MHASP Written Comments on Healthy PA

8/13/2019 MHASP Written Comments on Healthy PA

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Written Comments Regarding Healthy PennsylvaniaJacob Bowling, Director of Advocacy and PolicyMental Health Association of Southeastern PennsylvaniaJanuary 3, 2014

At the Mental Health Association of Southeastern Pennsylvania (MHASP), webelieve that a healthy Pennsylvania is one where people can easily access behavioralhealth support that contributes to overall wellness, and involvement in their communitiesand families. Among the principal stakeholders in this plan are citizens of theCommonwealth who have mental health conditions and their families: includingindividuals in our existing HealthChoices program and the additional Pennsylvanianswho will benefit from Medicaid Expansion who are currently uninsured and have amental health condition (twenty percent of the entire expansion population)1. As such,the Healthy Pennsylvania plan must be responsive to the needs of people with mentalhealth conditions and their families, and must reinforce Pennsylvanias leadership inmental healthcare. While we applaud the administrations commitment to increasing

health access for 500,000 Pennsylvanians, we have major concerns about this plan sinadequacy to meet the needs of people with mental health conditions.

A thirty-day comment period is insufficient.

First, Pennsylvanians deserve a plan that garners their expertise and values theirvoices. While the Healthy Pennsylvania plan is long, detailed, and complex, there arestill many unanswered questions that inhibit the ability of Pennsylvanians to offer aninformed contribution to this process. We need more time to learn about this plan andoffer comments. We would ask for thirty more days to issue written comments and atleast four more regional hearings. Thirty days during a busy holiday season for manyfamilies is not a sufficient amount of time to comment on a plan that will impact the livesand health of 500,000 Pennsylvanians and their families.

The behavioral health benefit in the High Risk plan is insufficient and unaligned withwhat is currently offered to individuals in HealthChoices.

What is offered through the Healthy Pennsylvania High Risk Plan is not only insufficientfor people with serious mental health conditions, but it is not aligned with the benefitsthat are currently offered through HealthChoices. One of the HealthChoices plans offers60 outpatient mental health visits per year (15 more than the Healthy PA High RiskPlan), and no limits on inpatient psychiatric hospitalization, inpatient drug and alcoholhospitalization, and outpatient drug and alcohol treatment (Healthy PA places limits onall of these services). For someone who relies on weekly therapy appointments to stayout of the hospital, he or she would be limited to only 45 therapy visits per year2.Individuals on the low risk plan will also lose targeted case management- a critical

1Medicaid Expansion and Mental Healthcare, National Alliance for Mental Illness, 2013, found at

http://www.nami.org/Template.cfm?Section=Health_Care_Reform&Template=/ContentManagement/ContentDis

play.cfm&ContentID=1557522Healthy PA: Impact on People with Disabilities,Pennsylvania Health Law Project, 2013.
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service that helps people coordinate their care. We would ask that HealthyPennsylvania removes all limits in the high risk plan for these critical services thatpromote recovery and whole health. By removing the drastic cuts to HealthChoices thatare inherent to this plan, DPW can support services that prevent and mitigate crises thatresult in enormous human and fiscal costs.

The process of moving from the Low Risk to High Risk plan is unclear.

Many individuals with mental health conditions may need to move from the low risk planto the high risk plan, because of a more severe episodic condition or the development ofa more severe condition. The Healthy Pennsylvania 1115 Waiver application does notexplain the process of obtaining a higher level of coverage. The process should beseamless and timely, and should not necessitate an onerous administrative process forconsumers or the disruption of critical services and supports. We would assert thatthose who need benefits in the high risk plan should gain immediate access to thosebenefits while any administrative functions are being processed, to prevent any delay or

disruption of services that could jeopardize their health.

A match to an appropriate level of benefits is contingent on an unclear self-assessmentprocess.

To be placed in the high or low risk plan, individuals must undergo a self-assessmentprocess that involves self-reporting their medical conditions. For a self-assessment tobe successful, the following must be true for every individual to ensure that they arecorrectly identified and appropriately placed in a plan that meets their needs. Eachindividual must:

Have been diagnosed (some individuals have untreated or undiagnosed mental

health conditions) Know the diagnosis (some individuals may not be aware of their official

diagnosis) Be willing to share medical conditions (stigma and discrimination toward people

with mental health conditions, drug and alcohol challenges, and other medicalconditions is prevalent, and may prevent an individual from sharing medicalinformation even if it would result in a more appropriate level of benefits).

Have additional support if a cognitive impairment may impact awareness ofdisability status or participation in the self-assessment

Have transportation if assessment is conducted in an office Have literacy and computer skills depending on how the assessment is

administered

We need to hear how these barriers will be addressed so that individuals withdisabilities will be accurately assessed to receive the appropriate benefits.


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Individuals with disabilities will be automatically placed into the low risk benefit if theself-assessment is not completed.

Individuals with disabilities may experience the aforementioned barriers and miss or failto complete their self-assessment. According to the Healthy Pennsylvania plan, these

individuals will automatically be placed in the low risk plan. The fact that individuals didnot show up or complete their self-assessment may be evidence that their disability isso severe that a higher level of benefits is needed. For those unable to complete theassessment, they should be enrolled in the high risk plan as a default. If, upon furtherreview, the High Risk plan is an inappropriate level of benefits for the individual, aredetermination can result in placement back into the Low Risk plan. People should nothave decreased access and more limitations to care just because their disabilityprevents them from jumping through administrative hoops.

People who are extremely poor must pay premiums and if premiums are not paid,policies will be cancelled.

In December, Iowas Medicaid Expansion plan received approval from the federalgovernment. However, CMS refused to allow one of the plans measures- thatindividuals at 50% FPL pay a premium- to pass3. Given CMSs disapproval of thismeasure in Iowa and the extreme poverty of individuals at 50% FPL (some make lessthan $500 per month) we would ask that premiums only be assessed at 100% FPL if atall.

Individuals with mental health conditions- like many other low-income Pennsylvanians-may experience difficulty paying premiums. To penalize them by the removal ofcoverage will only contribute to their involvement with more-expensive taxpayersubsidized systems and the decline of their health. We would ask that the failure to paypremiums not result in the punitive cancellation of coverage.

People who are deemed medically frailstill must satisfy arduous work searchrequirements.

While employment plays a critical role in the recovery of people with mental healthconditions, their healthcare should not be tied to their ability to work or their completionof work-related activities. People with mental health conditions need the opportunity tothoughtfully engage or re-engage with the workforce without the enormous pressure oflosing their healthcare benefits because they are unable to complete seventy-two work-related activities within a six month period. In addition, we have concerns thatJobGateway- the portal through which individuals can satisfy this requirement- may notbe a program that is user-friendly to individuals with disabilities. Also, it is unreasonablesomeonesinternet access and transportation (required to participate in JobGateway)

3Medicaid Expansion Through Premium Assistance: Arkansas, Iowa, and Pennsylvanias Proposals Compared, the

Henry J. Kaiser Family Foundation, 2013, found athttp://kff.org/health-reform/fact-sheet/medicaid-expansion-

through-premium-assistance-arkansas-and-iowas-section-1115-demonstration-waiver-applications-compared/
http://kff.org/health-reform/fact-sheet/medicaid-expansion-through-premium-assistance-arkansas-and-iowas-section-1115-demonstration-waiver-applications-compared/http://kff.org/health-reform/fact-sheet/medicaid-expansion-through-premium-assistance-arkansas-and-iowas-section-1115-demonstration-waiver-applications-compared/http://kff.org/health-reform/fact-sheet/medicaid-expansion-through-premium-assistance-arkansas-and-iowas-section-1115-demonstration-waiver-applications-compared/http://kff.org/health-reform/fact-sheet/medicaid-expansion-through-premium-assistance-arkansas-and-iowas-section-1115-demonstration-waiver-applications-compared/http://kff.org/health-reform/fact-sheet/medicaid-expansion-through-premium-assistance-arkansas-and-iowas-section-1115-demonstration-waiver-applications-compared/http://kff.org/health-reform/fact-sheet/medicaid-expansion-through-premium-assistance-arkansas-and-iowas-section-1115-demonstration-waiver-applications-compared/


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will be correlated with their medical coverage and care. We ask that the work searchrequirement for eligibility be removed.

The Pennsylvania taxpayers have no evidence that the Healthy Pennsylvania plan iscost-neutral.

DPW's plan must be cost-neutral, but the application does not demonstrate how. One ofthe potential revenue-generating components of this plan is the payment of premiumsfor people from 50% to 138% of the federal poverty level (FPL). In the Iowa plan, CMShas rejected attempts to levy premiums from anyone under 100% of the poverty level.Thus, it appears unlikely that the revenue-generating measure will contribute to theplan's cost neutrality (at least to the extent that the administration assumes it will).

Revenue is also lost when taxpayers subsidize private coverage for low-income peopleas opposed to expanding the traditional public Medicaid system. According to Health

Affairs, "Some intuitively believe that a public insurance expansion would be more costly

than expanding private insurance because Medicaid covers a wider range of benefitsthan those typically covered by private health insurance and requires less patient costsharing. On the other hand, Medicaid provider payment rates are typically lower thanthose offered by private insurers.4The Congressional Budget Office agrees. SinceMedicaid provides a lower reimbursement to doctors and hospitals, Medicaid savesmoney. Arkansas plan costs,the government $6,000 a year for Medicaid [and] wouldcost $9,000 on a private plan on the exchange."5Thus, Pennsylvania taxpayers will geta better return for their investment with a traditional Medicaid expansion.

Pennsylvania taxpayers lose out every day Medicaid Expansion is stalled.

Finally, according to the Rand Foundation, Pennsylvanians will lose out on 2.5 billiondollars of potential federal funding by delaying Medicaid Expansion until January of2015. It will also lose out on any potential job growth in year one (Medicaid Expansion isexpected to create 35,000 jobs the next few years, many of which will be well-paidpositions in the healthcare industry). The Southeast region alone will see 15,600 ofthese new jobs. Overall, Rand estimates that this additional federal funding would leadto 3.2 to 3.6 billion in additional economic activity in Pennsylvania over time6.Pennsylvania, unlike many other states in our region, is losing out on these much-needed economic benefits for at least one year.

In a few days, hundreds of thousands of hardworking people in our region will becomeeligible for Medicaid Expansion. In this New Year, these residents of Ohio, New York,and New Jersey were able to celebrate the stability of having healthcare coverage.

4Public And Private Health Insurance: Stacking Up the Costs. Health Affairs. Found at

http://content.healthaffairs.org/content/27/4/w318.full5The Arkansas Medicaid Model: What You Need To Know The Private Option Kaiser Health News. 2013, found

athttp://www.kaiserhealthnews.org/stories/2013/may/02/arkansas-medicaid-private-option-faq.aspx6For States that Opt Out of Medicaid Expansion: A Rand Report. Health Affairs. Found at

http://www.rand.org/pubs/external_publications/EP50279.html
http://content.healthaffairs.org/content/27/4/w318.fullhttp://content.healthaffairs.org/content/27/4/w318.fullhttp://www.kaiserhealthnews.org/stories/2013/may/02/arkansas-medicaid-private-option-faq.aspxhttp://www.kaiserhealthnews.org/stories/2013/may/02/arkansas-medicaid-private-option-faq.aspxhttp://www.kaiserhealthnews.org/stories/2013/may/02/arkansas-medicaid-private-option-faq.aspxhttp://www.rand.org/pubs/external_publications/EP50279.htmlhttp://www.rand.org/pubs/external_publications/EP50279.htmlhttp://www.rand.org/pubs/external_publications/EP50279.htmlhttp://www.kaiserhealthnews.org/stories/2013/may/02/arkansas-medicaid-private-option-faq.aspxhttp://content.healthaffairs.org/content/27/4/w318.full


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More than a year from now, hundreds of thousands of hard-working Pennsylvaniansmay be eligible for Medicaid Expansion. But these individuals- especially those withmental health conditions- will have an inadequate behavioral health benefit with drasticcuts to what is offered in HealthChoices. In addition, individuals with disabilities will berequired to navigate an insurmountable and laborious process to acquire healthcare

coverage. Finally, Pennsylvania taxpayers will be left with insufficient time to commenton the plan, no real evidence of cost-neutrality, and the costly consequence of stalling astraightforward Medicaid expansion plan that would create a vital economic boost.Thus, the Mental Health Association of Southeastern Pennsylvania recommends aprompt and straightforward expansion of our successful HealthChoices program- aMedicaid program with a proven track record that has positioned Pennsylvania as anational healthcare leader.

Documents

MHASP Written Comments on Healthy PA