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Written Comments Regarding Healthy Pennsylvania Jacob Bowling, Director of Advocacy and Policy Mental Health Association of Southeastern

Pennsylvania January 3, 2014 At the Mental Health Association of Southeastern Pennsylvania (MHASP), we believe that a healthy Pennsylvania is one where people can easily access behavioral health support that contributes to overall wellness, and involvement in their communities and families. Among the principal stakeholders in this plan are citizens of the Commonwealth who have mental health conditions and their families: including individuals in our existing HealthChoices program and the additional Pennsylvanians who will benefit from Medicaid Expansion who are currently uninsured and have a mental 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 mental health conditions and their families, and must reinforce Pennsylvania’s leadership in mental healthcare. While we applaud the administration’s commitment to increasing health access for 500,000 Pennsylvanians, we have major concerns about this plan’ s inadequacy 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 their voices. While the Healthy Pennsylvania plan is long, detailed, and complex, there are still many unanswered questions that inhibit the ability of Pennsylvanians to offer an informed contribution to this process. We need more time to learn about this plan and offer comments. We would ask for thirty more days to issue written comments and at least four more regional hearings. Thirty days during a busy holiday season for many families is not a sufficient amount of time to comment on a plan that will impact the lives and health of 500,000 Pennsylvanians and their families. The behavioral health benefit in the High Risk plan is insufficient and unaligned with what is currently offered to individuals in HealthChoices. What is offered through the Healthy Pennsylvania High Risk Plan is not only insufficient for people with serious mental health conditions, but it is not aligned with the benefits that are currently offered through HealthChoices. One of the HealthChoices plans offers 60 outpatient mental health visits per year (15 more than the Healthy PA High Risk Plan), and no limits on inpatient psychiatric hospitalization, inpatient drug and alcohol hospitalization, and outpatient drug and alcohol treatment (Healthy PA places limits on all of these services). For someone who relies on weekly therapy appointments to stay out 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
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“Medicaid 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=155752 2 “Healthy 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 Healthy Pennsylvania removes all limits in the high risk plan for these critical services that promote recovery and whole health. By removing the drastic cuts to HealthChoices that are inherent to this plan, DPW can support services that prevent and mitigate crises that result 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 plan to the high risk plan, because of a more severe episodic condition or the development of a more severe condition. The Healthy Pennsylvania 1115 Waiver application does not explain the process of obtaining a higher level of coverage. The process should be seamless and timely, and should not necessitate an onerous administrative process for consumers or the disruption of critical services and supports. We would assert that those who need benefits in the high risk plan should gain immediate access to those benefits 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-assessment process. To be placed in the high or low risk plan, individuals must undergo a self-assessment process that involves self-reporting their medical conditions. For a self-assessment to be successful, the following must be true for every individual to ensure that they are correctly identified and appropriately placed in a plan that meets their needs. Each individual 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 medical conditions is prevalent, and may prevent an individual from sharing medical information even if it would result in a more appropriate level of benefits).  Have additional support if a cognitive impairment may impact awareness of disability 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 with disabilities 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 the self-assessment is not completed. Individuals with disabilities may experience the aforementioned barriers and miss or fail to 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 did not show up or complete their self-assessment may be evidence that their disability is so severe that a higher level of benefits is needed. For those unable to complete the assessment, they should be enrolled in the high risk plan as a default. If, upon further review, the High Risk plan is an inappropriate level of benefits for the individual, a redetermination can result in placement back into the Low Risk plan. People should not have decreased access and more limitations to care just because their disability prevents 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, Iowa’s Medicaid Expansion plan received approval from the federal government. However, CMS refused to allow one of the plan’s measures- that individuals at 50% FPL pay a premium- to pass3. Given CMS’s disapproval of this measure in Iowa and the extreme poverty of individuals at 50% FPL (some make less than $500 per month) we would ask that premiums only be assessed at 100% FPL if at all. Individuals with mental health conditions- like many other low-income Pennsylvaniansmay experience difficulty paying premiums. To penalize them by the removal of coverage will only contribute to their involvement with more-expensive taxpayer subsidized systems and the decline of their health. We would ask that the failure to pay premiums not result in the punitive cancellation of coverage. People who are deemed “medically frail” still must satisfy arduous work search requirements. While employment plays a critical role in the recovery of people with mental health conditions, their healthcare should not be tied to their ability to work or their completion of work-related activities. People with mental health conditions need the opportunity to thoughtfully engage or re-engage with the workforce without the enormous pressure of losing their healthcare benefits because they are unable to complete seventy-two workrelated activities within a six month period. In addition, we have concerns that JobGateway- the portal through which individuals can satisfy this requirement- may not be a program that is user-friendly to individuals with disabilities. Also, it is unreasonable someone’s internet access and transportation (required to participate in JobGateway)

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Medicaid Expansion Through Premium Assistance: Arkansas, Iowa, and Pennsylvania’s Proposals Compared, the Henry J. Kaiser Family Foundation, 2013, found at http://kff.org/health-reform/fact-sheet/medicaid-expansionthrough-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 search requirement for eligibility be removed. The Pennsylvania taxpayers have no evidence that the Healthy Pennsylvania plan is cost-neutral. DPW's plan must be cost-neutral, but the application does not demonstrate how. One of the potential revenue-generating components of this plan is the payment of premiums for people from 50% to 138% of the federal poverty level (FPL). In the Iowa plan, CMS has 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 the plan'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 people as 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 benefits than those typically covered by private health insurance and requires less patient cost sharing. On the other hand, Medicaid provider payment rates are typically lower than those offered by private insurers.”4 The Congressional Budget Office agrees. Since Medicaid provides a lower reimbursement to doctors and hospitals, Medicaid saves money. Arkansas’ plan costs, “the government $6,000 a year for Medicaid [and] would cost $9,000 on a private plan on the exchange."5 Thus, Pennsylvania taxpayers will get a 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 billion dollars of potential federal funding by delaying Medicaid Expansion until January of 2015. It will also lose out on any potential job growth in year one (Medicaid Expansion is expected to create 35,000 jobs the next few years, many of which will be well-paid positions in the healthcare industry). The Southeast region alone will see 15,600 of these new jobs. Overall, Rand estimates that this additional federal funding would lead to 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 muchneeded economic benefits for at least one year. In a few days, hundreds of thousands of hardworking people in our region will become eligible 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.
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“Public And Private Health Insurance: Stacking Up the Costs.” Health Affairs. Found at http://content.healthaffairs.org/content/27/4/w318.full 5 “The Arkansas Medicaid Model: What You Need To Know The ‘Private Option’” Kaiser Health News. 2013, found at http://www.kaiserhealthnews.org/stories/2013/may/02/arkansas-medicaid-private-option-faq.aspx 6 “For States that Opt Out of Medicaid Expansion: A Rand Report.” Health Affairs. Found at http://www.rand.org/pubs/external_publications/EP50279.html

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More than a year from now, hundreds of thousands of hard-working Pennsylvanians may be eligible for Medicaid Expansion. But these individuals- especially those with mental health conditions- will have an inadequate behavioral health benefit with drastic cuts to what is offered in HealthChoices. In addition, individuals with disabilities will be required to navigate an insurmountable and laborious process to acquire healthcare coverage. Finally, Pennsylvania taxpayers will be left with insufficient time to comment on the plan, no real evidence of cost-neutrality, and the costly consequence of stalling a straightforward Medicaid expansion plan that would create a vital economic boost. Thus, the Mental Health Association of Southeastern Pennsylvania recommends a prompt and straightforward expansion of our successful HealthChoices program- a Medicaid program with a proven track record that has positioned Pennsylvania as a national healthcare leader.

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