The Repeal of Obamacare and California MFTs

What We Know; What We Don’t Know; and What to do Now

We know what it is now and we know it will be changing, but we don’t know how.  The following presents information about “what is now”, considerations related to potential change, and subsequent recommendations for California MFTs.

What We Know

  • Our Progress and Bi-Partisan Values

We know our history.  We have made progress in the past several years through the passage of national legislation that acknowledged the importance of providing support for mental health care.  As recently as December 2016, the 21st Century Cures Act was passed with strong bi-partisan support representing progressive policy regarding the need to address co-occurring substance use and mental health disorders, particularly to prevent incarceration.  Our progress has encompassed advances in both summative and formative evaluation, stressing methods of measuring outcomes to determine cost effectiveness, a critical component for assessing effectiveness across all party lines.

National Council President and CEO Linda Rosenberg offers inspiring words in stating:

The outcome of the presidential election doesn’t change the progress we’ve made, it doesn’t change our goal of effective, accessible care and it won’t change or limit the passion and intelligence that our community brings to work with a new administration and Congress.”

  • What is Now

What we know is that record numbers of individuals enrolled for coverage at the end of 2016.  We also know that insurance coverage takes the form of a contract, which means that funds must be allocated to cover the cost of the program at least through the end of 2017 for those who enrolled.

Nationally: we know that the number of insured is at an unprecedented high: 90% (20 million) of all Americans are covered as a result of the ACA (Affordable Care Act, a.k.a. Obamacare); the uninsured rate fell from 14.4% in 2013 to an historic low of 9.4% in 2015.  Jonathan Gruber, MIT economist, stated:  “The single most important accomplishment of the Affordable Care Act was to bring the United States in line with the rest of the developed world, as a place where people were not one bad gene or one bad traffic accident away from bankruptcy.”

In California: 91% are now insured with over 5 million gaining coverage as a result of the ACA.  The historic low of 8.5% in 2015 was a drop in the uninsured rate across all ethnic/racial groups with the greatest gains seen among Latinos.  Over 1 million Californians receive financial assistance to help them afford coverage, with the average federal premium subsidy per household at $438 per month.

For MFTs:  the Affordable Care Act included a provision that required insurance plans to provide coverage, at parity, for Ten Essential Health Benefits.  Behavioral Health (substance abuse and mental illness) was listed as one of the ten benefits.  Systems of comprehensive, integrated care have been developed that include Behavioral Health services and a subsequent role for MFTs.  Employment opportunities in these systems have increased substantially for clinicians who are adequately prepared to contribute within the new and evolving treatment context.

Potential Change

  • Easier Said Than Done

Easy enough to call Obamacare a failure and make repeated, impulsive promises to repeal it on Day 1, the Republican victory has lately been compared to the classic case of the dog who catches the car and says:  “Now what do I do with it?”  The repeal of the Affordable Care Act is a formidable and complicated challenge.  At the core of this challenge is the reality of the successful enrollment of record numbers of Americans:  nobody wants to be eliminating health insurance, in one fell swoop, from 20 million people.  As Rusty Selix points out: “never in history has congress taken action to take a major entitlement away from people who already have it.” Some reports indicate that a repeal would not result in loss of coverage for millions, it would just change the structure of payment, removing tax credits and subsidies that make the insurance products affordable.  That’s where more complications surface.

The challenges in replacing Obamacare with a better plan involve somehow dismantling a structure that, like a house of cards, has been built with one piece dependent on the next.  More specifically, coverage for those with pre-existing conditions has been made affordable by the mandate, requiring healthy people to purchase insurance.  It is the unused benefits that provide adequate funds for insurance companies to cover the cost of those members in need of more frequent or expensive care.  Affordable coverage for millions is endangered without this fiscal safeguard in place.  There are very few options, other than keeping most of the law intact, that make it work.

  • Insurance Companies and Hospitals Need the Subsidized System

Speaking for insurance companies, Marilyn Tavenner, chief executive of the association of America’s Health Insurance Plans, has stated:  “If insurance companies believe cost-sharing subsidies will not continue, they are going to pull out of the market during the next logical opportunity, leaving current Obamacare enrollees with no options for coverage.  She added that the industry would support a delay so it could prepare for the changes:  “We would love to see a three-year time frame, as long as possible”.  Hospital groups warned that a repeal of the ACA could cost them $165 billion by the middle of the next decade and trigger “an unprecedented public health crisis”.

  • Republican Leaders Reveal Principles for a Replacement Plan

Senate and House Republican leaders seem to agree on a “repeal and delay” strategy, which could keep parts of the ACA in place for several years while Congress works with the new administration to devise a replacement.  Republicans intend to develop a replacement plan built around four principles:  States, not the federal government, should have the primary responsibility for health policy; Patients and doctors should be “in control”; there should be more competition among health plans so consumers would have more choices; small businesses should have more discretion and flexibility to configure health benefits for their employees.  These principles are conceptual, however missing operational details make it impossible to gauge how many Americans could lose or gain health coverage and how much more some people might have to pay for it.

  • What About California?

No state has embraced Obamacare more enthusiastically and successfully than California, and no state has more to lose with its repeal.  If the repeal includes block grants to the states, the exact point-in-time will be important.  For California, the critical unknown is whether a block grant would take into account the cost of our now expanded Medi-Cal population.  Block grants are designed to grow, but only at a rate tied to general inflation, which is insufficient compared to increased rates for healthcare spending.  Discussions are taking place now at the state level about possible systems that could be developed through block grant funding, including various forms of single payer or universal health care plans.  California is committed to protecting our people and our progress.  It is not a question of “whether”, but a discussion about “how”, we will be able to continue to implement evolving, progressive and advanced systems of integrated healthcare reform.

While we cannot know how future decisions at the federal level will impact our progress in California, we can predict that, for the immediate future, our plans to expand remain in place:

  • California legislators and healthcare officials responded immediately after the election with public statements expressing their resolve to hold strong to our values and protect our progress.  Similar “statements” were made by the citizens of California in the form of voter approval for four statewide tax extensions or increases and a strengthened, super-majority for the Democrats in the legislature
  • The Proposition 63 “millionaires tax”, which has funded the transformative Mental Health Services Act (MHSA) since 2005, is protected.  It can only be repealed by popular vote of the citizens of California.
  • The passage this year of Proposition 64, which legalizes recreational marijuana, is estimated to create about one billion dollars annually in new taxes, 60% of which is earmarked for “Education, Prevention, Early Intervention and Treatment for Youth”.  Among other things, this will increase funds for treatment of substance use disorders.  MHSA co-author Rusty Selix encourages the initiation of a state level planning effort to “develop strategies to close gaps in the continuum of care and to coordinate and integrate efforts with Proposition 63”.
  • The 2016 passage of local housing bond measures in Los Angeles and Bay Area counties included funding for homeless individuals and their families.  We can leverage this funding to create an opportunity to serve more people through MHSA.
  • Federal legislation for the state Community Behavioral Health Centers pilot programs received bipartisan support in both houses, with all four of its co-authors still in office.  Ongoing bipartisan support for improved mental health treatment seems solid at the national level.  Most significant is the prediction that integrated care will be shown to reduce overall health care costs.  Confirmed outcomes related to cost savings will be likely to secure and solidify inclusion of behavioral health within evolving systems of care.

Recommendations:  What to do Now

For now, the message to MFTs who want to be employed in California public systems of care is:  “stay the course”.  AAMFT-CA Division has been assisting MFTs to prepare for employment in the new systems of care through recommending and offering continually updated education and training in the emerging competencies:  evidence based practice; cultural humility; substance use disorder; integrated care; language and culture of primary care; trauma informed care.  We stand by these recommendations and add to them suggestions for training to respond to the needs of underserved populations such as:  homeless; seriously mentally ill; youth; justice system.  And, we can’t emphasize enough, the value of experience and expertise in working with Substance Use Disorder.

For California public behavioral health, the immediate future is funded:  there will be community programs; there will be meaningful initiatives; there will be jobs for MFTs.  If you want to do the work, move forward with your plans.  If you want to consult with us, please feel free to contact me: