TRUMPCARE and CALIFORNIA MFTs

What’s happening there?  What’s happening here?  
What does that mean for the profession?

We know there will be changes and we know that changes in healthcare legislation will affect our work.  What does that mean for California MFTs in the immediate future?  The following presents information about what is happening federally and at the state level that will impact how we are funded and the way we deliver care.

What’s Happening There?

As you are most probably aware, the House passed the American Healthcare Act (ACHA, a.k.a. Trumpcare) by a very slim majority vote on May 4, 2017.  Some of the provisions of the bill are listed below:

  • Reduces funding for subsidies in a way that helps younger adults and increases premiums for older people.  Provides immediate tax cuts for those with incomes exceeding $200,000 per year ($250,000 for couples).
  • Allows states to seek waivers to opt out of the Affordable Care Act rules that prohibit insurers from charging sick people higher premiums (pre-existing conditions)
  • Allows states to opt out of or redefine the Essential Health Benefits (which includes behavioral health services).  Strips funding for Planned Parenthood for at least one year, a provision that is renewable every year.
  • Allows large employers to choose minimum benefit requirements from any state, including those who have waived all consumer protections.
  • Ends Medicaid (MediCal in California) as an open-ended entitlement and ends Medicaid expansion.  

We can state with much certainty that the AHCA, as passed by the House, will never become law.  We can also anticipate a lengthy process before any new law is passed:

  • The Congressional Budget Office (CBO) has reviewed the potential impact of the legislation as currently written and announced last week that it would significantly reduce the federal deficit but increase the projected number of uninsured Americans by about 82 percent over the next 10 years. This good/bad news dichotomy fails to define a united and clear direction for lawmakers.
  • The Senate will need to pass the bill.  Initial Senators’ reactions to the House bill imply that the AHCA, as currently written, will be completely gutted or substantially overhauled.  The rewrite will pose a significant challenge.  
  • Once passed in the Senate, the revised version of the bill must then go back to the House for reconciliation, potentially creating complications and generating the kinds of objections that previously stalled the first voting process.

Bottom line:  Obamacare is still the “law of the land” for now and we have a long way to go before any legislation is finalized – and even longer before any changes are implemented.  A Senate committee will likely begin actively working on their version of the bill in early June and it appears a second group of more moderate Senators has also formed, indicating a continuing divide within the majority party over the direction of health reform.  California Senators are not included in either of the major working groups.  

What’s Happening Here?

With record numbers now insured through enrollment in Obamacare, California marches ahead “as if”.  In our public system, Karen Baylor, MFT, who is the Deputy Director of Mental Health, Substance Use Disorder (MHSUD) for the Department of Healthcare Services (DHCS) has said:  “Keep your head down, nose to the grindstone”.  We are not changing course in the immediate future.  This means that public systems of expanded, integrated care will continue to evolve, including two DHCS pilot projects:  

  • Whole Person Care: coordinates behavioral health and social services in a patient-centered approach. 
  • Health Homes for Patients with Complex Needs: provides coordinated services for MediCal-eligible frequent users with multiple, chronic conditions.

In the state legislature, bills have been introduced that confirm a spirit of protecting our progress and moving forward, such as: *

  • AB 501: community residential crisis programs for children; 
  • SB 191: a framework for school-county mental health partnerships and targeted interventions; 
  • AB 473: University of California Criminal Justice and Health Consortium pilot project in sixcounties to create cost-effective services for MI/SUD adults in county jail systems; 
  • AB 477: establishes a statewide Behavioral Health Stakeholder Advisory Panel to provide ongoing assistance to improve collaboration of multiple agencies in the delivery system.  

Additionally of note:  our California budget subcommittees are led by two very knowledgeable MDs, both who have expressed interest in issues related to behavioral health:

Senate:  Dr. Richard Pan, pediatrician, interested in early intervention, prevention.  One of his goals is to make Behavioral Health screening a routine part of every primary care visit.

Assembly:  Dr. Joaquin Arambula, Emergency Room physician.  He supports alternatives to taking people to the E.R. or jail as a first/last resort for addressing the needs of people in crisis.

 While Governor Brown’s May proposed budget included shifting costs to counties in a way that would impose behavioral health funding cuts, California’s related goals remain solidly in place for the time being.  

As we continue to move forward, the growing behavioral health provider workforce shortage has emerged as an area of significant concern related to our expanding systems of care.  Veteran mental health lobbyist and Proposition 63 (MHSA) co-author Rusty Selix stated:  “…there is no question that the workforce challenge is greater now than any time in the past.” 

In March, the California Mental Health Planning Council’s Workforce Summit in Sacramento attracted a diversity of participants including legislators and policy makers as well as reps from counties, community agencies, education and all clinical provider disciplines.  Presentations addressed a range of topics concerning workforce issues from research and funding resources to educational/training programs and systemic, collaborative innovations.  It is clear and widely recognized that we need more behavioral health providers to work in California’s ongoing, expanding systems of care.

What Does This Mean for the Profession?

California’s current resolve to move forward with the implementation of integrated, coordinated and collaborative systems of care means expanded employment opportunities for MFTs. The growing provider workforce shortage can be good news for MFTs seeking employment, but this does not mean that anyone pursuing a placement or employment in public behavioral health is a good candidate.  Those clinicians who are aware of and prepared to work in the new systems of care will be the successful candidates.

Evolving systems are subject to continual change.  Clinician flexibility, spirit and attitude jump to the top of the “desirable traits” list as employers struggle to provide consumers with the security of consistent, continuous, quality care, while shifting long-standing procedures and structures in accordance with new outcome measures and funding requirements. It becomes a balancing act, requiring skills beyond clinical to navigate this often uncharted territory.  It is a challenging time.

This is also an exciting time and – something that MFTs may particularly appreciate – it is all about systems.  Evolving programs of care at the national and state levels involve systems that have historically overlapped but may not have structurally merged, such as mental health, social services, primary care, substance use disorder, schools, justice system.  In these new systems, the whole person is being viewed as the “patient” and the whole community is designated as responsible for care.  This concept produces programs that encompass an extended population of providers from a diversity of professional and clinical disciplines.  Some examples include:

  • Sutter Health/Steinberg Institute have joined One Mind at Work to develop programs of coordinated workplace intervention.  
  • Pilot programs sponsored by the national Health Resources and Services Administration (HRSA), in which multigenerational critical social services are provided to the entire family as part of integrated care.
  • Stepping Up: counties, state governments, justice center and APA collaborative program to reduce numbers of mentally MI/SUD adults in jails.

Considering the direction in which healthcare is moving, we encourage MFT educators and clinicians in California to broaden your perspectives in relation to treatment.  Policy briefs published by the national Behavioral Health Workforce Research Center in 2016 have called for the expansion of occupational scopes of practice and also highlighted the following conclusion:  “Integrated care training should be expanded in academic curricula, as most workers learn to work in team based care models on the job”. ** 

Integrated, expanding systems can be envisioned almost like nesting blocks:  the smallest piece is the individual in need of services; primary care enlarges the block; family, social services, employment counseling, justice system, schools, etc. all may be added as blocks that enlarge the world of treatment options surrounding the individual.  We’ve come full circle, back to the MHSA foundational principles:  “No Wrong Door” and “Whatever it Takes”.  With our training in systems and relational work, the MFT scope of practice can comfortably lend itself to expansion if we are able to see the professional landscape with altered views:

  • Think Context:  The clinical concepts and skills that you have learned are solid but the context within which you apply them may be different.  In expanded systems, there is a need for MFT knowledge and skills.  Because new structures are continually emerging and changing, you can help to define a place for MFTs and for yourself during the development process.  
  • Think Teamwork:  Emerging, expanded structures of care incorporate multidisciplinary provider teamwork.  To contribute most effectively on any team, you need to know the game plan, clarify your position and assess how your own personal competencies can contribute to the collective goals. As in all teamwork, there is an interdependence that requires inclusiveness, clear communication and mutual trust. 
  • Think Collaboration:  Beyond the collaborative approach among care providers, recovery oriented care encompasses collaboration with the consumers and their broader personal communities. Our expertise and skills in facilitating active communication can potentially become a critical part of a functional, integrated system.  
  • Think Inclusion/Overlap:  Ideally, our teams will honor and respect the input of all interested parties as well as all of the provider disciplines.  The goal is effective treatment response. There are enough consumers to go around and no place in these systems for a territorial spirit.  Could an addictions counselor, nurse practitioner or probation officer have information about your client that might be news to you?  Open arms reaching out to all providers can yield more comprehensive information and result in a more effective collaborative response.
  • Think Accountable Care:  How do we assure our funding sources that they have made the right decision in spending their money on us?  Systems of accountable care and funding shifts from “Volume to Value” require comprehensive assessment, careful treatment planning and skillful documentation.  These competencies are critical in the new structures of care.  

For private practitioners, even if you have no plans to work in a public setting, your practice referrals and payment mechanisms will be impacted by the impending, widespread changes and it will be to your advantage to stay informed about national and state legislation and the evolving systems.  

Finally, from broad concepts to more specific content, MFTs would benefit from gaining knowledge and skills about:

  • Recovery Oriented Care
  • Substance Use Disorder
  • Cultural Humility
  • Working With the V.A. and the Corrections Populations
  • Evidenced Based Practice
  • Integrated Services
  • Language and Culture of Primary Care 
  • Seriously Mentally Ill Population.

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:  olivialoewy@aamftca.org .

* For current detailed information about California legislation:  http://leginfo.legislature.ca.gov/

** http://www.behavioralhealthworkforce.org/