Supreme Court allows Affordable Care Act to stand by

There are several winners after today's Supreme Court decision that the Affordable Care Act is constitutional. [Here is a link to the majority opinion.] Among them are insurance carriers, rural hospitals, folks who can't afford insurance, and consumers of behavioral health services. Losers include those who can afford to self-insure and those with no intention of paying for services received. Other writers can spin this differently, but part of what I sense from those who oppose the law is a selfishness and very narrow in-group definition.

There are problems in this country related to basic fairness. Problems from those who think that everyone is trying to get something for nothing and those who are indeed seeking a free lunch.

My biggest concern about this law continues to be how it will be funded and implemented. Adding "accountability" will encourage reviewers to find problems with documentation--this will be called fraud, but could be as simple as not signing a note quickly enough. It will also stifle therapeutic innovation  and professional development in favor of "manualized treatment" and credentialing of lower level staff by state agencies.

Private insurance carriers and major hospital systems have begun to institute reforms touted in the law. This is because there are ways to streamline care while increasing quality and access. In many ways, the marketplace will solve problems when the environment changes and lead the way to a higher level of care. When politicians enter the business landscape things get complicated and lead to a lower level of care. I keep remembering a time I wanted to pay the IRS using a debit card; that experience showed me the worst of regulation and business--regulations designed to protect me combined with the convenience fee of the immediate service.

I expect the frontiers of healthcare reform to be in the expansion of "evidence-based treatments" by academic researchers--often supplementing eroding salaries with grant-funded projects and sales of programs--and crisis services. Reducing access to behavioral health services will continue to promote the use of crisis services.

Anyway, I hail the law and the increased access to healthcare it brings. My elation is tempered by experience in a rationed system. But...we'll see. The whole thing has to play out.

Moody's promotes Obamacare

Today it was reported that Moody's Investors Service supports "Obamacare", the Patient Protection and Affordable Care Act, because it provides a greater income base for non-profit hospitals. They are not as happy about reductions in Medicare payments for physicians, also included in the law.


I have been casually following the progress of this law and public challenges it faces with several thoughts in mind.

1. It is a good thing for all persons to have insurance. The more people have insurance the more costs can be spread and, at least theoretically, that should lower retail healthcare. I say that knowing that prices always go up, never down. I am reminded of the premiums paid for organic foods.
2. In North Carolina, mental healthcare reform led to increased rationing and increased overhead due to increased "accountability" to enforce fraud laws and to use recoupments  to balance the budget. This created a very dicey environment for providers and additional layers of administration that were funded with lower reimbursements for services.
3. Reduced services (not access, it is a policy goal to increase access) has led to increased importance of the crisis and intake assessments in promoting good behavioral health and "recovery engagement". This is not the system I was trained for in graduate school; true for most providers, surely.
4. While the politicians wrangle over power and donations business (especially insurance carriers and hospitals) is adapting to the new model(s).

So, what does the changing system mean for crisis services?

Good question. One worth spending some time with. If crisis services continues to be where the money is spent, clearly training and technology must adapt.