Do not turn out the lights on the public mental health system when the ACA is fully implemented

When all of the insurance and health care reforms of the ACA are fully implemented, some public financing needs for behavioral health services will remain. This commentary outlines a number of the residual functions of the public mental health system in an ACA world, and it identifies opportunities for expansions of service areas not covered by traditional insurance or the health delivery reforms for behavioral health services within the scope of the ACA.

Massachusetts reform plus President Bush's tax credits: a national model?

The Massachusetts health reform offers an important opportunity for a new federal-state strategy to cover the uninsured. President George Bush's proposed health insurance tax credits could be added to the Massachusetts health reform. The combined plan would include Medicaid expansions; offer workers affordable coverage through competitive insurance markets; and provide federal, state, employer, and individual financing. Many other states might be interested in similar federal-state partnerships for the forty-five million uninsured Americans. Ending the national impasse on coverage needs this kind of bold initiative.

The Third Wave Of Massachusetts Health Care Access Reform

In April 2006, Massachusetts passed its third major health care access reform law since 1988. This law establishes new structures and requirements that have never been attempted by any state. Key features include a shift of federal Medicaid dollars from institutional support to individual insurance subsidies, establishment of an insurance "Connector," individual and employer responsibility, a small-firm and individual insurance market merger, and provisions to address racial and ethnic health disparities. Massachusetts will engage in a multiyear implementation process. Only after this process is complete will the law's significance be clear.

[Knowledge of "Hardship Exemptions" in statutory sickness insurance]

OBJECTIVES

The German Statutory Sickness Fund comprises about 90 % of the total population. There are special relief or 'hardship' regulations in the Statutory Sickness Fund (the 'Härtefallregelungen') exempting those insured persons from co-payment for whom the co-payments would be an undue financial burden. The most important research questions are: How many of the insured persons do actually know about the possibility of being exempted? How did this group learn about the possibility? How many insured are not exempted from co-payment although they are entitled to be exempted? Why didn't they apply? According to our knowledge there is no comparable national or international study in this field of research.

METHODS

The data for the empirical study are collected in a Statutory Sickness Fund in the city of Augsburg (Southern Germany). 18 238 insured (pre-selected as not being exempted from co-payments, but probably entitled to be exempted) were addressed with a very short questionnaire in September 2000. They were asked about their household income, the number of the household members and the money spent for co-payments for medicaments, dental prostheses and other health-related services, in order to identify those entitled to be exempted, and a control group. Among those who responded 1.002 persons were interviewed by CATI (Computer Assisted Telephone Interview).

RESULTS

Within the study group interviewed by CATI there was only limited knowledge about the "Härtefallregelungen". About two-thirds of the respondents (61.58 %) were unfamiliar with the possibility of getting an annual reimbursement of the co-payments. Less than one-third (27.78 %) knew nothing about the regulation of being totally exempted from co-payments. Most persons learnt about the regulations from friends and relatives, but few from physicians and other health professionals. One of the reasons most frequently mentioned for not applying for the "Härtefallregelungen" was a presumably too high income. Reasons which lie within the formalities of the application or refer to the potentially embarrassing situation were reported less often.

CONCLUSION

Knowledge about the possibilities of being exempted from co-payments for medicaments and other health-related services and goods should be increased. With most of the respondents having learnt about the "Härtefallregelungen" from friends and relatives, patients could get relevant information from physicians and other health professionals more frequently. As financial aspects are the reasons reported most for not applying for the "Härtefallregelungen", the information policy could be enhanced e. g. by simplified examples for calculating the relevant income for being entitled. This way there is a chance that all insured persons who are entitled will actually benefit from the "Härtefallregelungen".

Shifting the costs of indigent care back to county governments

Despite a decade of steadily rising prosperity, Texans are losing health care benefits at an alarming rate. As many as 41 million people in this country, or 15% of the population, lack health care coverage of any kind. Most of these people are under age 65 and are gainfully employed, but their employers don't provide coverage and/or don't pay them enough to afford it themselves. Most have minimum wage jobs and are ineligible for Medicaid. These individuals plant the gardens, work in fine restaurants, clean expensive houses, and generally benefit the communities in which they reside. Texas law suggests that county governments and property owners should pick up the tab for the medically indigent. However, as the uninsured numbers grow, county governments are finding ways to extricate their taxpayers and the institutions they support from the obligatory role as payer of "last resort" for these people. While reimbursement from government programs, managed care, and commercial insurers is putting tremendous financial pressure on health care providers, the county systems simply are not assuming their financial, legal, or ethical responsibilities for those outside the protective cover of these programs. In my experience, health care for the medically indigent has become "charity care" at the profit and nonprofit hospitals in the state. The strain is palpable in the emergency rooms, where by law the medical crises of the poor must be treated. This de facto safety net is fraying, and our political leaders need to make the painful decision to raise sufficient tax revenues to remove the weight.

The therapeutic environment of psychiatric hospitals in Japan: a comparison of medical welfare facilities for senile dementia

With the dual purpose of protecting the human rights of mentally disordered persons and promoting their social rehabilitation, the newly revised Mental Health Law was enacted in July 1987. It has brought significant change in that it has shifted Japanese mental health care from a hospital-based to a community-based system. Consequently, the therapeutic environment in the psychiatric hospitals has been changing from a closed to an open one. Recently, the amenity of hospital environments has been discussed. Furthermore, in the revision of medical fees of April 1994 the government established the long-term care ward system, which is a good indication of the changing nature of psychiatric institutions in Japan. I will report on the current therapeutic environment in Japanese psychiatric hospitals, and will also compare it with the care environment in facilities for healthcare services for the aged (and/or senile dementia) and special nursing homes for the aged.

Charitable care and the nonprofit paradigm

Nonprofit hospitals have begun to focus once again on serving the health needs of their communities. Governmental needs for additional revenue and for-profit hospitals' contention that tax exemptions give nonprofit hospitals an unfair competitive advantage have resulted in changes in laws and regulations and have caused a change in the role of nonprofit hospitals. As local governments become more responsive to the health needs of their communities, they are requiring nonprofit hospitals to become more responsive as well. Laws, regulations, and court decisions have begun to require nonprofit hospitals to provide charity care and services at levels equal to the amount of their exempt taxes. In response, nonprofit hospitals are developing community benefit programs and public health services.

[Medical management of homeless persons]

Germany's health care system is based on statutory health insurance funds and the legal obligation of those physicians who work on a contractual basis with the health insurance companies to guarantee the outpatient medical care of the insured. Despite the widely acknowledged efficiency of this system it fails to have the desired effect on those sections of the population who cannot enforce their claims for help or who do not meet the requirements of institutional working conditions. Mostly concerned are homeless people with an additional drug problem or mental disease, immigrants as well as children from socially disadvantaged families. Their number increases especially in the big cities, but legal and organisational limitations render the necessary and time-consuming support impossible, which requires to call on and follow up on patients. The city of Cologne has temporarily established a mobile medical service at the public health department for the subsidiary care of the people concerned. The medical team treats its patients--unbureaucratically and without prerequisites on the part of the patients--in a mobile ambulance or in facilities of social institutions, which take care of drug addicts and homeless people. The physicians who work on a contractual basis with the health insurance companies cooperate with this service to take on this social-compensatory common task. The health insurance companies do not feel obliged to cooperate, although a great number of the patients are insured. Let us hope that the latest and current legislation will provide improvements for the patients concerned. Its aim is to provide an opportunity of medical treatment by the public health department and the opportunity to afterwards charge the costs of the treatment to the insurance branches of the social security system.

Austria's new attendance allowance: a consumer-choice model of care for the frail and disabled

Austria's new social welfare provision, an attendance allowance, adopted in 1993, is a prototype for a consumer-directed care model for persons who are frail or disabled. This article describes the background to and provisions of the new legislation, including the unique political interests from the left and the right that converged to facilitate its passage. The author discusses eligibility criteria, the consumer autonomy principles underlying the model, and the impacts and implications anticipated. Such a model has been mentioned as an option for states considering creative expansion of long-term care provisions in the United States.

The VA health care system: an unrecognized national safety net

The dominance of local health care markets in conjunction with variable public funding results in a national patchwork of "safety nets" and beneficiaries in the United States rather than a uniform system. This DataWatch describes how the recently reorganized Department of Veterans Affairs serves as a coordinated, national safety-net provider and characterizes the veterans who are not supported by the market-based system.

The politics and economics of mental health 'parity' laws

The enactment of the Domenici-Wellstone amendment in September 1996, which calls for the elimination of certain limits on coverage for mental health care under private insurance, is being hailed as a major step forward in the quest for "parity" in mental health coverage. Parity legislation is being introduced in a number of state legislatures and is finding new enthusiasm in Congress. In this paper we consider the efficiency rationale for these laws and examine their likely impact in the era of managed care. We conclude that although such successes represent important political events, they may offer only small gains in the efficiency and fairness of insurance markets.

Welfare reform: a women's health perspective

Welfare reform programs currently being considered and implemented by the federal government and the states pose serious risks to poor women's health. Many of the proposed reforms, such as inflexible work requirements and time limits that threaten to reduce or eliminate current benefits, will make it more difficult for women to leave abusive relationships and will exacerbate the risks associated with violence against women. Other proposals target women's reproductive behavior. Programs that, for example, deny welfare benefits to teen mothers or to children born to women on welfare, increase the emotional stress experienced by poor pregnant women and may effectively coerce some women to seek abortions they would not otherwise choose. Benefit cuts also exacerbate the well-documented ill effects of poverty on children and families. The goals of welfare reform-increasing work participation and reducing poverty-can be more effectively achieved by means that do not pose these serious health risks to poor women.

Delivering breast and cervical cancer screening services to underserved women: Part II. Implications for policy

Many breast and cervical cancer screening (BCCS) programs for underserved women employ strategies to increase the use of preventive services. In Phase I of a two-phase study, strategies were identified and assessed. In Phase II, we further assess strategies previously identified and comment on policy implications. Site visits were conducted at BCCS programs that had used one successful strategy identified during Phase I, provided services to underserved women, and were located in different geographic regions. The federally funded National Breast and Cervical Cancer Early Detection Programs (NBCCEDP) were also considered for site visits. Interviews were completed and available data were reviewed. A descriptive and qualitative analysis was completed. Programs visited were found to be increasing the use of BCCS services for the defined target populations. Some programs focused on outreach and recruitment. Other programs focused on clinical preventive services with little emphasis on outreach and recruitment. Management information systems were used by most programs. We found that there continues to be a large number of women not receiving BCCS services. Some programs have had to limit outreach and recruitment because the clinical preventive services offered are at capacity. Programs need to have a balanced approach to providing services from the outset. Existing programs may need to establish partnerships to provide comprehensive BCCS services to underserved women. Because the unmet need (women who have not received BCCS services) exceeds available clinical preventive services, it is a challenge to know how to best use available resources.