage through the marketplace regardless of their immigration status.
    • make a public plan option available in every state and give people the option of buying into Medicare starting at age 55.
    • invest $500 million annually in outreach and in-person assistance to enroll more uninsured in coverage, and she would enforce ACA transparency provisions.
    • authorize the federal government to review and disapprove unreasonable health insurance premium increases in states that do not have such authority, repeal the Cadillac tax.
    • proposed new private plan standards to waive the annual deductible for at least three sick visits per year, limit monthly cost sharing for prescription drugs to $250, and protect against surprise medical bills when patients inadvertently receive care out of network.
    • proposed a new refundable tax credit of up to $5,000 to subsidize out-of-pocket health expenses (including premiums in marketplace plans) for all Americans with private insurance.
  • Trump
    • complete repeal of the ACA, including the individual mandate to have coverage.
    • create high risk pools for individuals who have not maintained continuous coverage.
    • provide a tax deduction for the purchase of individual health insurance.
    • promote competition between health plans by allowing insurers to sell plans across state lines; an insurer licensed under the rules of one state would be allowed to sell coverage in other states without regard to different state laws that might apply.
    • promote the use of Health Savings Accounts (HSA), and specifically would allow tax-free transfer of HSAs to all heirs.
    • would also require price transparency from all hospitals, doctors, clinics and other providers so that consumers can see and shop for the best prices for health care procedures and other services.

Medicaid – Issues include states’ concerns regarding financing and unwillingness to expand to those too poor to qualify for a tax rebate required coverage

  • Clinton
    • encourage and incentivize states to expand Medicaid by providing states with three years of full federal funding for newly eligible adults, whenever they choose to expand.
    • would also continue to make enrollment easier and launch a campaign to enroll people who are eligible but not enrolled in coverage.
  • Trump
    • supports a Medicaid block-grant and a repeal of the ACA (including the Medicaid expansion).
    • would cover the low-income uninsured through Medicaid after repealing the ACA.
      • The House Republican Plan, which is part of a larger package designed to replace the ACA and reduce federal spending for health care, would offer states a choice between a Medicaid per capita allotment or a block grant.

Medicare – Issues include prescription drug costs, fate of provisions in ACA, public option for those 55-64

  • Clinton
    • supports maintaining the current structure of the Medicare program and opposes policies to transform Medicare into a system of premium supports. On the issue of prescription drug costs
    • supports allowing safe re-importation of drugs from other countries, allowing the federal government to negotiate drug prices in Medicare, especially for high-priced drugs with limited competition, and requiring drug manufacturers to provide rebates in the Medicare Part D low-income subsidy program equivalent to the rebates provided under Medicaid.
    • does not support repealing the ACA or any of the Medicare provisions included in the law; rather, she supports expanding the law’s value-based delivery system reforms.
    • proposed to allow people ages 55 to 64 to buy into Medicare.
  • Trump
    • No position on the issue of Medicare program restructuring or whether to allow older adults ages 55 to 64 to buy in to Medicare.
    • supports repealing the ACA, which would presumably mean repealing the law’s Medicare provisions.
    • supports allowing safe re-importation of prescription drugs from other countries.

Prescription drugs – Issues are pricing (generally more expensive in US than in other countries despite being manufactured in the same facility) and out-of-pocket costs (many plans have gone to a cost sharing rather than a deductible strategy

  • Clinton
    • proposes prohibiting “pay-for-delay” deals whereby companies make payments to competitors for agreeing to delay market entry
    • increasing funding for the FDA Office of Generic Drugs to reduce their approval backlog
    • reducing the market exclusivity period for biologics
    • and directing the FDA to prioritize biosimilar drugs with few competitors. To address price increases for generic drugs
    • proposes to establish consumer oversight in federal agencies
    • penalize drug companies for unjustified price increases
    • allow importation of lower-cost drugs from countries with similar safety standards.
    • She also supports eliminating tax deductions for direct-to-consumer advertising
    • requiring FDA approval of advertisements
    • tying federal support for drug companies to their investment in R&D
    • increasing transparency of the additional value new drugs have over existing treatments
    • allowing Medicare to negotiate drug and biologic prices. To address OOP spending on prescriptions,
    • proposes a $250 per month cap on cost sharing for covered drugs; and a rebate program for low-income Medicare beneficiaries that mirrors those in Medicaid.
  • Trump
    • supports allowing importation of drugs from overseas that are safe and reliable but priced lower than in the U.S.
    • supports greater price transparency from all health providers, especially for medical exams and procedures performed at doctors’ offices, clinics, and hospitals, but does not specify whether this policy would also apply to retail prescription drugs, which typically are not considered services or procedures.

Opioid epidemic – Issues include increased use (1 in 20 nonelderly adults used opioids for nonmusical purposes), increased addiction ( 2 million non elderly adults with of the level of opioid use increases to the level of opioid use disorder, often referred to as abuse, dependence, or addiction), increases in overdose deaths (those involving opioids have quadrupled since 1999).

  • Clinton
    • released a $10 billion (over ten years) plan to fight drug addiction.
      • includes a federal-state partnership to support education and mentoring programs
      • development of treatment facilities and programs
      • efforts to change prescribing practices, and criminal justice reform.
      • direct federal action to increase funding for treatment programs
      • change federal rules regarding prescribing practices
      • enforce federal parity standards
      • promote best practices for insurance coverage of substance use disorder services
      • issue guidance on treatment and incarceration for nonviolent and low-level federal drug offenders.
  • Trump
    • Will build a wall on the U.S.-Mexican border
      • will help stop the flow of drugs and thus address the opioid epidemic.

Reproductive health – Issues include access to preventive services, publicly funded family planning, and abortion services

  • Clinton
    • supports policies that protect and expand women’s access to reproductive healthcare, including affordable contraception and abortion.
    • defends the ACA’s policies, including no-cost preventive care and contraceptive coverage. promised to protect Planned Parenthood from attempts to defund it and would work to increase federal funds to the organization. called for the repeal of the Hyde Amendment which she believes limits low-income women’s access to abortion care.
    • would appoint judges to the Supreme Court who support Roe v. Wade, ensuring a women’s right to choose an abortion.
  • Trump
    • called for defunding Planned Parenthood if they continue to provide abortion
    • He states he is pro-life but with exceptions when the pregnancy is a result of rape, incest, and life endangerment.
      • has promised to appoint pro-life justices to the Supreme Court that seek to overturn Roe v. Wade
    • would also work to make the Hyde Amendment permanent law
    • would sign the Pain-Capable Child Protection Act, legislation that would sharply limit access to later term abortions.
    • would also repeal the ACA, which would eliminate minimum scope of benefits standards such as maternity care in individual plans and coverage of no-cost preventive services such as contraceptives in private plans.



I have a neighbor who is riding his bike from Mobile Alabama to Springfield Missouri to call attention to the need for better mental illness care. They happen to have a son who suffers from mental illness and thus (as many of us do) got involved because of their own son and then become involved with an organization that has a much larger purpose. Not only is D. G. riding his bike across country but his wife, Connie, is an officer in the local chapter of NAMI. Part of D.G.’s reason for taking this on, he says, is that

Even if we don’t raise money, if I can change the attitude of just one person relative to mental illness, it’s worth it. We talk about every other disease but we won’t talk about mental illness. There’s just such a terrible stigma associated with it.

Mental illness has been stigmatized since Biblical times. with Descartes being the most recent scapegoat. Part of the stigma was, I suspect, due to the nature of the affliction. Unlike pneumonia with its fever and coughing, those afflicted with mental illness have no outward manifestation, so the common belief seems to be that if they would only try hard enough, they could control their behaviors. In modern times we have devised treatments but the situation has not improved as much as we would hope. Some people don’t respond to the medications. Others may respond partially but feel so fuzzy headed that they want to stop the medication. Others respond so well that they feel normal, so figure they are cured and quit taking the medication for that reason. All in all, not a good illness to have and very difficult to treat, but an illness just like many other chronic illnesses. Because of the need to keep people taking medicine that makes them feel bad even when they are feeling better, mental health professionals developed “Assertive Community Treatment” options that include (from Wikipedia)

  • a clear focus on those participants (clients) who require the most help from the service delivery system;
  • an explicit mission to promote the participants’ independence, rehabilitation, and recovery, and in so doing to prevent homelessness and unnecessary hospitalization;
  • an emphasis on home visits and other in vivo (out-of-the-office) interventions, eliminating the need to transfer learned behaviors from an artificial rehabilitation or treatment setting to the “real world”;
  • a participant-to-staff ratio that is low enough to allow the ACT “core services team” to perform virtually all of the necessary rehabilitation, treatment, and community support tasks themselves in a coordinated and efficient manner—unlike traditional case managers, who broker or “farm out” most of the work to other professionals;
  • a “total team approach” in which all of the staff work with all of the participants, under the supervision of a qualified mental health professional who serves as the team’s leader;
  • an interdisciplinary assessment and service planning process that typically involves a psychiatrist and one or more nurses, occupational therapists, social workers, substance abuse specialists, vocational rehabilitation specialists, and certified peer specialists (individuals who have had personal, successful experience with the recovery process);
  • a willingness on the part of the team to take ultimate professional responsibility for the participants’ well-being in all areas of community functioning, including most especially the “nitty-gritty” aspects of everyday life;
  • a conscious effort to help people avoid crisis situations in the first place or, if that proves impossible, to intervene at any time of the day or night to keep crises from turning into unnecessary hospitalizations; and
  • a promise to work with people on a time-unlimited basis, as long as they demonstrate a continuing need for this highly intensive and integrated form of professional help.

The goal is to maintain the client’s ability to function in society, despite a high cost and potential loss of freedom. If done right, it is expensive. Unfortunately, it is often easier to allow people with mental illness to wander about with no access to care and walk on the other side of the street as we seem to do commonly here in Alabama.

As we fight to destigmatize mental illness and offer appropriate treatment to those who have it, society seems to be moving to stigmatize other folks with certain types of chronic illness. The most recent example is that of diabetes mellitus. I went to a presentation about health coaching at the National Rural Health Association meeting. This presentation discussed a model of care that, although less intensive, offers many elements of Assertive Community Treatment. The goal of the therapy is to move folks with diabetes to a disease-free  state by working with them to encourage lifestyle changes, medication compliance, and disease self-management. It is surprising how rapidly the conversation turns to “disincentives” such as more money in insurance premiums, encouraging “self control” through shame and stigmatization, and “if only they would stay out of McDonald’s.”

As we come to understand how much of our healthcare costs can be reduced through positive lifestyle modifications, I hope that we can celebrate the triumph of modern medicine over the frailty of the human condition. Instead we seem to be moving to punishing those who are less than perfect. A trend I will continue to fight.

Y’know, a town with money is like a mule with a spinning wheel. No one knows how he got it and danged if he knows how to use it!

Lyle Lanley

As you may recall, there was an oil incident in the gulf. As a consequence, Mobile Alabama is expecting a rather large windfall. Apparently, the fines associated with the oil spill could range from 4 to 16 billion dollars and are supposed to stay in the Gulf Coast region. Consequently, each of the affected states (though some feel more affected than others) will get some of this money to mitigate the damages.

Alabama put together a Coastal Recovery Commission, which was created by the Governor and populated by his office, various local politicians, and representatives of coastal concerns. This commission was charged with creating a roadmap leading to the transformation of the gulf region into one of increased resiliency. In their words:

We must position ourselves to respond not only to future oil spills but also to other forces beyond our control, including everything from hurricanes to sudden shifts in the economic environment. We must assure a future for our coast that strengthens its appeal to visitors and investors from around the world and protects its environmental assets for generations to come.

To do this they determined that a roadmap approach would be most effective.

Then, we will propose bold but attainable goals, based on the most authoritative research and reality-tested best practices. Our roadmap should guide Alabama, regional, and national leaders in implementing policies that protect, preserve and enhance the assets that make Alabama’s Gulf Coast so important, not only to Alabamians, but to the Gulf region and the nation as a whole.

The commission published the “Roadmap to Resiliance” here. The commission identified problems not only with the physical enviroment but the human environment (health care, education, economic development, and insurance). Problems identified may be directly related to the spill but more often than not were related to our physical location (hurricane alley) as well as the long term problems associated with limited educational resources and an economy that suffers from too little diversity.

The solutions take up 17 pages. Some are fairly vague but “feel good” such as “”Restore and enhance habitat for fisheries as needed.” Some are very concrete: “Require fire protection every 1,000 feet where public water is available.” Some are relatively inexpensive: “Combine county efforts for regional events.” Some would take all of the money for one project: “Build the I-10 Bridge and make it spectacular with reasons for travelers to stop at the Mobile end, not just pass on through – follow the example of the Sydney Opera House or the Bilboa, Spain, museum – a building that could house a Southern Cultural Center or the like.”

The aspect of this report that caught my eye was written up here in our local paper.

A gubernatorial commission making recommendations for oil spill recovery urges the creation of a Mobile-based Center for Coastal Health with a wide-ranging mission to address and research primary care, mental health, lifestyle issues and disaster response.The proposal for the independent center at the University of South Alabama is outlined in the 198-page report that the Alabama Coastal Recovery Commission gave to Gov. Bob Riley this month in Montgomery.

The commission report said that the center should focus on four areas: occupational health for coastal populations; primary care and mental health; disaster preparedness and management; and minority health care, including the mental health needs of immigrant and refugee populations.

Dr. Richard Powers, medical director for the Alabama Department of Mental Health, said the spill revealed that the coastal region is largely ill-equipped to “deal with its unique health needs” during times of crisis. Powers, a Riley appointee to the commission, said, “It would be nice to have a group of smart health care professionals wired to the national networks to be looking after our welfare, and not have to summon them up every time a disaster happens.”

Start-up of the center would likely cost $30 million to $50 million, according to Powers. He suggested that the funding should come from fines and grant payments made by BP PLC, majority owner of the ruptured well.

According to the commission report, the new center and its faculty would be supported by a foundation established for that purpose.

Now that’s a mule I can get behind.

The Alabama Rural Health Association is putting together a task force to deliver to policy makers a list of health reform actions that have been taken or will be taken as a result of the passage of the reform package. As a state, we tend to be a little wary of federal initiatives. We as an organization want to inform the gubernatorial candidates what policies are in place so that they can get beyond the political rhetoric. The National Rural Health Association has put together a list of initiatives that are already in the Patient Protection and Affordability Act which will help rural Alabama that we need to be prepared to react to as the opportunities arise. Perhaps one (or all) of the gubernatorial candidates will announce a rural health task force to allow his (all of the candidates are men) adminstration to take advantage of opportunities in a rapid fashion. The law has already been passed so I hope we won’t let politics get in the way of improving the health of our citizens:

Rural Health Care Workforce Improvements (as identified by the National Rural Health Association)

Rural Physician Training GrantsThese grants will help medical colleges to develop special rural training programs and recruit from students from rural communities.  This “grow-your-own” approach is one of the best and most cost-effective ways to ensure a robust rural workforce into the future. Alabama has some very good but underfunded programs

Expanding Area Health Education Centers (AHEC)  – Area Health Education Centers (AHECs) are critical to long-term health workforce strategies in rural America.  AHECs are directly responsive to State and local needs and serve to improve the supply, distribution, diversity and quality of the healthcare workforce, ultimately increasing access to health care in medically underserved areas.  The bill makes a strong investment in the continued success of this program. ALABAMA DOES NOT HAVE AN AHEC

Graduate Medical Education (GME) Improvements – Rural America faces a severe physician shortage, and this bill seeks to partially address this problem by improving GME.  First, it establishes a program for training of medical residents in community based settings by awarding grants or contracts.  This funding would help develop new primary care residency programs in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).  It would do so by creating a demonstration project program for RHCs, FQHCs and other “approved teaching health centers” in non-provider settings for which centers would be eligible for payments for their own direct GME primary resident costs in a manner similar to the payments hospitals would receive for providing similar services.  Additionally, the bill would establish a grant/contract program to train primary care residents in community-based settings.  These programs would recruit and train new residents and faculty, and would either create new programs or operate out of existing primary care residency facilities.  Preferences for this funding would go to programs serving underserved communities. ALABAMA does not have mechanisms in place to take advantage of this at this time.

Redistribution of residency slots – The bill redistributes unused residency slots under the Medicare GME program, enhancing the national capacity for health care provider training.  Not only does this provision protect rural programs from losing their slots, which may be difficult to fill, it also prioritizes the redistribution of slots to rural programs and rural training tracks and ensures additional placements to residents in primary care and general surgery. The funding mechanism was recently announced. Alabama does not have a mechanism to pay for the excess teaching costs associated with these new slots.

National Health Service Corps – The NHSC is critical to addressing the provider shortage crisis in rural America.  This bill includes a significant investment in the NHSC and allows health professionals to fulfill their commitment by teaching, further investing in the future of the health care workforce. The state office that formerly worked with the National Health Service Corps has had significant decreases in staffing.

Undergraduate medical education – Workforce improvements must be made at all stages of the process and a grant program to improve primary care training will enhance the primary care workforce nationally. The Alabama Family Practice Rural Health Board has some resources available to help position us to take advantage of this but they are not adequate.

National Health Care Workforce Commission – The Commission would provide recommendations to enhance the status of the health care workforce across the country.  It would be comprised of health workforce experts and require a balance between rural, urban, suburban, and frontier perspectives.  Additionally, the geographic distribution of the health care workforce would be a priority area for study. The Alabama Rural Health Association has some resources should policymakers have interest.

Important Medicare and Medicaid Improvements

10 Percent Bonus to Primary Care Physicians  – Building on the 10 percent bonus fee schedule payment already offered to physicians meeting certain guidelines, such as those practicing in health professional shortage areas (HPSAs), the bill includes a five-year 10 percent bonus on certain fee schedule evaluation and management (E & M) codes related to office, home, nursing facility, domiciliary, rest home, or custodial care visits. This bonus is available to primary care, general internal medicine, general pediatric and geriatric physicians, nurse practitioners, clinical nurse specialists, or physician assistants for whom primary care Medicare services accounted for at least 60 percent of their charges the abovementioned E & M visits. Alabama Medicaid and Blue Cross should follow suit.

10 Percent Bonus to General Surgeons Performing Major Surgeries in HPSAs – Any general surgeon performing major surgeries in health professional shortage areas (HPSAs) are eligible for an extra 10 percent bonus payment between 2011 and 2016.  Alabama Medicaid and Blue Cross should follow suit.

Medicare Physician Fee Schedule Improvements – Adjustment of the Geographic Practice Cost Indices (GPCI) Formula – For years 2010 and 2011, the “practice expense” component of the GPCI formula will reflect “1/2 of the difference between the relative costs of employee wages and rents in each of the different fee schedule areas and the national average of such employee wages and rents.”    Additionally, the bill includes a hold-harmless provision in the event of an area being adversely affected by this provision.  The legislation also directs the HHS Secretary to analyze a method of establishing geographic adjustments that “fairly and reliably establishes distinctions in the costs of operating a medical practice in the different fee schedule areas.” For the years following (2012 and beyond), the HHS Secretary is required to update the PE GPCI to reflect accurate geographic adjustments based on office rents and other factors.  Alabama Medicaid and Blue Cross should follow suit.

Medicare Rural Home Health Add-On

Because home health is more expensive to provide in rural communities due to distance and the availability of providers, Congress implemented, as part of the MMA of 2003, a 5 percent bonus payment bonus payment to providers supplying home health services in rural areas.  This bonus payment was first implemented in 2004, but because Congress did not extend the program it expired on December 31, 2006.  The health reform bill reinstated this program for the period between April1, 2010 and December 31, 2016.  Instead of the previous bonus amount, however, the bill provides a 3 percent bonus payment.

One-Year 5 Percent Bonus to Mental Health Physicians  – For 2010, physicians offering psychotherapy services will receive a 5 percent bonus payment. Alabama is in a mental health delivery crisis. Te system is broken and needs significant attention. This will help but will not be enough.

Providing Adequate Pharmacy Reimbursement   – The bill includes reimbursement for retail community pharmacies of no less than 175 percent of the weighted average of the most recently calculated average manufacturers price (AMP).  There are many area of Alabama that are not served by pharmacy services

Technical Correction for Critical Access Hospital Method II Billing Reimbursement (Section 3128) – This provision would correct a technical error in current statute relating to CAHs who elect to use the Method II, or Optional Payment Method.  This was in response to the recent CMS Inpatient Prospective Payment System (IPPS) final rule in which CMS interpreted current law to disallow CAHs who bill under Method II from receiving the typical CAH 101 percent reimbursement. Because of reimbursement policies of  Alabama Medicaid and Blue Cross, Alabama has been unable to take advantage of the Critical Access Hospital rules to improve care.

Additional Payments to Hospitals in Counties with the Lowest Medicare Spending – For 2 years, hospitals in the lowest quartile of counties in terms of Medicare spending on benefits will receive additional payments to offset their disproportionately low rates.  These payments will equal $400 million in ($200 million in FY2010 and $200 million in FY 2011) to address geographic disparities for PPS hospitals in the lowest spending quartile of the country.  Alabama needs to be prepared to take advantage of this.

Extension of Important Programs Ensuring Access to Physicians and Other Services Otherwise Set to Expire

–          Extension of Payment for Technical Component of Certain Physician Therapy Caps Physical therapy services are unavailable in many counties of Alabama

Extension of Ambulance Add-Ons Ambulance services are in financial difficulty in many counties of Alabama

–          Extension of physician fee schedule mental health add-on Mental Health  services are unavailable in many counties of Alabama

Extension of Important Rural Medicare Protections  – The Medicare Modernization Act (MMA) of 2003 included a number of provisions important to protecting the fragile rural health care safety net.  These protections are set to expire, and the NRHA is glad this bill includes provisions extending these programs.  They are:

–          Extension of Outpatient Hold Harmless Provision

–          Extension of Medicare Reasonable Costs Payments for Clinical Diagnostic Laboratory Tests Furnished to Hospital Patients in Certain Rural Areas

–          5 year extension and improvement of the Rural Community Hospital Demonstration Program

–          Extension of the Medicare-Dependent Hospital (MDH) Program

–          Temporary Improvements to the Medicare Inpatient Hospital Payment Adjustment for Low-Volume Hospitals

–          Improvements to the Demonstration Project on Community Health Integration Models in Certain Rural Counties

–          Extension of and Revisions to Medicare Rural Hospital Flexibility Program

–          Extension of Section 508 Hospital reclassifications

We need to be in a position to take advantage of these in Alabama

Additional Improvements

Strengthening Indian Health Services – The bill ensures Indians below 300 percent of the federal poverty level will not face any cost-sharing when enrolled in the state exchange.  The bill also eliminates the sunset for reimbursement for all Medicare Part B services furnished by certain Indian hospitals and clinics. We need to be in a position to take advantage of these in Alabama

Small Business Tax Credit   – This would create tax credit for small businesses who offer health insurance for their employees.  The credit would be equal to 50 percent (35 percent for tax exempt employer) of an eligible employer’s requirement set forth by the bill through the exchange or a suitable alternative. We need to be in a position to take advantage of these in Alabama

Increases in Funding for Community Health Centers – Community Health Centers are a cornerstone for patient-directed care for populations with limited access to primary health care services.  This critical additional new funding will allow health centers to increase care to millions of underserved patients. We need to be in a position to take advantage of these in Alabama

Expansion of the 340B drug program – The 340B Drug Pricing Program provides low cost drugs to certain facilities.  This bill would expand the program to include Critical Access Hospitals, Sole Community Hospitals and Rural Referral Centers, allowing these facilities to better serve their patients. We need to be in a position to take advantage of these in Alabama

Community Transformation Grants – These grants provide for the implementation, evaluation, and dissemination of evidence-based community preventive health activities. According to the manager’s amendment, at least 20% of these grant funds must go to rural or frontier communities. We need to be in a position to take advantage of these in Alabama

In this country we have had difficulty delivering basic health care to our citizens. We have had a larger problem delivering basic dental care to our citizens. We are almost unable to deliver mental health care given the constraints of the current system. Health insurance reform at this time will not provide the delivery system reform necessary to fix the oral health problem. It may provide resources that will help people get needed mental health care.

The Milbank Fund has published a report on mental health care delivery system transformation. In it they point out that the method of care delivery is important:

A comprehensive health care system must support mental health integration that treats the patient at the point of care where the patient is most comfortable and applies a patient-centered approach to treatment. Integration is also important for positively impacting disparities in health care in minority populations.

A 2008 report by Funk and Ivbijaro cited seven reasons for integrating mental health into primary care. Each must be considered in any effort to design or implement a collaborative approach, partial integration, or a fully integrated model.

  1. The burden of mental disorders is great. Mental disorders are prevalent in all societies and create a substantial personal burden for affected individuals and their families. They produce significant economic and social hardships that affect society as a whole.
  2. Mental and physical health problems are interwoven. Many people suffer from both physical and mental health problems. Integrated primary care helps to ensure that people are treated in a holistic manner, meeting the mental health needs of people with physical disorders, as well as the physical health needs of people with mental disorders.
  3. The treatment gap for mental disorders is enormous. In all countries, there is a significant gap between the prevalence of mental disorders and the number of people receiving treatment and care. Coordinating primary care and mental health helps close this divide.
  4. Primary care settings for mental health services enhance access. When mental health is integrated into primary care, people can access mental health services closer to their homes, thus keeping families together and allowing them to maintain daily activities. Integration also facilitates community outreach and mental health promotion, as well as long-term monitoring and management of affected individuals.
  5. Delivering mental health services in primary care settings reduces stigma and discrimination.
  6. The majority of people with mental disorders treated in collaborative primary care have good outcomes, particularly when linked to a network of services at a specialty care level and in the community.
  7. Treating common mental disorders in primary care settings is cost-effective.

The writers acknowledge barriers, including the traditional mind-body dualism which has led to silo thinking, the problems inherent in attempting information sharing with sensitive information,  and the fact that payment for mental health care is not assured even with the new law. helping is the fact that organizations such as the Carter Center are working to de-stigmatize mental illness

The report points out that vital to improving this care is the Patient Centered Medical Home, the team approach to care (incorporating mental health professionals and primary care practices), and stepped care. In addition, they propose the use of a (proven) model where patients with low health and high needs and low behavioral health needs are cared for in the primary care medical home, and those with high behavioral needs and low and high health needs are cared for in the primary care and specialty mental health setting, all in a coordinated fashion.

The report makes for an interesting read and offers concrete solutions to some vexing problems.